THORACOLUMBAR Flashcards
True Ribs
Ribs 1-7
False Ribs
Ribs 8-10
Floating Ribs
Ribs 11-12
Caliper Action
11-12 (lateral)
Bucket Handle Rotation
7-10 (forward, backward, and lateral)
Pump Handle Action
1-6 (anteroposterior)
Spondylosis
degenerative changes in the intervertebral disc
Spondylolysis
defect in the pars interarticularis or arch of vertebra
Spondylolisthesis
anterior displacement
Retrolisthesis
backward displacement
Lumbarization
S1 becomes the sixth lumbar vertebrae
Sacralization
L5 fuses with sacrum and coccyx
Lumbar Facet
carries 20-25% of axial loading
T7
greatest spinous process angulation; upper limb rotation alternates with lower limb rotation
Annulus Fibrosus
outer layer; strength and torsional movements
Nucleus Pulposus
85-90% of water; decreases to 65% with age; avascular; slightly posterior
Schmorl’s Nodules
herniations of nucleus pulposus
Disc Protrusion
disc bulges posteriorly without rupture of annulus fibrosus; affects nerve root below
Disc Prolapse
annulus fibrosus contains the nucleus
Disc Extrusion
annulus fibrosus is perforated and disc material flows into the epidural space
Sequestrated Disc
discal fragments form outside the disc proper
Cauda Equina
saddle anesthesia; bladder/ bowel dysfunction
Lifting a 20kg with back bent and knees forward
169% of disc pressure at L3
Walking
15% of disc pressure at L3
Coughing or Straining
5-35% of disc pressure at L3
Bending Forward
150% of disc pressure at L3
Scheuermann’s Disease
13-16 years old
Idiopathic Scoliosis
adolescents
Lumbar Disc Problems
15-40 y/o
Ankylosing Spondylitis
18-45 y/o
male
Spondylosis and OA
> 45 y/o
Malignancy
> 50 y/o
Scoliosis and LBP gender predisposition
females d/t menstruation
(ask: changes in menstruation, altered pain pattern, irregular menstruation, swelling of abdomen and breast)
Pain in thoracic disc lesion
no pain in active movements
Pain in nerve root/ spondylosis of thoracic
“through the chest pain”
Pain in breathing
pulmonary issues; trauma, structural deformities, thoracic pathologies
Pain referred around the chest
costovertebral in origin
Pain on true thoracic ribs
Localized
Constant ache
mechanical, inflammation
Pain on movement
mechanical stimulus
Pain accumulates with activity
repetitive mechanical stress, inflammation, and degenerative disc
Pain increases with sustained posture
fatigue on supporting muscles, gradual creep of tissues
Latent nerve root pain
Movement produces acute and temporary neuropraxia
Facet syndromes
local pain but can also be referred; ROM is same (restricted from the beginning)
Mechanical LBP/ Lumbago
unilateral with no referral to knee (muscle strain/ sprain);
Muscles and Ligaments Affectation
movements will decrease and pain will increase
Bilateral pain
disc injury, central protrusion, spondylolisthesis, spinal stenosis, metastasis
Thoracic Nerve Pain
severe referred in a sloping band along intercostal space
Lumbar Disc Protrusion
pain in back and buttocks
Lumbar and Sacroiliac Pain
back and posterior leg (lateral aspect)
Hip Pain
groin and anterior thigh (medial side of knee)
Pressure on nerve root sheath d/t disc lesion
pain followed by paresthesia
Paresthesia without pain
cord compression, diabetes, pernicious anemia, multiple sclerosis
Upper lumbar/ lower thoracic disc lesions
septic, metabolic disorders, tumors, rheumatic inflammation
Dural Pain
coughing, sneezing, straining on thoracic region
extra segmental and felt at larger areas in the lumbar
Radicular Pain
felt on 1 dermatome in lumbar
Aggravating Movements in Thoracic
active use of arms
pushing and pulling
Costal Pain
overhand arm motions and breathing
Intrathecal Pressure
lumbar spine affectation (neurological tissue)
Disc Pathology
inc in sitting, light twisting, and bending
Relieving Factors in Thoracic
raising or bracing arms facilitates accessory muscles of respiration
Acute Back Pain
3-4 weeks
Subacute Back Pain
up to 12 weeks
Chronic Back Pain
> 3 mos
accompanied by deconditioning syndrome
Predictors of Chronicity within 6-8 weeks of Back Pain (Yellow Flags)
nerve root pain/ spinal pathology
severity of pain during acute phase
beliefs about pain being work related
psychosocial aspects of work
psychological distress
compensation
time off work
longer someone is off work= lower probability to return to work
Sitting upright into full extension
facet pathology
Sitting increases pain
sustained flexion causing mechanical deformation of the spine/ discogenic pain
Forward flexed posture
anterior vertebral compression fx
Pain on standing relieved by walking & pain on forward flexion s substantial muscle spasm
disc involvement in lumbar spine
Pain inc in relaxed standing, walking, and prone
extension as cause of pain
Stiffness or pain after rest
Ankylosing Spondylosis or Scheuermann’s Disease
Unilateral pain in upper sacroiliac region or groin in extension
Iliolumbar Ligament
Difficulty in moving into a seated position
lumbar instability or lumbar muscle spasm
Progressive pain in supine or no relieving position
neurogenic or space occupying lesion
Postural/ Static
spasm or adaptive shortening (iliopsoas)
Phasic/ Dynamic
abdominals (atrophy)
Referred pain for costovertebral, costotransverse, and ribs
along the ribs
Referred pain for lumbar/ SI
buttocks, posterior leg, or lateral aspect of leg
Referred pain for cardiac
C4-T2 (posteriorly)
Referred pain for stomach
T6-T8 posteriorly
Referred pain for ulcers
T4-T6
Visceral pain
abdominal structures: stomach, liver, pancreas
vague, dull, discrete
follows dermatome
accompanied by nausea
Centralization
centered on lumbar spine
no radiculation
mechanical LBP
Peripheralization
moves to the limb
Mechanical Low Back Pain
cyclic pain
referred to buttocks and thighs
morning stiffness and pain
start pain
pain in forward flexion and returning to erect position
aggravated by extension, side flexion, rotation, walking, standing, sitting, and exercise
relieved by lying down (fetal position) and change in position
pain worsens throughout the day
4 Categories of LBP
Mechanical LBP/ Back Pain
>disc involvement
>facet joint involvement (strain)
Non-Mechanical LBP/ Leg Pain
>nerve root involvement
>neurogenic intermittent claudication
Waddell’s signs
pts that need more intense psychosocial examination
Acute Back Pain
some degree of antalgic painful posture
loss of lumbar lordosis
lateral shift
involuntary d/t muscle spasm
Spinal Dysraphism
incomplete fusion of the spinal neural tube; manifests as excessive midline hair
Herpes Zoster (Shingles)
unilat pain on thoracic spine that manifests with erythema
Cafe Au Lait Spots
neurofibromatosis or collagen disease appearing like a birthmark
Spina Bifida Oculta
faun’s beard tuff along the spine that can indicate dystrophies
Step Deformity in the Lumbar Spine
Spondylitic Spondylolisthesis: vertebra above
Spondylolytic Spondylolisthesis:
affected vertebra
Normal Alignment of the Scapula to the Thoracic Spine
medial edge: T3
inferior angle: T7-9
medial border: ~5cm lat to spinous process
Breathing
children: abdominally
women: upper thoracic
men: upper and lower thoracic
aged: lower thoracic and abdominally
Pigeon Chest/ Pes Carinatum
sternum projects downward and forward
increased anteroposterior diameter
restricting ventilation volume
Funnel Chest/ Pes Excavatum
sternum projects posteriorly due to overgrowth of ribs
anteroposterior diameter is decreased
when breathing, sternum is depressed and kyphosis
Barrel Chest
common in pts c emphysema
sternum projects forward and upward
increased anteroposterior diameter
Depressed Rib in Breathing
in inhalation, ribs stopped moving relative to others
highest restricted rib
Elevated Rib in Breathing
in exhalation, ribs stopped moving relative to others
lowest restricted rib
Rib Spring
pain when stressing the joint; sign of hypomobility
Anteroposterior Movement Palpation
pt supine; PT’s hands on upper chest
Lateral Movement Position
from axilla to the lateral aspect of rib cage
check for pump handle, bucket handle, and caliper action when breathing
Structural Rib Dysfunction
subluxation or dislocation
Torsional Rib Dysfunction
hypomobility or hypermobility
Respiratory Rib Dysfunction
hypomobility of the intercostal spaces, costovertebral, costotransverse
Rib Hypermobility
elevates relative to the transverse process
Rib Hypomobility
stops to move before thoracic spine
Anterior Subluxation of Rib
less prominent rib angle
Posterior Subluxation of Rib
more prominent rib angle
Superior First Subluxation of Rib
superior aspect of first rib is elevated
Anterior Posterior Rib Compression
less prominent rib angle and prominent axillary line
Lateral Compression of Rib
more prominent rib angle and less prominent midaxillary line
External Rib Torsion
superior border is prominent
Internal Rib Torsion
inferior border is prominent
Inhalation Restriction
rib angle cease rising
Exhalation Restriction
rib angle stops falling
Kyphosis
normal 20-40 deg
inc with age (>40 y/o); specifically in females
check for T4-T12 angle (cobb’s method)
Hyperkyphosis
> 40 deg
limited forward flexion
Round Back Posture
dec pelvic inclination of about 20 deg
kyphosis
Structural Kyphosis
d/t tightened muscles from prolonged posture or structural deformities
compensate and maintain center of gravity
Scheuermann’s Disease
adolescents; structural kyphosis
Gibbus/ Hump Back Deformity
sharp posterior angulation of one or two thoracic vertebrae
structural kyphosis
pelvic inclination is normal (30 deg)
Flat Back Posture
decreased pelvic inclination of 20 deg
mobile thoracic spine
no presence of excessive kyphosis
Dowager’s Hump
postmenopausal osteoporosis
anterior wedge of upper and middle thoracic spine
decreased height
Non Structural or Functional Scoliosis
mechanical or muscle spasm
scoliotic curve disappears on forward flexion
straight shift
Structural Scoliosis
genetic, idiopathic, congenital problems (spine affectation)
scoliotic curve maintains on forward flexion
compensating curves that does not disappear
lateral shift
Convex
ribs pushed posteriorly (posterior rib hump)
vertebral body
ribs are farther apart
lamina is thicker
intervertebral disc is wider
vertebral canal is wider
Concave
ribs pushed anteriorly
spinous process
ribs are closer together
lamina is thinner
intervertebral disc in narrower
vertebral canal is narrower
Dextroscoliosis
convexity on right
Levoscoliosis
convexity on left
Torticollis
apex on C1-C6
Cervicothoracic Curve
apex on C7 or T1
Thoracic Curve
apex between T2-T11
Thoracolumbar Curve
apex at T12 or L1
Lumbar Curve
apex bet L2-L4
Lumbosacral Curve
apex at L5 or S1
Normal Pelvic Tilt
10-13 deg
Severe Scoliosis/ Razorback Spine
ribs rotate even in quiet standing
Pelvic Crossed Syndrome
excessive lordosis
weak long dynamic muscles (inhibited): abdominals & g max
short strong postural muscles (tight): back extensors (erector spinae) and hip flexors (iliopsoas)
Layer Syndrome
upper and lower crossed syndrome
C7-T12 (Thoracic Level)
2.7 cm/ 1.1 inch diff in flexion and extension
2.5 cm/ 1 inch diff in extension
C7-S1(Thoracolumbar Level)
10 cm/ 4 inch diff
T12-S1
most movement occurs
~7.5 cm/ 3 inch diff
Modified Schober’s Test (Lumbar Flexion)
PSIS level
10 cm above
5 cm below
Fingertip to Floor (Lateral Flex)
no standard value; both sides should be equal
Forestier’s Bowstringing Sign
tight ipsilateral paraspinal muscles during side flexion
presence of ankylosing spondylitis
Limited lateral flexion and rotation
internal joint capsular problem
Limited lateral flexion
inside the joint
Limited extension and rotation
facet syndrome
Instability Jog
sudden rippling of the muscle during active movement= instability
SLR difference in sitting and lying
10-20 deg difference
Capsular Pattern in the Spine
lateral flexion= rotation > extension
End feel
tissue stretch on all four movements
Active Movements on Thoracic Spine
forward flexion: 20-45 deg
extension: 25-45 deg
lateral flexion: 20-40 deg
rotation: 35-50 deg
costovertebral expansion (breathing) : 3-7.5 cm or 1-3 inch
Active Movements of the Lumbar Spine
forward flexion: 40-60
extension: 20-35
side bending: 15-20
rotation: 3-18
Myotomes
L2: hip flexion
L3: knee extension
L4: ankle dorsiflexion
L5: great toe extension
S1: ankle plantar flexion, eversion, hip extension
S2: knee flexion
Chest Expansion
Method 1: 4th intercostal space
Method 2: at 3 levels
>axilla: apical expansion
>nipple area/ xiphisternal joint: mid thoracic
>T10: lower thoracic
L5-S1
most common site problem
bears more weight
CoG passes through
transition between vertebra
Dermatomes of Lower Limb
L1: inguinal area and sup aspect of medial thigh
L2: middle or lateral ant thigh
L3: medial condyle of femur running inferomedial across the thigh
L4: medial malleolus and anterolateral aspect of the leg
L5: dorsum of the foot at the 3rd MTP
S1: lateral aspect of calcaneus
S2: midpoint of popliteal fossa
S3: horizontal gluteal piece
S4-5: perianal region
Reflex Testing
patella: L4-L5
medial hamstring: L5-S1
lateral hamstring: S1-S2
posterior tibial: L4-L5
achilles tendon: S1-2
Thoracic Nerve Root Symptoms
epigastric area: T7-T8, T10-11
umbilical area: T10-T11
nipple area: T5
groin: T12
Differences in pain perception
skin: superficial, sharp, precisely localized, burning
chest: intermediate in localization and depth, aching, sharp, dull
thoracic viscera: vague, diffuse, deep, aching, dull
