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PTRS 845 > Thoracic spine > Flashcards

Thoracic spine Flashcards

1
Q

What is the prevalence of thoracic spine pain?

A

Spinal pain in general population: 66%
LBP: 56%
Neck- 44%
Thoracic- 15%

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2
Q

What are the rule of 3 with thoracic surface anatomy?

A

SP of T1-3 @ same level as TP
SP of T4-6 @ 1/2 level below level of TP
SP of T7-9 @ 1 level below level of TP
SP of T10-12 @ same level of TP

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3
Q

What is osseous anatomy of TS?

A

Highest vertebrae share commonalities with CS
Lowest vertebrae share commonalities with LS
Thoracic vertebrae A/P and transverse dimensions of the vertebral bodies are a uniform ratio
Height is slightly higher posteriorly

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4
Q

What are orientation of facet joints in TS?

A

Joints are synovial and planar.
Primarily oriented in frontal plane
Superior articulation: 60 degrees above horizontal and 20 degrees from the frontal plane laterally
Inferior articulation: match superior and face anterior, inferior, and slightly medially

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5
Q

What are the disc ratios in the body?

A

CS: 2:5 (28.5%)
TS: 1:5 (16.6%)
LS: 1:3 (25%)

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6
Q

What are attachments of ribs 1 and 2?

A

1: no superior portion of CVJ, attaches to sternum under SC joint
2: CVJ with demifacets above and below, attaches anterior at sternomanubrial junction

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7
Q

What are attachments of ribs 3-7?

A

Typical posterior attachment, direct attachment to sternum anteriorly

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8
Q

What are attachments of ribs 8-10?

A

Typical posterior attachment, attach to sternum via costocartilage of 7th rib anteriorly

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9
Q

What are attachments of ribs 11-12?

A

no articulation with superior vertebra, no CTJ, no anterior articulation

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10
Q

What is neurological supply of thoracic spine?

A

Each thoracic spinal nerve divided into anterior and posterior primary rami exiting below its respective vertebra.
Anterior rami travels along each relative nerve and becomes the intercostal nerve (supplies internal/external intercostals and serratus posterior)

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11
Q

What is posterior rami divided into?

A

Divided into medial and lateral branches

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12
Q

What does lateral branch of posterior rami nerve supply?

A

longissimus, iliocostalis, costotransverse joints

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13
Q

What does medial branch of posterior rami nerve supply?

A

upper 6 levels: semispinalis, multifidus, skin of upper back
Lower 6 levels: transversospinalis, longissimus
Every level: facet joints above and below that level

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14
Q

What are sinuvertebral nerves in TS?

A

small nerves that branch from the spinal nerve near the origin of the anterior and posterior rami and then re-enter the intervertebral foramen

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15
Q

What does sinuvertebral nerve supply?

A

PLL, proximal ribs and outer fibers of disc, venous plexus, post vertebral bodies, anterior aspect of laminae, the dura
Has spinal root and sympathetic root

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16
Q

What is path of sympathetic chain in TS?

A

lies anteriorly along rib heads and costovertebral joints

Thoracic dysfunctions may lead to sympathetic and visceral symptoms

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17
Q

What is the critical zone in the TS?

A

Spinal canal is more narrow in the mid thoracic spine (T4-T9).
Decreased blood supply (only one blood vessel, anterior spinal artery, supplies this area)
Disc herniation/injury can lead to central spinal cord compression here causing tension along the path of a nerve
T6= tension point (positive slump)
Treat with mobilization and manipulation

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18
Q

What are the thoracic pain and referral patterns?

A

Facet joints- 1/2 segment superior to 2.5 segments distal and slightly lateral
Clowards areas: cervical disc dysfunction will radiate to medial scapular border and T spine
60% incidence of osteophyte encroachment of costovertebral on sympathetic chain

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19
Q

Where is pain with dissecting thoracic aneurysm, CAD, Peptic ulcer?

A

Aneurysm: sudden chest pain radiating to back that’s unrelenting, emergency
CAD: anterior chest pain, has CPR
Ulcer: boring pain to mid T-spine after eating

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20
Q

What is CPR of CAD?

A 
Age (>65 for females, >55 for males)
Known for vascular disease
Pain worse during exercise
Not reproduced with palpation
Patient feels that it is cardiac in nature
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21
Q

What are serious conditions associated with thoracic pain?

A

Cancer historical information (history of cancer, age over 50, failure of conservative therapy, unexplained weight loss)
Ankylosing spondylosis (chest expansion 30 minutes, improvement of back pain with exercise but not with rest, awakening because of back pain during second 1/2 of the night only, alternating buttock pain)
Fever for infection

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22
Q

What happens during flexion/extension of TS?

A 
Superior vertebral body translates anteriorly and rotation anteriorly in sagittal plane.
Posterior rib translates superiorly
Anterior rib translates inferiorly
Anterior rotation of rib
Reverses for extension
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23
Q

What happens when TS rotates?

A

Greatest in upper segments and reduced in lower
Coupled SB: ipsilateral in upper TS, opposite in lower
Ipsilateral rib translates inferiorly and rotates posteriorly
Contralateral rib translates superior and rotates anteriorly

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24
Q

What happens when TS side bends?

A

Most limited in upper segments and increases in lower segments
Ipsilateral rib moves inferiorly and rotates posteriorly
Contralateral rib moves superiorly and rotates anteriorly
Ipsilateral facet joint extends and glides inferolaterally
Contralateral facet joint flexes and glides anteromedially

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25
Q

What is thoracic spine and rib movement during respiration?

A

Sagittal view: pump handle movement (ribs 1-6)
Frontal view: bucket handle (ribs 7-10)
Transverse view: caliper movement (ribs 11-12)

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26
Q

What are coupled movements in TS?

A 
Cervicothoracic region (C7-T1, T1-T2): SB and rot occurs on same side
Thoracolumbar region (T11-12, T12-L1): SB and rot occurs on opposite side
Mid TS region: variable coupling of SB and rot
T2-7: extend, rotation and SB to ipsilateral side with full elevation of arm
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27
Q

What are neurodynamic problems with TS?

A

Sympathetic chain is tensioned during flexion, contralateral rotation, contralateral SB
@T6 in slump position the cord is tensioned cranially toward C-spine and caudally toward L-spine
T4 syndrome- stiffness @ T4 causing HA, neck pain, UE pain, bilateral stocking glove paresthesias

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28
Q

What are pathomechanics of TS ?

A

Flexion movement impairment: most often in upper TS, relative reduction of kyphosis, rear impact injury, can be unilateral
Extension movement impairment: more common in CT junction and highest segments, excessive kyphosis posture, if advanced age and chronic vertebral bodies may become wedge shaped

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29
Q

What are rib pathomechanics?

A

Superior subluxation: first rib, limit painful caudal glide, progress to thoracic outlet if bad enough
Anterior subluxation: traumatic blow to posterior chest wall, may be able to palpate prominence of rib anteriorly or concavity posteriorly
Posterior subluxation: anterior chest wall trauma, most treatments are mobilization or manipulation

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30
Q

For objective assessment of TS what is part of your postural assessment?

A

Hips- level greater trochanters, asymmetry of hips in frontal or transverse plane
Pelvis- pelvic obliquity, A/P rotation of pelvis, SLS
L-spine- curvature in sagittal plane, mm tone, tenderness to palpation
T-spine- scapular positioning, curvature in sagittal/frontal plane, looking at each region independently, verticality of spine (acromion in line with GT), shoulder height
C-spine- forward head posture, asymmetry in C-spine tone, vertical neck

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31
Q

What are parts of motion analysis in TS assessment?

A 
Standing tri-planar movement of trunk- lumbopelvic rhythm, symmetrical rotation/SB, inclinometer measurements, combined movements, single leg stance
Seated thoracic spine active movement
Scapulohumeral rhythm
Cervical motion analysis
Gait analysis
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32
Q

What is part of palpation assessment in TS?

A

muscle tone of paraspinals/trigger points
PPAVM and PPIVM- central PA/unilateral PA/rib screws
First rib mobilization assessment
Cervical traction/compression
Rib expansion assessment in seat position
Skin mobility- gliding and rolling in various directions

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33
Q

What is part of strength assessment in TS?

A 
Seated in "collar up" position
Prone trunk extension endurance test
Cervical/lumbar flexor endurance test
Resisted rib expansion testing
Scapular stabilizer MMT
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34
Q

What is the number 1 thoracic spine problem mark sees in the clinic?

A

Thoracic pain associated with something else

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35
Q

Who gets thoracic vertebral fractures and how?

A

Often associated with osteoporosis or impact injuries

Most frequent in 5th decade and afterward

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36
Q

What are objective findings for vertebral fractures?

A

Tends to be in kyphotic position

Extension activities may help reduce stress on vertebral body and increase blood flow to area

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37
Q

What is treatment for vertebral fractures?

A

Safely restoring function while preserving integrity of healing
Surgical vertebroplasty is option but research shows it’s no better than sham

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38
Q

What is functional scoliosis?

A

Lateral curvature w/o rotational component

Curvature can be corrected by changing patient position

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39
Q

what causes functional scoliosis?

A

Can be lead to by mm spasm, inflammatory conditions, injuries, hamstring injury, nerve root

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40
Q

How do you treat functional scoliosis?

A

Treat underlying cause and the scoliosis will resolve

Stretch concave side, strengthen convex

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41
Q

What is structural scoliosis?

A

Lateral curvature with rotational component
Does not change with position
Vertebral bodies can become wedge shaped in frontal plane

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42
Q

What is cause of structural scoliosis?

A

Congenital, secondary to a neurological disorder, or idopathic

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43
Q

What is treatment of structural scoliosis?

A

Curves irreversible

Work on managing symptoms

44
Q

What are treatment ideas for scoliosis?

A 
Stretch shortened high tone concave side
Strengthening stretched out convex side
Postural correction training
Bracing
Surgical intervention
45
Q

What is the thoracic outlet?

A

space between clavicle and first rib

subclavian artery and brachial plexus

46
Q

What causes thoracic outlet syndrome?

A

Due to elevated or abnormal first rib after a traumatic injury or overuse of repetitive overhead activities

47
Q

What are symptoms of thoracic outlet syndrome?

A

Nerve symptoms
Blood vessel symptoms
Difficulty with overhead activities

48
Q

What are nerve symptoms of thoracic outlet syndrome?

A

vague aching pain in neck, shoulder, arm, or hand
May also cause pain, numbness, or tingling on inside of forearm and the 4th/5th fingers of hand especially with shoulder elevation.
Weakness may make hands clumsy

49
Q

What are blood vessel symptoms of thoracic outlet syndrome?

A

reduced blood flow resulting in swelling and redness of your arm and hands
May feel cool and easily fatigued

50
Q

What is treatment of thoracic outlet syndrome?

A

first rib mobs, scalene stretch, pec stretch, soft tissue mobs, strengthening mid and lower traps

51
Q

What is cause of flattened upper thoracic spine

A

increasd tension in the nervous system; stiff surrounding joints; natural posture
history of MVA and whiplash

52
Q

What are signs of flattened upper thoracic spine?

A

Stiffness of CTJ and mid thoracic (T3-7)
Flexion restriction
May lead to constant loading of joints and mid back pain

53
Q

What is treatment for flattened upper thoracic spine?

A

Unload joints, improve mobility, scapular and thoracic stability

54
Q

Who gets generalized upper/mid thoracic stiffness?

A

Middle or older aged person

55
Q

What is cause of generalized upper/mid thoracic stiffness?

A

prolonged acquired posture, natural posture, metabolic changes

56
Q

What are objective findings of generalized upper/id thoracic stiffness?

A

generalized stiffness at multiple levels, loss of elastic end-feel, limited arm elevation, stiff and painful accessory glides, muscle imbalance

57
Q

What is treatment for generalized upper/mid thoracic stiffness?

A

mobilization, flexibility, strengthening, posture education, breathing techniuqes

58
Q

Can thoracic spine have referred pain?

A

can refer pain and paresthesia to th ehead, upper limbs, and hands

59
Q

What does sympathetic nervous system have to do with thoracic spine and referred pain?

A

sympathetic outflow to head is supplied by T1-4 and upper limb is supplied by T2-5
Due to sympathetic ganglion, the SNS could be pathway for referral from the thoracic spine to upper limb

60
Q

What are subjective findings for T4 syndrome?

A

parasthesis, altered and extreme temperature perception and puffiness in the glove distribution of both hands
intermittent posterior thoracic pain or pain around the scapula region

61
Q

What are aggravating and relieving factors of T4 syndrome?

A

symptoms worse last thing at night or with activities involving thoracic flexion/slumping
Position of comfort tends to be laying completely flat

62
Q

What are postural objective findings for T4 syndrome?

A

Increased cervical lordosis and cervico-thoracic kyphosis

Flattened and restricted upper thoracic spine (T2-7)

63
Q

What are findings with palpation for T4 syndrome?

A

Local tenderness and symptoms reproduced with mobilization of spine anywhere between levels T2-7 (historically T4)

64
Q

What are mobility findings of T4 syndrome?

A

Minimal thoracic movement during single arm elevation to either side
Local hypomobility of vertebral segment associated with symptoms

65
Q

What are nerve objective findings for T4 syndrome?

A

Positive ULTT

Positive slump test

66
Q

What is treatment for T4 syndrome?

A 
Central or unilateral PA
soft tissue work
rib mobility
mobility exercises
posture training
67
Q

What are symptoms and aggravating factors for costal joint derangement?

A

Pain with breathing, trunk rotation, unilateral PA over CTJ, pain and stiffness with rib mobility
Aggravated by twisting or reaching

68
Q

What is costal joint derangement?

A

reduced costal mobility–>rotation

69
Q

What is treatment for costal joint derangement?

A

limit trunk rotation in acute stage, rib mobilize and exercise in chronic stage, soft tissue work

70
Q

What are causes of elevated first rib?

A

chronic neck pain

poor posture

71
Q

What is the rib vulnerable too?

A

vulnerable to superior movement due to lack of superior supporting ligament at the costotransverse joint
Scalenes attach to ribs 1 and 2

72
Q

What are symptoms for elevated first rib?

A

trapezius spasm, neck pain, headaches, shoulder pain, radiculopathy, jaw pain, mid back pain, chest and sternal pain.
TOS
End range cervical rotation limits and shoulder elevation

73
Q

How do you test the first rib?

A

stabilize first rib
rotate head to contralateral side
side bend to ipsilateral side
positive sign: pain at rib, decreased ROM, firm end feel

74
Q

What are symptoms of rib subluxation?

A

localized pain, reduced motion during inspiration/expiration, coughing and sneezing; local muscle spasms

75
Q

What is treatment for rib subluxation?

A

rib mobilization/manipulation, MET, posture training, soft tissue work

76
Q

What are signs of anterior or posteriorly subluxed rib?

A

anterior: concavity of rib posteriorly
Posterior: prominence of rib posteriorly

77
Q

What are signs and symptoms of thoracic disc lesions?

A

Pain may be isolated to upper back or radiate in dermatomal pattern
Pain shooting around or through chest wall
Possible sensory deficits (numbness/tingling below herniated level, neurological weakness in LEs)

78
Q

What are aggravating factors of thoracic disc lesions?

A

any movements, deep breathing, cough/sneeze

79
Q

What are causes of thoracic disc lesions?

A

Acute- forceful rotation injury
Chronic- degenerative changes
Most occur in lower TS levels
about 15% of population

80
Q

What are objective findings of thoracic disc lesions?

A 
local muscle spasms
\+PA
\+AROM
\+UMN/LMN
\+/- slump
\+Beevor's sign (T10-12)
81
Q

What is treatment for thoracic disc lesions?

A

traction, mobilization, breathing exercises, position and posture exercise, cervical and/or lumbar core strengthening

82
Q

What is Tietze’s syndrome?

A

Chostochondritis- localized irritation of costosternal joint (2nd rib)
Includes swelling of costal cartilages (costochondral junction)

83
Q

What are causes of Tietze’s syndrome?

A

rib lesion, inflammation, viral infection, repetitive movement

84
Q

What are symptoms of Tietze’s syndrome?

A

Anterior chest pain, localized and superficial, worse with breathing and trunk movement
hypomobility of TS
Pain and swelling over joint

85
Q

What are treatment for Tietze’s syndrome?

A

Usually resolves in 12 weeks

Treat posterior lesion, RICE, ice, anti-inflammatories

86
Q

What is ankylosing spondylitis?

A

Systemic rheumatic disease causing inflammation of spine.

Gradual onset, progressive stiffness-fusion of joints

87
Q

Where does ankylosing spondylitis occur?

A

starts in SI and migrates up spine

young people

88
Q

What are symptoms of ankylosing spondylitis?

A

pain, limited chest excursion, limited spinal mobility, X-ray, +bone scan

89
Q

What is treatment for ankylosing spondylitis?

A

mobility exercise and active life style

90
Q

What is cause of osteoporosis?

A

female, body size, use of steroids, lack of nutrition, and exercise

91
Q

How does osteoporosis affect TS?

A

wedging and increased kyphosis, compression fracture of TL vertebrae and ribs

92
Q

What are symptoms of osteoporosis?

A

symptomless, increase kyphosis and overall loss of height, x-ray, bone scan

93
Q

What are symptoms of compression fracture?

A

Pain with movement, breathing and palpation

94
Q

What is treatment for osteoporosis?

A

weight bearing exercise, muscle strengthening, dietary advice

95
Q

What is pathology of osteoporosis?

A

Fish vertebrae: biconcave appearance of vertebra, indicates osteopenia

96
Q

What is Scheuermann’s disease?

A

Wedging of multiple vertebral bodies.

97
Q

What happens when someone has Scheuermann’s disease?

A

Vertebra grow unevenly in sagittal plane
Deformity progresses until skeletal maturity is reached
More likely to suffer from thoracic disc herniation

98
Q

What are Schmoral’s nodes?

A

small herniation of disc material into the endplate of vertebral bodies

99
Q

What can nodes lead too?

A

Juvenile arthritic kyphoscoliosis/vertebral osteochondrosis

Premature disc degneration

100
Q

What are symptoms of scheuermann’s disease and schorals nodes?

A

pain and stiffness

rigid curved spine

101
Q

What are treatments for scheuermann’s disease and schorals nodes?

A

exercise to improve mobility and back care
bracing
surgical intervention

102
Q

What are general suggested treatments for thoracic spine hypomobility conditions??

A

mobilization/manipulation of appropriate segments and joints followed by appropriate HEP

103
Q

What are general suggested treatments for thoracic spine muscular conditions??

A

stretching and strengthening, patient education, etc

104
Q

What are general suggested treatments for thoracic spine posture conditions?

A

address posture and work situation, HEP

105
Q

What are general suggested treatments for thoracic spine hypermobility conditions??

A

stabilization (strengthening), patient education, check mobility of other joints, treat possible hypomobile segments

106
Q

How do you mobilize ribs?

A

Joint line of costotransverse and costovertebral joints are in general anterior-medial
Mobilize perpendicular to joint line- anterolateral
Stabilize contralateral side to prevent rotation

PTRS 845 (9 decks)

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