Thoracic Spine Common Presentations

Question 1

What is a pancoast tumor? What structures are involved?

Answer 1

• tumor at the apex of the lung
• may involve C8 and 1st thoracic nerve structures

Question 2

Symptoms of pancoast tumor

Answer 2

symptoms similar to radicular pain/radiculopathy, thoracic outlet, and/or peripheral nerve entrapment

• chronic cough
• bloody sputum
• unexplained weight loss
• malaise
• dyspnea

Question 3

physical exam findings of pancoast tumor

Answer 3

• fever
• wheezing

Question 4

MI referred pain

Answer 4

• center chest
• neck
• medial arm

Question 5

pericarditis referred pain

Answer 5

substernal pain that may radiate to costal margins, neck, upper back/trap, and left medial arm

Question 6

pneumothorax referred pain

Answer 6

upper and lateral thoracic wall with referral to ipsilateral shoulder, across the chest, or over the abdomen

Question 7

pleuritis referred pain

Answer 7

chest pain with referred pain on ipsilateral shoulder, upper trap, neck, lower chest wall, or abdomen

Question 8

compression fracture common MOI

Answer 8

axial loading in flexed position
- traumatic - high energy or osteoporotic

Question 9

What part of the vertebrae is typically involved with a compression fracture?

Answer 9

anterior column affected

Question 10

burst fractures involve which parts of the vertebrae
- What part of the spine does this most commonly occur at?

Answer 10

anterior and middle columns
-most common at T/L junction (T12, L1)

Question 11

MOI of burst fractures

Answer 11

• MVC
• falls from heights
• high-speed sport injury
• potential neural involvement

Question 12

What type of fracture usually involves all 3 columns? What is the MOI?

Answer 12

rotation/translation
- fall from a height or heavy object falling on body with bent trunk that causes horizontal displacement of one T/L vertebral body on another
- causes facet joint dislocation

Question 13

MOI of distraction fracture

Answer 13

forced flexion or forced extension
- anterior and posterior ligaments, anterior and posterior bony structures, both

Question 14

red flags for vertebral fractures

Answer 14

• older age
• significant trauma
• corticosteroid use
• contusion/abrasion

Question 15

Criteria used to ID presence of an osteoporotic vertebral compression fracture

Answer 15

• age > 52 years
• no presence of leg pain
• BMI = 22
• does not exercise regularly
• female

Question 16

symptoms of rib fracture

Answer 16

• focal pain, radiating pain
• pain with inspiration
• pain with coughing/sneezing

Question 17

physical examination of rib fracture

Answer 17

• focal tenderness
• possible palpable defect

Question 18

What is scheuermann’s disease? What does it cause?

Answer 18

• congenital abnormality where endplate of vertebra hasn’t fully formed
• defective growth of vertebral endplate
• causes wedging of vertebral body

Question 19

criteria for diagnosis of scheuermann’s disease

Answer 19

• thoracic kyphosis > 45 deg
• wedging x 3 adjacent vertebrae > 5 deg
• thoracolumbar kyphosis > 30 deg

Question 20

What is a schmorl’s node?

Answer 20

• common spinal disc herniation in which the soft tissue of the intervertebral disc bulges out into the adjacent vertebrae through an endplate defect
• Vertebra structure is compromised – strength may be affected

Question 21

physical exam findings of scheurmann’s disease

Answer 21

• scoliosis
• excessive thoracic kyphosis
• vertebral wedging, schmorl’s nodes, disc space narrowing
• limited thoracic ROM - multidirectional A/PROM limited
• neurologic complications

Question 22

What causes costochondritis?

Answer 22

• repetitive stress (coughing)
• involves >/= 1 rib

Question 23

symptoms of costochondritis

Answer 23

• pain and local tenderness at costochondral or chondrosternal articulations
• at rest, during trunk movements, and respiration

Question 24

physical exam findings of costochondritis

Answer 24

• local tenderness
• painful with chondrosternal joint mobility testing

Question 25

Why is disc disease less common in the thoracic spine?

Answer 25

- There is less motion and more skeletal stability in the thoracic column - Tend to see them in the lower T spine (transition zone and not as much articulation)

Question 26

symptoms of disc disease

Answer 26

- back or chest pain at the same level - radicular band like pain in affected level's dermatome - progressive/insidious - may see multidirectional ROM deficit and pain with spring testing, coughing, wrapping around pain

Question 27

symptoms of thoracic spine myelopathy

Answer 27

- sexual dysfunction - bowel and bladder dysfunction - should see more bilateral distributions

Question 28

physical exam findings of thoracic spine myelopathy

Answer 28

- sensory/motor impairments - UMN signs (Babinski's, gait dysfunction, ankle clonus, hyperreflexia in lumbosacral)

Question 29

MOI of intercostal neuralgia

Answer 29

- infection (varicella zoster) - mechanical compression (disc protrusion, osteophyte complex, neuroma, fracture) - following thoracic surgery

Question 30

symptoms and physical exam of intercostal neuralgia

Answer 30

symptoms - burning pain/paresthesia along intercostal nerve path physical exam - focal tenderness of intercostal area

Question 31

who is more likely to have T4 syndrome

Answer 31

women > men (4:1)

Question 32

symptoms of T4 syndrome

Answer 32

- glove-like paresthesias unilateral/bilateral UEs - neck/scapular/bilateral upper extremity pain - gets worse with side-lying or supine - generalized headache (bilateral)

Question 33

physical exam findings of T4 syndrome

Answer 33

- tender spinous process - + thoracic slump test - + upper quarter neurodynamic tension tests - hypomobile thoracic segment

Question 34

How is scoliosis named?

Answer 34

for the direction of convexity

Question 35

symptoms and physical exam findings of zygapophysial arthropathy

Answer 35

symptoms - local and/or referred pain physical exam - painful movement with closing of z-joints (A/PROM) - painful spring testing/hypomobility w/ joint mobility testing - ipsilateral referred pain

Question 36

symptoms and physical exam of rib dysfunction

Answer 36

symptoms - aggravated w/ deep inspiration, trunk rotation, sneezing/coughing physical exam - diminished rib mobility - pain/hypomobility w/ joint mobility testing - limited/painful thoracic spine motion

Question 37

what motion is the most provoking during rib dysfunction? A/PROM?

Answer 37

A/PROM rotation should both be painful with rib dysfunction

Question 38

what structures can be compressed with thoracic outlet syndrome?

Answer 38

- subclavian artery - subclavian vein - brachial plexus

Question 39

potential areas of compression in thoracic outlet syndrome

Answer 39

- scalenes - cervical rib - pec minor - first rib - clavicle

Question 40

symptoms of thoracic outlet syndrome

Answer 40

- UE pain - paresthesia, anesthesia/weakness (glove-like) - chest/anterior shoulder pain - typically progressive/insidious onset

Question 41

physical exam findings of thoracic outlet syndrome

Answer 41

- cervicothroacic/scapulothoracic muscle guarding - provocation w/ contralateral neck lateral flexion - provocation w/ stretching

Question 42

Vascular TOS physical exam findings. How can you determine this?

Answer 42

edema, cyanosis, coldness of hand, diminished pulses Take BP on both arms and if there is a 20 mmHg difference - involved side will be diminshed

Question 43

Neurologic TOS physical exam findings

Answer 43

C8/T1 distribution LMN signs, possibly atrphy abductor pollicic brevis

Question 44

what special tests would potentially be positive with thoracic outlet syndrome

Answer 44

- Roo's test - hyperabduction test - adison's test - wright's test - cervical rotation lateral flexion test: restricted 1st rib - 1st rib spring test: restricted 1st rib