(7) Functional anatomy, clinical exam, and pathologies of T-spine

Question 1

Why do the thoracic vertebra have extra facets?

Answer 1

Articulations with the ribs

Question 2

Where do the superior and inferior costal facets articulate with?

Answer 2

The head of the rib

Question 3

Where do the transverse costal facets articulate with?

Answer 3

The tubercle of the ribs

Question 4

What joint lies at the superior and inferior costal facet?

Answer 4

costovertebral joint

Question 5

What joint lies at the transverse costal facet?

Answer 5

costotransverse joint

Question 6

What is the bony anatomy of the thoracic spine?

Answer 6

• progressively inferiorly angled (most prominent mid-thoracic)
• Generally sp.pro may be as low as facet joint one spinal level below
• Upper/lower T-spine project more horizontally

Question 7

What are some general guides on the surface anatomy of certain T-spine vertebra?

Answer 7

• T1: 2nd below last moving cervical sp.pro
• T3: in line spine scapula
• T7: in line inferior angle scapula
• T12: in line 12th rib

Question 8

What is the function of the muscles in the thoracic spine?

Answer 8

• Mobility
• Stability
• Proprioception

Question 9

Where does the erector spinae travel from?

Answer 9

3 bilateral columns extending from the skull to the sacrum

Question 10

What are the 3 muscles of the erector spinae?

Answer 10

• spinalis thoracis
• longissimus thoracis
• iliocostalis thoracis

Question 11

What is the function of the erector spinae?

Answer 11

• extension (bilaterally & concentrically)
• lateral flexion (ipsilaterally & concentrically)
• counter balancing postural disturbances

Question 12

What joints connect the ribs and the vertebrae?

Answer 12

• costovertebral
• costotransverse

Question 13

What part of the rib connects to the costovertebral joint?

Answer 13

convex facet on head of rib

Question 14

What part of the rib connects to the costotransverse joint?

Answer 14

the tubercle of the rib

Question 15

What is the normative amount of T-spine flexion?

Answer 15

~30-40 degrees in sagittal plane

Question 16

How does the T-spine move during flexion?

Answer 16

Inf articular facet vertebra slides sup & ant. relative to superior facet below

Question 17

What is the normative amount of T-spine extension?

Answer 17

~ 20-25 degrees in sagittal plane

Question 18

How does the T-spine move during extension?

Answer 18

inf. articular facet of vertebra slides inf post. relative to superior facet of vertebra below

Question 19

What is the normative value for T-spine lateral flexion?

Answer 19

~ 25 degrees in the frontal plane

Question 20

How does the T-spine move during lateral flexion?

Answer 20

inf articular facet of vertebra slides sup (contralaterally) & inf (ipsilaterally) relative to superior facet of vertebra below

Question 21

What is the normative value for rotation in the T-spine?

Answer 21

~ 30 degrees in the axial plane

Question 22

How does the T-spine move during rotation?

Answer 22

inf articular facet of vertebra above slides against sup articular facet of vertebra below

Question 23

What is included in the clinical interview for T-spine?

Answer 23

• PC
• HPC
• DH
• PMH
• SH

Question 24

What are some red flags to look out for during a clinical interview of the T-spine?

Answer 24

• Thoracic myelopathy
• Malignancy
• Infection
• Fracture
• Inflammatory
• Deformity

Question 25

What do you have to be extra cautious of when carrying out a clinical interview with a T-spine patient?

Answer 25

- chest pain - flank pain - abdominal pain - diffuse pain

Question 26

What does a clinical examination for T-spine normally look like?

Answer 26

- observation - AROM - Muscle tests - palpation - if upper or lower T-spine pain, may have to clear cervical & lumbar spine

Question 27

What is looked for during AROM?

Answer 27

- range - symptom response - quality

Question 28

How is a Slump Test carried out?

Answer 28

- patient is asked to sit on edge of bed and slump their back - flex hip ~90 degrees & extend knee - chin to chest - plantar/dorsiflex foot

Question 29

What does the plantarflexion & dorsiflexion do during the Slump Test?

Answer 29

Dorsiflexing the foot loads the dura, whereas plantarflexing the foot will unload it

Question 30

What is non-specific thoracic back pain?

Answer 30

- anything that is not serious or radicular - postural - mechanical (disc, soft tissue, facet)

Question 31

How does non-specific thoracic pain present?

Answer 31

- pain - motion loss - posture - muscle involvement - disability - impact QOL

Question 32

What is scoliosis?

Answer 32

- abnormal lateral curvature (+ rotation) - 'S' or 'C' shaped

Question 33

How does scoliosis develop?

Answer 33

- 65% idiopathic (unknown) - 15% congenital - 10% neuromuscular disease

Question 34

How does scoliosis present on examination?

Answer 34

- variable spine pain - movement restriction - uneven musculature - prominent ribs/scapula - loss of motion

Question 35

What is the Rx for scoliosis?

Answer 35

- None - Exercise Rx (Schroth approach) - bracing - surgery

Question 36

What is Scheuermann's disease?

Answer 36

- Juvenile (hyper-) Kyphosis - altered vertebral body growth - anterior wedging (>5 degrees) in 3/more adjacent vertebral bodies

Question 37

How does Scheuermann's Disease present?

Answer 37

- prominent curvature (with trunk flexion) - pain - rigid kyphosis

Question 38

What is Hyper kyphosis?

Answer 38

When the Cobb angle is >40 degrees (norm 20-40 degrees)

Question 39

What is the Rx for Scheuermann's Disease?

Answer 39

- <60: stretching, mods, NSAIDs - 60-80: extension bracing - >80: surgical opinion

Question 40

What is the Cobb angle?

Answer 40

- line drawn along superior endplate of most tilted vertebrae on cephalad portion - line drawn along inferior endplate on most tiled vertebrae on caudal portion - angle when perpendicular lines cross

Question 41

How is osteoporosis diagnosed?

Answer 41

DXA scan

Question 42

How do osteoporotic fractures of the thoracic spine occur?

Answer 42

- spontaneously (cough or twist) - traumatic (fall) - single / multiple levels

Question 43

How does an osteoporotic fracture present?

Answer 43

- variable pain/disability - older age - localised tenderness - kyphotic

Question 44

What is the Rx for osteoporotic fractures of the thoracic spine?

Answer 44

- analgesia - rest - bracing - +/- physio - meds to optimize bone health

Question 45

What is Ankylosing Spondylitis?

Answer 45

- inflammatory back pain - systemic rheumatic disease - inflammation on sites where tendons/ligaments insert into bone

Question 46

How is ankylosing spondylitis diagnosed?

Answer 46

4 out of 5 - onset <40 yoa - gradual onset - improved exercise - not improved with rest - night pain/waking

Question 47

What are symptoms of ankylosing spondylitis in the thoracic spine?

Answer 47

- inflammation of whiteness in eyes - morning stiffness - imaging - improved with NSAIDs

Question 48

How does thoracic disc syndrome occur?

Answer 48

- less common (less mobile) - lower thoracic - ~70% asymptomatic - localised - +/- radicular

Question 49

What causes thoracic radiculopathy?

Answer 49

- root impingement/compression - disc herniation - metastatic tumour - scoliosis - diabetes

Question 50

What are the symptoms of thoracic radiculopathy?

Answer 50

pain, paraesthesia dermatomal distribution

Question 51

What is Multiple Myeloma?

Answer 51

cancer of plasma cells in the vertebrae

Question 52

What are the symptoms of multiple myeloma?

Answer 52

- vague & variable (easy to miss) - bone pain (lytic bone lesions) - fatigue - night sweats - decrease in appetite - weight loss

Question 53

What is spinal tuberculosis?

Answer 53

- ultra rare bacterial infection in intervertebral disc and endplates

Question 54

What are the risks for developing spinal tuberculosis?

Answer 54

- Exposure (SE asia, India) - Immunosuppression

Question 55

What are some symptoms of spinal tuberculosis?

Answer 55

- generally unwell - weight loss - loss appetite - developing kyphosis - developing spinal cord involvement