Thoracic Spine, Ribs, & Scoliosis Information Flashcards
Important anatomy considerations of Thoracic vertebra
- 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
Rib anatomy
- Named for vertebra inferior
- Costovertebral joint
- 2-10 articulate with vertebral body & disc
- Costotransverse joint
- 1-10 articulate with transverse process
Rib classifications
1-7 True ribs
8-10 False ribs
11-12 Floating ribs
Thoracic arthrology
Stronger annulus
- limits sagittal motion
Important thoracic musculature
Anterior
- Pectoralis major and minor
- Scalenes, SCM
Posterior
- Trapezius
- Levator scapula
- Rhomboids
- Serratus anterior
- Latissimus
Thoracic nervous system considerations
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
Thoracic fun facts
Majority of rotation occurs here
Stable region
Nerve dysfunction is a ring
Thoracic RoM
Flexion: 20-45 (B facet opening)
Extension: 20-45 (B facet closing)
Side bending: 20-40 (ipsi closing)
Rotation: 35-50 (ipsi foramen opening)
Rotation’s effects on the ribs
R rotation
- L posterior rib goes up, front down
- R posterior rib goes down, front up
Spondylosis clinical findings
- Pain with PA testing
- Pain with A/PROM (closing)
- Pain posterior, lateral; UL
- May present as chest pain
Rib Sprain
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
Rib dysfunction
- Asymmetry of motion
- First rib elevation
- Subluxation
Rib subluxations
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
Muscle strain
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
Disc pathology
Occurs on convex side, lower thoracic due to increased mobility
Nerve root pathology
Mechanical or chemical irritation
Symptom patterns:
- anterior > posterior
Dural entrapment/adhesion
- vague symptoms up/down spine
- tension point + small container = critical zone
- + slump, SLR
Ankylosing Spondylitis (bamboo spine)
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
Ankylosis Spondylitis clinical presentation
Insidious, progressive
AM stiffness > 30min
Waking up second half of night
Sx inc with rest & dec with activity/exercise
Decreased chest expansion
Ankylosing Spondylitis Diagnosis
Increased erythrocyte sedimentation rate
Increased levels of C-reactive protein
Scheurman’s Disease
Forward head posture
Rounded shoulders
Flexion contractures
Short hamstrings & protuberant abdomen
Address impairments
Bracing
Dowagers Hump
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
Thoracic fractures
Kyphoplasty
- baloon & cement
Vertebroplasty
- cement into fracture
Conservative
- Brace, rest, medication
- 10 weeks of manual therapy, strengthening, & flexibility + tape
Rib fractures
Severe pain
Presentation
- breathing pain
- TTP
- +/- Hematoma
- Tap test
- Tuning fork
Treatment
- Rest, NSAIDs
- Splinting & education
Costochondritis
Painful chronic inflammation of costochondral junction
Treat hypomobility posterior & lateral
If there is swelling & reddening of skin = Tietzes syndrome
MT + exercise + medical management
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
Thoracic outlet syndrome
UE, chest, neck, shoulder
Symptoms are positional, intermittent
Compression of brachial plexus, and/or subclavian A & V
Where does thoracic pain refer to?
T4-7 = pseudo anginal pain
Lower thoracic -> abdomen & iliac crest
What is pain here coming from?
Facet pathology
Adhesion of dura
Neck spondylosis
Rib sprain
Where is pain here coming from?
Facet pathology
Adhesion of dura
Neck spondylosis
Scoliosis
Cervical radiculopathy
Where is pain here coming from?
Facet pathology
Adhesion of dura
Neck spondylosis
Scoliosis
Cervical radiculopathy
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
Acute, pleuritic, red flag considerations in thoracic spine
*PE
*Pericarditis
*Pleurisy
*Tracheo-bronchial pain
Acute, non-pleuritic, red flag considerations in thoracic spine
*MI
*Aortic dissection
*Cholecystitis
*Esophageal
*Renal disease
Non-acute red flag considerations in thoracic spine
Cardiac
- Angina
GI
- Esophageal
- Peptic ulcer
- Cholecystitis
Cardiac pain reports
Squeezing sub-sternal sensation, tightness, pressure
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
Aortic dissection reports
Sudden/rapid, severe pain not changed by position
Aortic dissection objective findings
Distress
Pale, or cyanotic
BP normal
Distal pulses decreased or absent
Strong throbbing pulse
What to do for aortic dissection
Immediate medical evaluation
Pericarditis reports
Mild to severe chest pain, epigastrium and L parasternal
Agg: respiration, cough, thoracic ROM
Ease: sitting, flexion
Pericarditis objective findings
Fever
Chills
Weakness
Tachycardia
Cough
Pain in trapezius
What to do for pericarditis?
Send to ER
Esophageal disorder reports & course of action
Reports:
- Heart burn
Course of action:
- Referral to PCP
Tracheobronchial pain reports & course of action
Reports:
- Dyspnea, dysphonia
Course of action:
- Referral to PCP
- Referral to ED
Pulmonary embolism reports
UL swelling and chest pain
Dyspnea 80%
Hemoptysis 20-30%
Tachypnea
Pulmonary embolism course of action
Medical emergency, must be treated immediately
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)
Cholecystitis course of action
ED or PCP
Peptic Ulcer reports
Burning in epigastrium or LUQ
Boring sensation through back
Perforation -> pain in shoulder
1-2hr after meal
Peptic ulcer course of action
PCP
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
Renal disease course of action
Send immediately to physician
Red flags of thorax sources, fracturs
Compression fractures
Acute pain from trivial strain in >60
- can treat but good idea to send to team
Red flags of thorac sources, inflammatory disorders
Ankylosing spondylitis
Morning pain & stiffness
Peripheral joint involvement
- can treat but good idea to send to team
Red flags of thorax sources, inflammatory or systemic disorders
Osteomyelitis
Discitis
Epidural infection
Pericarditis
Red flags of thorax sources, neoplastic conditions
> 50
History
Unexplained weight loss
Constant pain without relief
Night pain
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
Evaluation steps for a patient with thoracic spine pain
- Rule out red flags
- ID regional pain source: (upper t/s vs lower c/s)
- Avoid over analysis of pathoanatomy - ID impairments and classify
- Mobility restrictions
*mechanical thoracic
*mechanical rib
*muscle length
- Movement impairments
*balance of strength
*form & quality of movement
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
Screening questions for thoracic spine
Pain pattern with:
- Movement or posture (MSK)
- Respiration (rib, pleuritic)
- Eating/drinking (gastric)
- Exertion (rib, cardiac)
Bowel & bladder
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
Regional interdependence shoulder management CPR
Pain free shoulder flexion <120
Shoulder IR <53
Negative neers test
Not taking medication
Symptoms <90 days
What is scoliosis?
3 dimensional deformity
Deformity in the coronal plane of the spine >10
May alter sagittal plane
Spinal rotation causes posterior prominence
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
Types of scoliosis
Congenital
Neurological
- CP
Syndrome related
- Marfan’s syndrome
Idiopathic
- 80%
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)
Scoliosis classification based on age
Infantile: 0-3 (0.5%)
Juvenile: 4-11 (10.5%)
Adolescent: 10-17 (89%)
Adult: >18
Scoliosis classification based on curves
Mild: 10-25
Moderate: 25-50
Severe: >50
How is the scoliosis curve pattern defined?
By the direction of convexity and location in the spine
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)
How do we diagnose scoliosis?
Uneven shoulder or hip height
Rib hump in flexion AROM
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
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
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
When do we treat a patient with scoliosis with an 11-25 degree curve that is at skeletal maturity?
Follow up as needed
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
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
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
What do we do for a patient with scoliosis with a >40-50 degree curve?
Consider surgical intervention
How long do we brace for scoliosis?
23 hours a day
Until skeletally mature
What types of braces are there for scoliosis?
Milwaukee
Underarm orthosis
Charleston nighttime bending brace
Rigo cheneau brace (Schroth)
Who is scoliosis bracing best for?
Girls
More flexible curves
Younger patients
When is surgery indicated for scoliosis?
Failed bracing
Curves >45
Unbalanced curves >40
What is the surgery for scoliosis?
Fusion with instrumentation
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
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
Whats in the neurologic exam for scoliosis?
Gait
Heel and toe walking
Myotomes
Reflexes
Sensation
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
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
Physical therapy intervention for scoliosis
Patient education
Posture awareness & breathing
Strength/flexibility
Maintrain/restore joint mobility in adjacent areas
Retrain movement
