Thoracic Spine & Ribs - working Flashcards
Describe a pancoast tumor.
Tumor at apex of lung.
A pancost tumor may involve what neurological structures?
C8-T1
Pancoast tumors present similar to
MSK origin, especially TOS
Symptoms of a pancoast tumor include
- Chronic cough + blood sputum (red flag)
- Unexplained weight loss
- Malaise
- Dyspnea
Pancoast tumor physical exam findings
- Fever
- Wheezing
What non-MSK diagnoses should be included for the thoracic spine?
(Visceral Pain Patterns)
- MI
- Pericarditis
- Pneumothorax
- Abdominal Organs
- Pleuropulmonary disorders
Vertebral body fractures can be divided based on what portion of the vetebrae they involve. What are those parts?
- Anterior column
- Middle column
Posterior component vertebral fractures involved what anatomic structures?
Posterior column
Transverse processes, spinous processes, etc.
Why are vertebral fractures dangerous?
- Increase mortality
- Predictor for subsequent vertebral fractrue (4-5x) and hip fracture (3x)
The three classification elements fo the TLICS include:
- Morphology
- Integrity of Posterior Ligamentous Complex (PLC)
- Neurologic status
The posterior ligamentous complex includes
- Supraspinous ligament
- Intraspinous ligament
- Ligamentum flavum
- Z-joint capsule
3 Morphologies of Vertebral Fractures
- Compression
- Rotation/Translation
- Distraction
Compression vertebral fractrure types
- traditional compression
- Burst
Traditional Compression Fractures
- Stable v unstable?
- What portion of vertebrae involved?
Stable, anterior column
A common mechanism resulting in traditional compression fractures includes:
Axial loading in a flexed position (trauma: high energy v osteoporotic)
Burst Fractures
- What portion of vertebrae is involved?
- Most common region of spine involved?
- Anterior/Middle columns
- T/L junctions (T12/L1)
Common MOI for burst fractures?
high force axial load (+/- flexion)
MVC, Fall from height, high-sport injury
Rotation/Translation vertebral fractures are associated with what MOI?
- Fall from a height
- Heavy object falling on body with bent trunk
What force is involved in a rotation/translation vertebral fracture?
shear + torsion
Which fracture type can result in dislocation of the facet joints?
Rotation/Translation
Distraction Vertebral fractures occur due to
a tensile load
What segments of the spinal column are invovled in distraction vertebral fractures?
Anterior and posterior column.
RED FLAGS associated with vertebral fractures
- Bruising/Abrasions (trauma)
- Older Age
- Significant trauma
- Corticosteroid use
Henschke recommends clustered findings to identify vertebral fractures. They include:
- Age >70 Y
- Significant trauma
- Prolonged corticosteroid use
- Sensory alterations from trunk down
Think trauma!!
Roman proposed clusters of findings that suggest a vertebral compression fracture in the osteoporotic individual, including:
- Age >52 Y
- No presence of leg pain
- BMI </= 22
- Does not exercise regularly
- Female gender
Scheuermann’s Disease
defective growth of vertebral endplate (poor vascularized disc)
Proposed etiology of Scheuermann’s disease includes:
- genetics
- Excessive stress on pre-disposed (weak) endplate
Risk of Scheuermann’s disease increases amoung…
- Manual workers who begin at early age
- High intensity athletes?
- High BMI
- “Short sternum”
What is the criteria for diagnosis of Scheuermann’s disease?
- Thoracic kyphosis >45º
- Wedging x3 adjacent vertebrae >5º
- Thoracolumbar kyphosis >30º
Symptoms of Scheuermann’s disease
- Thoracic pain, commonly apex of curvature
Due to muscular tension, IV disc bulging/spondylosis.
Potentially lumbar pain
Disc Disease is most common where in the T-spine?
Lower T-spine, T8-T12
Physical examination findings of Scheuermann’s disease
- Scoliosis
- Excessive thoracic kyphosis/compensatory hyperlordosis
- Rounded shoulders, forward head
- Pelvic rotation
- Vertebral wedging
- Schmorl’s nodes
- Disc space narrowing
- Limited thoracic ROM
- Neurological complications (less common)
Herniation occuring with disc disease typically occurs where?
- Central
- Lateral
- Posteriolateral
How does disc disease typically occur?
Degeneratively
Symptoms of disc disease include
- Midline back/chest pain that is radicular, band-like in affected level’s dermatome
- Paresthesia/anesthesia that is radicular, band-like in affected level’s dermatome
- Leg pain
- Progressive/insidious (months to years)
Physical exam findings of disc disease
Commonly asymptomatic, but presents variably. Potential for myelopathy.
Health conditions related to thoracic spine myelopathy include?
- Compression Fracture
- Stenosis
Symptoms of thoracic spine myelopathy
- Sexual dysfunction
- Bowel and bladder dysfunction
Physical exam findings for thoracic myelopathy include
- Sensory/motor impairments
- UMN signs LEs
Intercostal Neuralgia etiologies
- Traumatic injury
- Infection
- Mechanical compression (disc protrusion, osteophyte comples, neuroma, fracture)
Symptoms of intercostal neuralgia includes
- Burning pain
- Paresthesia/anesthesia
Occurs along intercostal nerve path
Physical Examination of intercostal neuralgia
- Focal tenderness of intercostal area
- Dermatomal distribution of rash with grouped vesicles and pustules (herpes zoster/shingles)
T4 Syndrome etiology?
Unknown, thought to be a sympathetic reaction with hypomobile segment
What patient population is commonly affected with T4 syndrome?
Women
T4 Syndrome most commonly affects
T2-T7
Primary pain generators with T4 syndrome include
- Thoracic IV disks
- Thoracic Z-joints
Symptoms of T4 syndrome include
- glove-like paresthesias (unilateral or bilateral UEs)
- Neck/scapular/bilateral UE pain (constant or intermittent)
- Pain worsens in side-lying or supine
- Generalizes HA
Physcial Examination findings of T4 syndrome include:
- Tender spinous process
- +Thoracic Slump Test
- +Upper quarter neurodynamic tension tests
- Hypomobile thoracic segment
Scoliosis is named for
the convexity and invovled region based on the patient’s left and right
Scoliosis etiology
- congenital: adolescent idiopathic
- aquired: degenerative
Zygopophysial Arthropathy
Symptoms + Physical Exam
- Local +/- referred pain
- Painful movement with closing Z-joints (AROM=PROM)
- Painful spring testing/hypomobile with joint mobility testing
Scoliosis
coronal and rotational (transverse) spinal deformities
Why do rib fractures raise concern?
Potential for brachial plexus/vascular damage, laceration of pleura, lungs and abdominal organs
What treatment is NOT supported to rib fractures?
Taping/strapping
How long do rib fractures take to become stable?
~6 weeks
Symptoms and physical exam findings of a rib fracture includes:
- Focal pain, radiating pain
- Pain with inspiration
- Pain with coughing/sneezing
- Focal tenderness
- Possible palpable defect
How many rib(s) does costochondritis involve?
1 or more rib
Costochondritis is likely due to ____ and resolves within ______
repetitive stress, one year.
Symptoms and physical exam of costocondritis
- Pain and local tenderness at costochondral or chondrosternal articulations (at rest, trunk movement, respiration)
- Local tenderness
- Painful with chondrosternal joint mobility testing
Rib dysfunction
inflammatory or degenerative health conditions
3 types of rib dysfunction
- Structural
- Torsional
- Respiratory
Structural rib dysfunction
subluxation of joint (anterior or posterior)
Torsional rib dysfunction
- rib held in rotated position
Respiratory rib dysfunction
related to posture, may affect respiration
Rib Dysfunction symptoms and physical exam findings
- Aggravated with deep inspiration, trunk rotation, sneezing/coughing
- Diminished rib mobility (structural)
- Pain/hypomobility with joint testing
- Limited/painful thoracic spine motion
