Thoracic Spine Flashcards
What percent of population with spinal pain reports thoracic/lumbar/cervical pain?
15% thoracic
56% lumbar
44% cervical
Which spinous process is in line with inferior angle of scapula?
Conventionally: T7.
More recent study: Most often at T8, can vary from T4-T11
Rule of 3s for spinous process alignment in t spine
T1-3: Spinous process at level of transverse process
T4-6: Spinous process 1/2 vertebral level below transverse process
T7-9: Spinous process full vertebral level below transverse process
T10-12: Spinous process at level of transverse process
Description of vertebra size/shape in t spine
- Vertebral bodies become larger and denser from superior to inferior
- Taller posteriorly > kyphosis
- Thoracic discs are thinner than cervical and lumbar
Review anatomy of rib articulation with vertebrae
Ribs 3-9 are “typical” > 2 facets (inferior and superior)
Ribs 1, 10-12 only have 1 facet
Costotrasnsverse joints are concave/convex from T1-T6, planar from T7-T12 > pump handle upper, bucket handle lower with inspiration. Other studies have shown rib cage motion is similar at all levels.
11th/12th ribs move in caliper-type motion b/c no anterior attachment or costotransverse joint.
Spinal extensor weakness and reduced muscle density has been associated with:
Thoracic hyperkyphosis, osteoporosis, decreased QOL, increased risk of falling in older adults
Neurovascular review
- Each thoracic spinal nerve exits below its disk
- Each thoracic spinal nerve contributes preganglionic sympathetic fibers to sympathetic chain
- Subcostal nerve (T12th spinal nerve) irritation at thoracolumbar junction could lead to referred pain in the hip region.
- There is potential for upper thoracic spine to refer to UEs.
“Critical zone”
T4-9> Smallest spinal canal diameter, reduced blood supply. Significant pathology here could cause central spinal cord compression.
Mobility impairments here can > neurogenic and sympathetic signs (T4 syndrome)
Thoracic spine joint referral
Zygapophyseal joints:
- C5-T1: paravertebral region, inferior to parascapular region
- T3-T11: Usually right around or slightly below level affected
Costovertebral joints: Pain directly over joint. Osteophytes here can > pseudovisceral pain due to proximity to sympathetic chain.
Patients with more chronic pain usually have less localized sxs
ROM of t spine based on region
- Flexion/extension: Increases from T1 to T12 as facets become more oriented in sagittal plane.
- Sidebending: Increases from T1- T12. Controversy as to whether thoracic rotation couples contralaterally or ipsilaterally during sidebending.
- Rotation: Higher in upper segments. Average = 26 deg.
S/s of T4 syndrome
HA, neck pain, UE pain, bilateral stocking glove paresthesia.
Thoracic flexion mobility impairment
Typically occurs in middle t spine, T3-7
Thought to occur after whiplash-type injury as a result of rear-impact collision
Thoracic extension mobility impairment
Typically occurs in upper thoracic/CTJ region and lower thoracic spine.
Common in older adults, associated with decreased QOL and increased risk of falling.
Can be improved with exercise programs.
Clinic prediction rule to rule our CAD in primary care
In patients >35 yo and reporting anterior chest pain:
- Male >54, female> 64
- Known clinical vascular disease
- pain worse during exercise
- pain not reproducible with palpation
- patient assumes pain is of cardiac origin
^Presence of 3 = 87% Sn, 80% Sp
Murphy sign
For cholecystitis
Pain with deep inspiration while palpating the right subcostal region
Renal colic
Pain in flank accompanied by lower abdominal pain that spreads into labia/ testicles
Pts at risk for kidney infection
Hx or current UTI
Primary cancers most likely to metastasize to t spine
Breast
Lung
Colon
Greatest shift in probability of cancer is with ____history/subjective finding
Hx of cancer
Clinical prediction rule to identify ankylosing spondylitis
- Morning stiffness >30 min
- Improvement in back pain with ex but not rest
- Awakening with back pain during second half of night only
- Alternating buttock pain.
94% Sp if 3 positive
Key physical examination implicating ankylosing spondylitis
Limited chest expansion
Normal: 5cm measured at nipple
Limited: <2.5 cm
HLA-B27 has high false positive rate
Infection in t-spine
Not common
Red flags include: Fever, chills, night sweats, recent infection, current IV therapy or drug use, recent surgery.
Risk factors for osteoporosis
Caucasian Hx of smoking Early menopause Thin body build Sedentary lifestyle Steroid treatment Excessive consumption of caffeine or alcohol
Risk:
Gradually increases for men
Sharply increases after 65 for women
Vertebroplasty for compression fracture
No benefit over passage of time.
Imaging for t-spine
- Acute pain with risk for osteoporotic fx: Xray
- Suspected CA or infection: MRI, bone scan
- Trauma: No imaging unless they have spinal tenderness, neurological signs, or altered consciousness.
Lifestyle factors potentially associated with tspine pain
Tobacco use, alcohol use, lack of PA, work related stress, family issues.
Association between posture and pain
No relationship except in most severe postural abnormalities.
Should use symptom modification procedure to identify whether posture is relevant to patient’s pain.
Measuring thoracic kyphosis
Inclinometer at T1-2 and T12-L1, Sum the two angles.
Kyperkyphosis = Cobb angle > 50 deg
Identifying C7
Doesn’t move with cervical flexion.
Thoracic segmental mobility testing
Better when assessment is based on regions rather than a specific segment.
Potential risk factors for poor recovery
Depression
Fear of movement
Pain catastrophizing
Life stressors, substance abuse, poor sleep
Manipulation: General vs. specific
Equal results. Manipulation likely produces forces to a region of the spine as opposed to only at the targeted segment.
Contraindications to seated thoracic manipulations
Shoulder discomfort in position
History of anterior shoulder instability
Therapist can’t reach arms around the patient
Purpose of lower trap training in tspine pain
Improve or maintain extension in middle-lower thoracic region
Facilitate normal scapular-thoracic motion
Manip to mid-lower t spine can facilitate lower trap firing
Prone thoracic extensor strengthening
Decreased incidence of vertebral fracture in 10-year follow up
Manual therapy to t spine for pts with cspine or shoulder pain
Typically beneficial.
Unlikely that shoulder kinematics will be affected, but pain often benefits pain.
