Thoracic Spine Pathology & Assessment Flashcards
What are some major changes from cervical vertebrae to thoracic?
Change from bifid spinous process and 45 degree angle in cervical to being more layered like fish scales in thoracic.
Sympathetic chain ganglia more posterolateral closer to where costa comes into vertebra, costovertebral joints, this is the sympathetic chain
What is the etiology of a thoracic disc lesion?
Etiology: Nucleus pulposus herniation (typically central or central lateral)
Thoracic disc lesions make up what percentage of all disc lesions?
0.5-1.5 %
Not very common.
Thoracic disc lesion:
___ percent are below T8 = more flexible area of thoracic spine
___ percent are at T11/12
75% are below T8
26% at T11/T12 (most common)
Calcification is reported to occur in ___ to ___% of cases of thoracic disc herniations, which may increase _______ extension (tension?)
30 to 70%
intradural
What are the main symptoms of thoracic disc lesion?
- Radiating pain straight through to the chest/sternum (occasionally around ribs as well).
- All movements limited, especially end of range inhalation and exhalation.
- Pain with cough and/or sneeze.
- Bladder dysfunction (24%) – presents as urgency especially with lower T spine disc herniation
What are the causes of thoracic spine disc herniation?
- Traumatic injury is associated with approximately 25% of Tsp herniations
- Degeneration:
- i) Lumen narrows
- ii) Smaller circular spinal canal
- iii) Variable blood supply to cord (medullary feeders) not at every level so some are not as well-fed by vasculature
What is the main “water shed” for blood supply to the spinal cord?
Note: Water shed for blood supply for the spinal cord is between T4-T9
What is the etiology of a subluxed rib? Cause?
A rib is stuck at one end of its range of motion (anterior or posterior roll) stressing and sometimes exceeding its ligamentous and bony restrictions. Can occur at its costochondral joint, costovertebral and/or costotransverse joint.
Need to have major trauma to have a stuck rib.
What are the symptoms of a “stuck rib”?
- Sharp pain at time of injury.
- Muscle spasm around area of injury.
- Possible radiating pain around the length of the rib that starts at the midback and radiates to the sternum.
- Increased pain with deep inspiration or expiration
Where is the least likely area of T-spine to get a disc protrusion?
Where scapula is rarely get any disc protrusions.
Which is worse, thoracic or lumbar disc herniation? What is the “classic” sign of thoracic disc herniation? What will people think is happening? Other signs?
Thoracic disc herniations are very uncommon but when they do happen they are much worse than lumbar disc herniation. Classic sign is pain that shoots straight through to sternum. People will think they are having a heart attack (which is something you need to clear). Will usually present to ER first. Everything hurts, all movements limited, back in spasm, difficulty breathing. Some people pain at end of inhalation/exhalation and some people breathing shallowly.
Note: this presents as urgency. Different than cauda equina which presents as urinary retention first.
Where does the vertebral artery branch off of? What artery branches off of the vertebral?
Vertebral artery off subclavian artery, goes up through cervical, comes together to form basal artery forms circle of Willis.
PICA (posterior inferior cerebellar artery) comes off vertbral.
How is the spinal cord fed with blood (what arteries)? What level is the main feeder for the spine?
Anterior spinal artery – feeds 2/3rds of cord
PICA gives off two posterior spinal arteries – together feed 1/3 of cord
Throughout spine at varying levels you have random feeders that come out of vertebral foramen.
Different in each person. When you are developing you have one at every level of vertebral foramen but they disappear as you get older.
Going up, T9, T11 main feeder for spine from bottom up
Why are disc herniations less common in thoracic area? What conditions are more likely to happen in T-spine?
Least amount of disc herniation as least mobile part of spine. Manipulate the most because it gets the tightest. More likely to have necrotic vertebra in T spine
If people get bone pain here that does not go away after manipulation, that is something to be concerned about.
Proximity to lung field, metastic cancers from lung cancer.
Breathe in the ribs roll _______, breathe out roll _______.
At what range will the rib get stuck?
Posteriorly; anteriorly
Will be stuck at end range and will not want to move out of end range.
If a rib is stuck in posterior there will be more pain when breathing in or out? Why?
If stuck in posterior there will be more pain when breathing out as it will want to follow exhalation but won’t be able to.
Which joints may be affected by a stuck rib?
Can be affected at costal transverse, vertebral and costalchondral joints
Demi-facets on vertebrae above and below.
Chosto-chondral – ribs to sternum.
If you have pain with deep breathing and pain that follows the rib all the way around what condition should you automatically think of?
Subluxed rib
What are common causes of subluxed rib?
- Excessive coughing and/or sneezing,
- Lifting and throwing activities
- Quick twisting motions with underlying pathology.
What other conditions should you differentiate from if diagnosing a subluxed rib?
- Cardiac events
- Thoracic disc lesion
- Thoracic sprain/strain
- T-4 syndrome
Differentiate disc lesion from subluxed rib based on pain pattern.
Thoracic disc lesions can radiate around the spine like a subluxed rib but more often shoot straight to the sternum.
With subluxed rib you will have pain even with shallow breathing. With a disc lesion you may have limited breathing ROM or pain with deep breathing but will not be as tied to breathing as subluxed rib.
Can do tests to differentiate:
- Pushing straight on spinous process of thoracic vertebra affected will be extremely painful, even light pressure, if it is a disc lesion. This will not be the case with a subluxed rib.
- Rib springing test will be positive/painful with rib subluxation but not as much with disc lesion.
Which muscles are often weak in the thoracic area? Why might someone throw out their back doing a small innocuous movement?
Multifidus often weak as paraspinals have been working hard for so long.
It is often small innocuous movements that throw out the spine because we are not actively engaging the muscles. However there is often underlying pathology already.
What is chostochondritis? Etiology?
Costochondritis is an inflammation of the junctions where the upper ribs join with the cartilage that holds them to the breastbone, or sternum.
This is an acute and often temporary inflammation of the costal cartilage.
What are the symptoms of chostochondritis? Differentiation from subluxed rib?
Symptoms can be similar to the chest pain associated with a heart attack. The condition causes localized chest pain that you can reproduce by pushing on the cartilage in the front of your ribcage.
–> Almost always affects multiple ribs (typically the 3rd,4th and 5th rib)
–> Pain is often worse with coughing, deep breathing, or physical activity (dependent on amount of rib expansion needed)
Differentiation from subluxed rib: subluxed rib can affect any one of the ribs but usually just one. Can follow the pain around to the back.
