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Thoracic Spine, Ribs, & Scoliosis Information Flashcards

1
Q

Important anatomy considerations of Thoracic vertebra

A
  • Oblique spinous processes (limits extension)
  • Overlapping lamina
  • Demifacets (costal facets)
  • Transverse costal facets (T1-10)
  • Transverse process posterior and superior
  • Articular facets
    • 1-6 frontal ( more rotation)
    • 6-12 sagittal (more flexion & rotation)
  • T2-9 heart shaped, superior facet
  • T1 facet more cervical resembling
  • T10-12 only one costal facet
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2
Q

Rib anatomy

A
  • Named for vertebra inferior
  • Costovertebral joint
    • 2-10 articulate with vertebral body & disc
  • Costotransverse joint
    • 1-10 articulate with transverse process
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3
Q

Rib classifications

A

1-7 True ribs
8-10 False ribs
11-12 Floating ribs

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4
Q

Thoracic arthrology

A

Stronger annulus
- limits sagittal motion

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5
Q

Important thoracic musculature

A

Anterior
- Pectoralis major and minor
- Scalenes, SCM
Posterior
- Trapezius
- Levator scapula
- Rhomboids
- Serratus anterior
- Latissimus

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6
Q

Thoracic nervous system considerations

A

Canal is narrower which leads to dural adhesions
T4-9 is the critical zone due to canal narrowness
- T6 is tension point
Sympathetic chain is anterior to rib heads
Viscera & thoracic spine have shared innervation

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7
Q

Thoracic fun facts

A

Majority of rotation occurs here
Stable region
Nerve dysfunction is a ring

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8
Q

Thoracic RoM

A

Flexion: 20-45 (B facet opening)
Extension: 20-45 (B facet closing)
Side bending: 20-40 (ipsi closing)
Rotation: 35-50 (ipsi foramen opening)

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9
Q

Rotation’s effects on the ribs

A

R rotation
- L posterior rib goes up, front down
- R posterior rib goes down, front up

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10
Q

Spondylosis clinical findings

A
  • Pain with PA testing
  • Pain with A/PROM (closing)
  • Pain posterior, lateral; UL
  • May present as chest pain
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11
Q

Rib Sprain

A

History:
- Illness, cough
Reported findings:
- pain in rib cage region
- pain with breathing, coughing, sneezing, laughing, rotation
Examination findings:
- intercostal tissue stretch is painful
- Pain with palpation of sternocostal, costochondral, costotransverse
- Pain with palpation of rib angles
- Pain with palpation of intercostal myofascia

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12
Q

Rib dysfunction

A
  • Asymmetry of motion
  • First rib elevation
  • Subluxation
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13
Q

Rib subluxations

A

Anterior
- sublux of costovertebral joint/anterior sheer
- Palpation of rib more anterior, depression on posterior
- MOI: blows to back, falls, MVA, muscle strain
Posterior
- Rib angle more prominent posteriorly
- Costochondritis pain
- MOI: MVA, surgery, muscle strain

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14
Q

Muscle strain

A

Reported Findings
- Aching or sharp pain in muscle region
Examination findings
- Pain with limitation in muscle length tests
- Pain with limitation in muscle strength tests
- Tenderness upon palpation, potential divot, guarding, or spasm

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15
Q

Disc pathology

A

Occurs on convex side, lower thoracic due to increased mobility

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16
Q

Nerve root pathology

A

Mechanical or chemical irritation
Symptom patterns:
- anterior > posterior
Dural entrapment/adhesion
- vague symptoms up/down spine
- tension point + small container = critical zone
- + slump, SLR

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17
Q

Ankylosing Spondylitis (bamboo spine)

A

Prevalence 0.2%
Late adolescent to early adulthood
Spondyloarthritis of spine and pelvis of unknown etiology
HLA-B27 & other inflammatory diseases
Leads to structural & functional impairments
Affects synovial and cartilaginous joints, tendon, & ligaments

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18
Q

Ankylosis Spondylitis clinical presentation

A

Insidious, progressive
AM stiffness > 30min
Waking up second half of night
Sx inc with rest & dec with activity/exercise
Decreased chest expansion

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19
Q

Ankylosing Spondylitis Diagnosis

A

Increased erythrocyte sedimentation rate
Increased levels of C-reactive protein

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20
Q

Scheurman’s Disease

A

Forward head posture
Rounded shoulders
Flexion contractures
Short hamstrings & protuberant abdomen
Address impairments
Bracing

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21
Q

Dowagers Hump

A

Post menupausal osteoporosis
Trunk weakness
Somatosensory function
Impaired spinal mobility
Multiple compression fractures
Consequences:
- Decreased LE performance
- Decreased balance
- Decreased gait speed
- Increased fall & fracture risk
Treatment:
- Extensor strength

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22
Q

Thoracic fractures

A

Kyphoplasty
- baloon & cement
Vertebroplasty
- cement into fracture
Conservative
- Brace, rest, medication
- 10 weeks of manual therapy, strengthening, & flexibility + tape

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23
Q

Rib fractures

A

Severe pain
Presentation
- breathing pain
- TTP
- +/- Hematoma
- Tap test
- Tuning fork
Treatment
- Rest, NSAIDs
- Splinting & education

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24
Q

Costochondritis

A

Painful chronic inflammation of costochondral junction
Treat hypomobility posterior & lateral
If there is swelling & reddening of skin = Tietzes syndrome
MT + exercise + medical management

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25
T4 syndrome "glove syndrome"
New job/hoby Thoracic dysfunction & SNS influence Diffuse in neck, head, mid back, & UE Dull hand pain +/- neuro signs UL or BL Medical management Mobilizations, TrP, flexibility, postural exercise
26
Thoracic outlet syndrome
UE, chest, neck, shoulder Symptoms are positional, intermittent Compression of brachial plexus, and/or subclavian A & V
27
Where does thoracic pain refer to?
T4-7 = pseudo anginal pain Lower thoracic -> abdomen & iliac crest
28
What is pain here coming from?
Facet pathology Adhesion of dura Neck spondylosis Rib sprain
29
Where is pain here coming from?
Facet pathology Adhesion of dura Neck spondylosis Scoliosis Cervical radiculopathy
30
Where is pain here coming from?
Facet pathology Adhesion of dura Neck spondylosis Scoliosis Cervical radiculopathy
31
Visceral referral pattern to thorax
Heart: T1-5 Lung: T2-4 Stomach: T6-10 Liver & gallbladder: R T7-9 Kidney: T10-L1 Bladder: T10-L2 Male genitalia: TL Appendix: R mid/lower thoracic
32
Acute, pleuritic, red flag considerations in thoracic spine
*PE *Pericarditis *Pleurisy *Tracheo-bronchial pain
33
Acute, non-pleuritic, red flag considerations in thoracic spine
*MI *Aortic dissection *Cholecystitis *Esophageal *Renal disease
34
Non-acute red flag considerations in thoracic spine
Cardiac - Angina GI - Esophageal - Peptic ulcer - Cholecystitis
35
Cardiac pain reports
Squeezing sub-sternal sensation, tightness, pressure
36
Cardiac pain conditions and what to do
Angina pectoris - increased pain with exertion, relieved with rest *eval by physician ASAP Acute MI - intolerable gripping/crushing substernal, diaphoresis and SOB *Send to ER
37
Aortic dissection reports
Sudden/rapid, severe pain not changed by position
38
Aortic dissection objective findings
Distress Pale, or cyanotic BP normal Distal pulses decreased or absent Strong throbbing pulse
39
What to do for aortic dissection
Immediate medical evaluation
40
Pericarditis reports
Mild to severe chest pain, epigastrium and L parasternal Agg: respiration, cough, thoracic ROM Ease: sitting, flexion
41
Pericarditis objective findings
Fever Chills Weakness Tachycardia Cough Pain in trapezius
42
What to do for pericarditis?
Send to ER
43
Esophageal disorder reports & course of action
Reports: - Heart burn Course of action: - Referral to PCP
44
Tracheobronchial pain reports & course of action
Reports: - Dyspnea, dysphonia Course of action: - Referral to PCP - Referral to ED
45
Pulmonary embolism reports
UL swelling and chest pain Dyspnea 80% Hemoptysis 20-30% Tachypnea
46
Pulmonary embolism course of action
Medical emergency, must be treated immediately
47
Cholecystitis Reports
Pain - Paroxysmal (sudden) or gradual, severe - 1-2hr after heavy meal, resolves in 10 hours - RUQ of abdomen, R subscapular Other - Moderate fever - Chills - Distress - Murphy's sign (R upper quadrant tenderness worsens with deep inspiration)
48
Cholecystitis course of action
ED or PCP
49
Peptic Ulcer reports
Burning in epigastrium or LUQ Boring sensation through back Perforation -> pain in shoulder 1-2hr after meal
50
Peptic ulcer course of action
PCP
51
Renal disease reports
Genitourinary: costovertebral angle Acute inflammation will have signs of UTI then flank pain No relief with change in position Fever, chills, sweats Pain with percussing CV angle
52
Renal disease course of action
Send immediately to physician
53
Red flags of thorax sources, fracturs
Compression fractures Acute pain from trivial strain in >60 * can treat but good idea to send to team
54
Red flags of thorac sources, inflammatory disorders
Ankylosing spondylitis Morning pain & stiffness Peripheral joint involvement * can treat but good idea to send to team
55
Red flags of thorax sources, inflammatory or systemic disorders
Osteomyelitis Discitis Epidural infection Pericarditis
56
Red flags of thorax sources, neoplastic conditions
>50 History Unexplained weight loss Constant pain without relief Night pain
57
Thoracic spine and ribs considerations
15% of all spine complaints - lifetime prevalence of 77% Limited evidence means we rely on anatomy, biomechanics, SINSS, and the ICF Differential diagnosis is important
58
Evaluation steps for a patient with thoracic spine pain
1. Rule out red flags 2. ID regional pain source: (upper t/s vs lower c/s) - Avoid over analysis of pathoanatomy 3. ID impairments and classify - Mobility restrictions *mechanical thoracic *mechanical rib *muscle length - Movement impairments *balance of strength *form & quality of movement
59
Subjective questions for thoracic pain
History: MOI Medical history Area of symptoms - Behavior, nature, severity Aggravating factors - Beware of constant pain Red flag screen - Night pain, chest pain, abdominal pain, neurologic symptoms Diagnosis
60
Screening questions for thoracic spine
Pain pattern with: - Movement or posture (MSK) - Respiration (rib, pleuritic) - Eating/drinking (gastric) - Exertion (rib, cardiac) Bowel & bladder
61
Regional interdependence cervical spine CPR
Symptoms <30d No symptoms distal to shoulder Looking up is not an agg FABQ PA <12 Diminished upper thoracic kyphosis Cervical extension ROM <30
62
Regional interdependence shoulder management CPR
Pain free shoulder flexion <120 Shoulder IR <53 Negative neers test Not taking medication Symptoms <90 days
63
What is scoliosis?
3 dimensional deformity Deformity in the coronal plane of the spine >10 May alter sagittal plane Spinal rotation causes posterior prominence
64
How is the anatomy changed with scoliosis?
All bony elements are altered - vertebra are wedge shaped - rib vertebral angle altered - pedicles rotated Discs are wedged was well
65
Types of scoliosis
Congenital Neurological - CP Syndrome related - Marfan's syndrome Idiopathic - 80%
66
Where can adult scoliosis come from?
ASA (adolescent scoliosis in adults) - pre-existing scoliosis carried over from childhood Neuomuscular: - PD - MS DDS (degenerative De-Novo Scoliosis)
67
Scoliosis classification based on age
Infantile: 0-3 (0.5%) Juvenile: 4-11 (10.5%) Adolescent: 10-17 (89%) Adult: >18
68
Scoliosis classification based on curves
Mild: 10-25 Moderate: 25-50 Severe: >50
69
How is the scoliosis curve pattern defined?
By the direction of convexity and location in the spine
70
Scoliosis terminology
Named by apex - cervical: C2-6 - cervicothoracic: C7-T1 - thoracic: T2-T11 - thoracolumbar: T12-L1 - lumbar L2 down Primary vs secondary Structural (scoliotic) vs nonstructural (unwinds with AROM)
71
How do we diagnose scoliosis?
Uneven shoulder or hip height Rib hump in flexion AROM
72
Rotation of scoliosis
0: no rotation +1: pedicle toward misline +2: pedicle 2/3 to midline +3: pedicle in midline +4: pedicle beyond midline Spinous process rotates into concavity
73
Skeletal maturity by risser sign
0: no ossification at the level of the iliac crest 1: 25% apophysis of iliac crest 2: 25-50% 3: 50-75 4: 75% 5: complete ossification & fusion of the iliac crest apophysis
74
What is the natural history of scoliosis?
If curve <30 at maturity - no adult consequences, unlikely to progress Curves >45 - may progress a degree/yr Curves >90 - right heart failure - decreased pulmonary function
75
When do we treat a patient with scoliosis with an 11-25 degree curve that is at skeletal maturity?
Follow up as needed
76
When do we treat a patient with scoliosis with an 11-25 degree curve that is NOT at skeletal maturity?
Follow up until skeletal maturity every 6 months
77
When do we treat a patient with scoliosis with a 25-45 degree curve that is at skeletal maturity?
Follow up every 5 years to assess progression
78
When do we treat a patient with scoliosis with a 25-45 degree curve that is NOT at skeletal maturity?
Follow up every 4-6 months Consider bracing
79
What do we do for a patient with scoliosis with a >40-50 degree curve?
Consider surgical intervention
80
How long do we brace for scoliosis?
23 hours a day Until skeletally mature
81
What types of braces are there for scoliosis?
Milwaukee Underarm orthosis Charleston nighttime bending brace Rigo cheneau brace (Schroth)
82
Who is scoliosis bracing best for?
Girls More flexible curves Younger patients
83
When is surgery indicated for scoliosis?
Failed bracing Curves >45 Unbalanced curves >40
84
What is the surgery for scoliosis?
Fusion with instrumentation
85
What is the physical exam for scoliosis?
Iliac crest height - leg length discrepancy Shoulder height Arm trunk space Scapular position Trunk shift Inspection os skin - Cafe au lait spots
86
Tell me about Adam's test
It shows rib deformity on the concave side You can use a scoliometer with it It is meant to identify people with scoliosis It is sensitive
87
Whats in the neurologic exam for scoliosis?
Gait Heel and toe walking Myotomes Reflexes Sensation
88
In posture and movement analysis of scoliosis what are you looking for?
If the curve is flexible or rigid If the curve unwinds with motion
89
What are you doing in the palpation and manual assessment of scoliosis?
Assessing bony landmarks Assessing leg length Assessing muscle length Assessing muscle strength Assessing spine mobility - accessory motion testing - cervical/thoracic/lumbar - rib mobility & respiration
90
Physical therapy intervention for scoliosis
Patient education Posture awareness & breathing Strength/flexibility Maintrain/restore joint mobility in adjacent areas Retrain movement

MSK (14 decks)

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