Clinical Conditions

Question 1

osteoporosis

Answer 1

vertebral bodies, lose bone trabeculae

loss of transverse trabeculae lead to collapse of loadbearing beams

end plates collapse leads to end plate concavity

Increase kyphosis and loss of stature with aging

Question 2

fused mid thoracic vertebrae

Answer 2

Results results from diffuse idiopathic spondylitic hyperostis DISH
Or ankylosing spondylitis

Question 3

hypomobility

Answer 3

localized posterior slightly off the midline towards one side
Suggesting costotransverse joint

One side radiates slightly a few inches
Chest wall pain common
Costochondral region
Low back pain as a referral from the TL junction

Question 4

Traumatic thoracic injuries

Answer 4

In flexion or axial compression vertebrae or more injured more often than the discs

In the upper thoracic spine extension causes more injury with thoracic facet injuries, almost as common as cervical facet injuries

Question 5

traumatic injuries in order of severity, least to most

Answer 5

endplate fracture
bone bruise
Wedge compression
Burst fracture

Question 6

disc injuries versus vertebral body injuries prevalence

Answer 6

Disc injuries predominate in cervical spine
vertebral body injuries predominate in thoracic spine

Question 7

what are the most regularly injured segments?

Answer 7

T12 and L1

Question 8

Flexion compression trauma

Answer 8

affect the anterior elements
end plate fracture
Bone bruising
Wedge compression fracture
Burst fracture
Disk disruption

Question 9

highest level was for compression fractures

Answer 9

T 11
T12
L 1

Question 10

kyphoplasty cannot correct

Answer 10

An established deformity of the spine and certain patients with osteoporosis are not candidates for the treatment

Question 11

Who are likely candidates for kyphoplasty?

Answer 11

patient experiencing painful symptoms or spinal deformities from recent osteoporotic compression fractures

Within an eight weeks of the fracture

Question 12

Changes in height and spinal alignment can lead to

Answer 12

chronic or severe pain
Limited function and reduce mobility
Loss of independence in daily activities
Decreased lung capacity
Difficulty sleeping

Question 13

Greatest percentage of patients presenting with thoracic pain will

Answer 13

Have been involved in any trivial accident, such as a fall, someone bumping into the rib cage or prolonged loading

Question 14

thoracic disc lesions

Answer 14

Attachment of ribs to annulus fibers may be one reason for higher incidence

Blow to rib may affect or disrupt the disc

other reasons
Higher viscosity of IVD
Asymmetrical loading-

Question 15

most affected area for thoracic disc lesions

Answer 15

Lower thoracic spine
Thoracolumbar junction

common on convex side of a scoliosis or kyphosis
Due to asymmetrical loading

Question 16

thoracic radiculopathy

Answer 16

mechanical pressure on a healthy nerve root results in numbness, weakness and paresthesia, not pain

local ischemia may occur for local discomfort

Question 17

nerve root pain is either mechanical compression or chemical irritation

Answer 17

Mechanical- local discomfort with numbness and paresthesia

Chemical - severe pain distal is greater than proximal

may occur due to
Disc lesions
Facet injury or swelling
Osteophytes
Scarring

Question 18

True nerve root pain, distal pain will be

Answer 18

Distal pain( anterior next to sternum) will be greater than proximal pain(back)

Question 19

Costochondritis may closely simulate

Answer 19

Thoracic nerve roots symptoms because the pain is also located anteriorly at the sternum

Question 20

upper thoracic spine will refer symptoms into

Answer 20

The upper extremities

Question 21

facet joint injuries are common in

Answer 21

both regions
Cervical and thoracic spine

Question 22

facet joint dysfunction

Answer 22

Usually produce localized sharp pain unilaterally

For chronic stage, it may be dull and achy

Pain more likely to be aggravated by compressing or closing down facet joints extension

Pain may be Referred into nerve root distribution, but no neurological symptoms

referred pain will be more intense proximally versus distally

Question 23

ligamentous injuries

Answer 23

Pain in the thoracic spine can be from highly ligamentous reinforced joints

Small ligaments-sprain

Any force applied to the rib cage can affect ligaments

Ligaments stabilize and play important role in proprioception

Question 24

Pain from ligamentous structures

Answer 24

described as vague, ill defined
Spread around the area
Not producing symptoms, distillate, nor producing neurological symptoms

Both ALL and PLL innervated by sinovertebral nerve
will cause pain that spread up and down the spinal canal

Question 25

rib cage injuries

Answer 25

Breathing may increase pain area very tender palpation acute -Hematoma may be present -tap test with reflex hammer or vibration chronic -Old slow, healing rib fractures may become a chronic source of discomfort

Question 26

Muscle injuries

Answer 26

True muscle injuries of the spine are very uncommon musculoskeletal system does get affected through joint injuries and postural changes Muscle spasms are very common in upper thoracic spine especially around the scapula

Question 27

T4 syndrome

Answer 27

etiology unknown Maybe an autonomic syndrome or mechanical problem involving facet joints Glove Syndrome because of dull aching symptoms covering whole hand, non-dermatome and with or without pins and needles Symptoms usually unilateral

Question 28

cervical uncovertebral joint symptoms

Answer 28

very little pain, vague discomfort stiffness is greater problem than pain no Referred or neurological symptoms Morning Stiffness

Question 29

posterior primary rami innervate

Answer 29

Skin on the back between angles of the ribs Can mimic trigger points when traveling through the muscles

Question 30

common red flags

Answer 30

unaffected by spinal movement Associated symptoms like heartburn Past medical history Insidious onset of symptoms Age under 20 or over 50 Family history Past personal history Sudden, unexpected weight loss or gain

Question 31

Cardiac pain

Answer 31

pain for myocardium from decreased blood flow buildup of metabolites and ischemic segment of the heart Characterized as squeezing substernal sensation tightness, or pressure Usually in the morning or end of the day

Question 32

acute myocardial infarction

Answer 32

Intolerable, gripping or crushing sensation under their sternum Diaphoresis and shortness of breath

Question 33

angina pectoris

Answer 33

Increased pain with exertion Regardless of location, pain is always worsen with exertion and relieved with rest

Question 34

aortic dissection

Answer 34

Marked distention of aortic adventitial coat which contain high concentration of nociceptive fibers pain is sudden and rapidly becomes severe paint is unrelenting and not changed by position Patient appears in distress and may be pale or cyanotic Blood pressure is often normal, but distal pulses are frequently decreased or absent

Question 35

Pericarditis

Answer 35

inflammation of the pericardium Secondary to Infection- bacteria, viral or fungal systemic disease - rheumatoid arthritis, connective, tissue diseases or uremia Metastatic tumors Drugs - procainamide, hydralazine, phenytoin, anticoagulants Idiopathic

Question 36

Pericarditis symptoms

Answer 36

mild to severe chest pain that is aggravated by respiration cough or thoracic motion Pain may be relieved with sitting and forward bending Fever, chills and weakness are common Tachycardia and cough are variable

Question 37

pericarditis pain pattern

Answer 37

Within epigastrium and left parasternal region If the diaphragm is irritated, pain is referred to the left trapezius Patient with acute symptoms should be transferred immediately to an ER

Question 38

mitral valve prolapse

Answer 38

Results from thickened leaflets that are large and redundant Effect 4 to 7% of population More common in women than men Chest pain reported 40 to 50% of affected patients Pain is characteristically, sharp or sticking in nature Some may report dull pain

Question 39

Agina like symptoms for mitral valve prolapse

Answer 39

10 to 20% of affected patients stethoscope Mid systolic non-ejection click and late holosystolic murmur Pain generally non-exertional and momentarily but occasionally lingers minutes to hours

Question 40

mitral valve prolapse frequency and location

Answer 40

More frequent during periods of emotional stress Typically Retro sternal Left sided chest Not referred to distal sites

Question 41

esophageal disorders

Answer 41

Irritation from foreign bodies or tumors, erosion from acid reflux and motility problems Gastro esophageal reflux leads to a mild severe burning sensation in the epigastric to retro sternal area Pain often worse at night because of a supine position allows reflux of stomach acid into the esophagus Patient may complain of brackish taste, and frequent belching

Question 42

tracheobronchial pain

Answer 42

Pain from inflammation of the tracheobronchial tree characteristically is referred to the upper portion of the sternum and lateral to the sternum at points corresponding to the major bronchi

Question 43

Pleurisy

Answer 43

parietal pleural contains pain fibers that are conveyed through the chest wall through the intercostal nerves Irritation of the pleura, thereby results in chest wall pain widening Of the intercostal space during inspiration stretches, the inflame parietal pleural and accentuates the pain

Question 44

Pleural inflammation, may be caused by

Answer 44

Underlying lung insult from pneumonia or pulmonary infarction Direct entry of infection to the pleural space empyema Hematological or lymphatic spread - TB, uremia, cancer, collagen, vascular disease Pleural trauma like rib fracture

Question 45

pleurisy pain pattern

Answer 45

over side of pleurisy or the chest wall Central diaphragm is irritated Pain may be referred to the neck and shoulder.

Question 46

pulmonary embolism

Answer 46

Caused by a sudden lodging of a blood clot in the pulmonary vascular tree with resultant obstruction of blood flow Complete obstruction - pulmonary infarction, which may lead to a consolidation necrosis of lung tissue Medical emergency Thrombus formation usually occurs at a distance site like the venous system of the leg or subclavian vein in the arm

Question 47

Predisposing factors of pulmonary embolism

Answer 47

recent surgery less than one month Trauma Immobilization Cancer Pregnancy Oral contraceptive use Obesity Advanced age

Question 48

pulmonary embolism pain

Answer 48

usually Secondary to pleurisy from a peripheral infarction same pain pattern Dyspnea hemoptysis tachypnea

Question 49

Thoracic pain referred from abdominal

Answer 49

Generally transmitted through T6 to T 12 Some structures in the chest are innervated as low as T9

Question 50

cholecystitis

Answer 50

inflamed gallbladder Typically occur one to two hours after a heavy meal Sudden or gradual onset of severe pain which peaks after 2 to 3 hours and resolves in approximately 10 hours Passing gallstones gives the sudden intense proximal pain of biliary colic pain is characteristically located in the right upper quadrant of the abdomen the right subscapular area or both

Question 51

acute cholecystitis

Answer 51

Fever Chills Moderate to severe distress Tenderness could be elicited in the right upper quadrant that verses on deep inspiration aka Murphy sign

Question 52

peptic ulcer disease

Answer 52

Increase production of gastric acid or decreased cytoprotection of the stomach lining from chronic NSAID use leads to erosion of the gastric mucosa Pain originating from the stomach transmitted through the seventh through ninth thoracic nerve roots

Question 53

peptic ulcer disease pain

Answer 53

Burning felt in epigastrium below the xiphoid process or left upper quadrant of the abdomen significant erosion may cause patient to complain of boring sensation through the back Burning pain typically begins when two hours after a meal and could be temporarily relieved with antacids Perforation of the stomach wall lead to free air accumulation under the diaphragm and causes referred pain to the shoulder

Question 54

renal disease

Answer 54

Pain originating from the genitourinary system involves the thorax only at the costovertebral angle Pain could be result of either renal inflammation (pyelonephritis) or distention (sudden obstruction) Patient with acute pyelonephritis generally will have signs of urinary tract infection, which will proceed the development of flank pain

Question 55

renal disease symptoms

Answer 55

Fever, chills, sweats, and tenderness can be elicited by percussing the costovertebral angle no change of position relieves the pain