Thoracic Spine & Rib Cage Flashcards
What are the thoracic spine red flags?
- Unexplained weight loss
- History of cancer
- Night pain/sweats
- Constant, unremitting pain
- Age > 50
- Violent trauma
- Fever
- Saddle paraesthesia
- Altered bowel/bladder function
- IV drug use
- Progressive neurology
- Systemic stenosis
What are the spinal cord red flags?
- Sensory changes in hand (esp bilateral)
- Wasting of intrinsic muscles of hand
- Unsteady gait
- Hyper-reflexia (Hoffman’s sign)
- Weakness/sensory changes at multiple levels
- Bladder/bowel changes
What is Hoffman’s sign?
- Hand in neutral position
- Flick distal phalanx of middle finger
- Look for flexion of distal phalanx of thumb
What are the characteristics of vertebral compression fracture?
- Associated with weakening of vertebral trabecular bone (e.g. OP)
- Severe thoracic spine pain (acute onset)
- Progressive thoracic kyphosis
- Respiratory compromise
- Pressure sores
- Often caused by low force (bending, lifting light object)
What is the difference between OP & osteopenia?
- Osteoporosis: T score <2.5
- Osteopenia: T score -2.5 to -1, may progress to OP
What are the types of VCFs?
- Wedge
- Biconcave
- Burst
How are VCFs managed?
- Address causative factors (medical, endocrinology)
- Symptom management (pain relief)
- Prevent/manage complications (respiratory, posture/bracing)
- Corrective (surgery if very severe)
When does a rib stress fracture commonly occur?
- Golf, kayaking, swimming, baseball, squash
- Rowing (8-16% elite)
- Causes large time loss from raining & competition
What are the characteristics of rib stress fractures?
- Generalised rib pain in lateral chest wall
- Anterolateral/lateral location
- Increased pain with activity & deep breathing, shoulder f/abd/e, trunk f & EOR e, scapular protraction/retraction
What are the differential diagnoses for rib stress fractures?
- Serratus anterior strain
- Intercostal strain
- Ewing’s sarcoma (younger, non-elite, no recent increase in training load)
What is the treatment for rib stress fracture?
- 3-8 weeks rest/modified training (e.g. smaller oars)
- Avoid NSAIDs
- Graduated return while monitoring symptoms
What are the characteristics of facet joint pain?
- Deep, dull ache
- Inferior & lateral to injection location
How is facet joint pain commonly treated?
- Diagnostic injection of local anaesthetic
- >80% pain reduction in 42% of patients with chronic thoracic pain
What articulations occur between the thoracic vertebrae & the ribs?
- Costovertebral (costocoporeal) joints: Head of ribs with vertebral bodies
- Costotransverse: Neck of ribs with transverse processes
Which costotransverse joints are commonly painful?
- Left T3, T5, T7
- Right T2, T4, T6
What is thoracic outlet syndrome?
- Compression of brachial plexus, arteries, veins in the thoracic outlet
- Pain, paraesthesia, weakness & discomfort in upper limb
- Doesn’t follow exact dermatomal/myotomal distribution
- Aggravated by elevation of arms or movements of neck
What are the common sites of compression in TOS?
- 1st rib & between anterior & middle scalene
- Beneath clavicle
- Sub-coracoid tunnel (beneath pec minor)
What are the subtypes of TOS?
- Neurological (nTOS, approx 95%)
- Vascular (vTOS, approx 5%)
What is the epidemiology of TOS?
- Common in 30-60 years
- Women > men
- Often follows neck/shoulder injury
- Common occupations: Secretary, manual labour, truck driver
- Common sports: Swimming, diving, water polo, rowing, baseball (pitching)
What is the treatment for TOS?
Surgery (removal of 1st rib)
Physio:
- Loss of motor control, breathing dysfunction, central sensitisation
- Neck/shoulder ROM & strength, thoracic spine mobility, scapular control training)
What is scoliosis?
- Abnormal curvature/rotation of the spine
- Starts at puberty
- Unknown causes but strong genetic link
- 1-3% of children aged 10-16
- Majority requires no intervention
What does the screening for scoliosis involve?
- Adams forward bend test
- Definitive: Cobb angle >10 deg (from XR)
- Description: Right convex
What is the natural history of scoliosis if untreated?
- Curve progression
- Back pain
- Cardiopulmonary problems
- Psychosocial concerns
What is Scheuermann’s disease?
- Increased kyphosis due to wedge shaped vertebrae
- >5 deg wedging in >3 adjacent vertebrae
What is the cause of Scheuremann’s disease?
- Vertebral end plate defective growth or deterioration
- Genetic link
What is the natural history of Scheuremann’s disease?
- Back pain
- Disability due to back pain
- Sciatic pain
- Difficulty going up stairs
What is the treatment for Scheuremann’s disease?
- Avoid sports with heavy loading
- Bracing
- Posture
- Strengthening
- Stretching (pecs & hamstrings)
What are the physio treatment modalities for thoracic spine & rib pain?
- Education (contributing factors)
- Passive treatments (massage, mobs, manipulation, taping, EPA)
- Active treatments (home exercise)
- Lifestyle (PA, stress management)
What can treatment of thoracic spine pain also help?
- Neck pain
- Shoulder ROM
