Exam 3: Thoracic Flashcards
1
Q
What plane of motion does most of the movement in the thoracic spine?
A
sagittal plane
2
Q
The upper thoracic spine acts more like…
A
the cervical spine
3
Q
The lower thoracic spine acts more like…
A
the lumbar spine
4
Q
As you progress down the t-spine, you have more and more…
A
flexion/extension/sagittal plane motion
5
Q
The reason the thoracic spine has fewer and fewer amounts of rotation is because the it’s becoming more and more _____.
A
vertical
6
Q
The upper and mid thoracic have ______, but as you get down to like T10 or so it doesn’t.
A
rotation/horizontal plane motion
7
Q
What is the natural amount of thoracic kyphosis?
A
40-45 degrees
8
Q
What is the normal amount of lumbar lordosis?
A
45 degrees
9
Q
What is the normal amount of cervical lordosis?
A
30-35 degrees
10
Q
What is the normal amount of thoracic kyphosis?
A
40 degrees
11
Q
See:
Slide 4
A
12
Q
Thoracic kyphosis is basically saying that the thoracic spine is in a relatively ____ position.
A
flexed
13
Q
Review:
Bony landmarks/facets from thoracic ppt. slide 8.
A
14
Q
List:
The functions of the t-spine.
A
- provide support - allows upright posture
- provide protection - vital organs
- acts as transitional zone between mobile cervical spine and mobile lumbar spine
15
Q
T-spine is designed for?
A
- rigidity to protect spinal cord
- facilitates mechanical activity of the lungs
16
Q
Primary motion at T1-T4 level?
A
mostly rotation
acts like neck
17
Q
Primary motion at T5-T10 level?
A
combo
T6-T8 has most rotation potential overall
18
Q
Primary motion at the T11-T12 level?
A
more flex/ext
more sagittal motion
19
Q
Thoracic Facet Orientations?
A
avg is about 60 degrees
closer to 45 in upper, closer to vertical in lumbar
20
Q
Hands behind head: elbows to lap
Norm Thoracic Flex?
A
30-40
21
Q
Hands behind head: elbows to ceiling
Norm Thoracic Ext?
A
15-20
22
Q
Total degrees of motion for thoracic spine?
A
45-60
23
Q
Hands behind neck like a butterfly
Norm thoracic lateral flexion?
A
30-45
24
Q
Hands crossed on shoulders, c-spine in neutral to avoid provocation
Norm thoracic rotation?
A
25-30
25
What is the AROM that you don't utilize overpressure for in the t-spine?
flexion
| more of a guide
26
# degrees, coupling, limited motions
Upper and middle thoracic facets
* 60 degrees from transverse
* 20 degrees from frontal
* Limits flex/ext
* Coupled SB/rot ipsilateral in flexion
* Coupled SB/rot contralateral in extension
27
# motion, location, coupling?
Lower thoracic facets
* sagittal facets from T9-T12
* more flexion and extension
* coupling evidence is unclear
28
Most people lack thoracic...
extension
29
# Generally
Thoracic flexion...
opens up
30
# Generally
Thoracic extension...
closes down
31
Review slide 15.
32
Thoracic ZAJ pain stays relatively ...
local
33
Thoracic ZAJ Pain Study
* study performed on asymptomatic patients
* T3/4-T10/11 were injected with a noxious stimuli and subjects reported where they experienced pain
* pain occurred one segment inferior and slightly lateral to joint injected
* no joints referred pain more superior than one half of the vertical height of that vertebral segment
* distal referral was up to 2.5 segments below injected level
* 2 subjects had anterior chest wall and sternal pain when T3/4 and T4/5 segements were injected
34
See slide 17.
35
# Overview
T1-T4?
* acts like c-spine
* canal is narrowing
* inherent stability protects discs
* also rotates like c-spine
36
# Overview
T4-T10?
* true t-spine
* narrowed canal
* critical vascular area or zone
* inherent stability protects discs
37
# Significance in T4-T10
Critical Vascular Area/Zone
* poor blood supply
* poor healing
* disc pathology has hard time healing
* pathology more rare in this area, but more difficult to treat
38
# Overview
T6-T8?
* greatest rotation
* need mobility for interaction between upper and lower quarter
39
# Overview
T11-T12?
* acts like lumbar spine - more mobile
* canal widens (cauda equina)
40
When is the ZAJ most stressed?
3D motion
41
If pain was with 3D motion at ZAJs, what might you do next?
local exam, checking for familiar symptoms that could indicate the ZAJs are the pain generator
| ex. to the L, ext and SB and rot, closes L?
42
# Critical Zone
What area is known as the critical zone and why?
* T4-T10
* small diameter of the vertebral canal
43
# Critical Zone
Which spinal cord segment is reported to be a tension point?
T6
44
# Critical Zone
Neural/dural tension test my be a result of what in this area? what test is positive?
* result of poor mobility in area
* positive slump test
45
# Critical Zone
Mobilization and manipulation may be helpful in imporving joint ... and allow for .....?
* mobility
* normalized neural tissue dynamics
46
# Palpation
Simplified finger rule for finding TP.
* 1 finger above SP at each level
* about 1 inch lateral to SP
## Footnote
Others say T1-T2 and T11-T12: 1 finger above SP
T3-T4 and T9-T10: 2 fingers above SP
T5-T8: 3 fingers above SP
47
# Palpation
What is level with T12?
head of 12th rib
48
# Palpation
What is level with T7/T8?
inferior angle of scapula
49
# Palpation
What is level with T4?
level with root of spine of scapula or apex of axillary fold
50
# Palpation
What is level with L4?
superior border of iliac crest
51
# Palpation
What is level with S2?
PSIS inferior portion
52
# Palpation
What is level with sacral apex?
upper greater trochanter
53
# Palpation
What is the first palpable SP below the occipital bone?
C2
54
# Palpation
Thoracic TP Palpation Rule of 3s
* T1-T3: at level of corresponding SP
* T4-T6: 1/2 segment above SP
* T7-T9: at level of SP of vertebrae above
* T10-T12 have SPs that project from a position similar to T9 and rapidly regress until T12 is like T1
55
# Palpation
Most prominent SP at base of neck?
C7 or T1
56
# PPIVMs
PPIVMs - What does it stand for? What does it assess? How to assess?
* Passive Physiological Intervertebral Movements
* assessment of movement available at the spinal level identified by application of a passive physiological motion
* PT palpates between or on posterior aspect of adjacent SP
57
# PAIVMs
PAIVMs - What does it stand for? What does it assess? How to assess?
* Passive Accessory Intervertebral Movement
* Mobilization technique that produces movement of a mobile vertebral segment without the active participation of muscles related to the movement
* PT applies posterior-anterior force on SP
* Assess mobility and provocation
* hyper/hypombile
* painful/non-painful
## Footnote
Angle hand to appreciate kyphosis of t-spine, V position judy chop TP R
58
# Ribs
Rib Joints?
* costotransverse joint
* costocorporeal/costovertebral joint
59
# Overview/general function
Ribs?
* 12 pairs of ribs enclose the thoracic cavity, forming protective cage for cardiopulmonary organs
* head of the tubercle articulates with a thoracic vertebra, forming 2 costovertebral joints
60
# Posterior and Anterior structures
Typical Ribs 3-9
* posterior end of a typical rib has a head, neck, and articular tubercle
* anterior end of rib consists of flattened hyaline cartilage
| see slide 28 image
61
# which ones, attachment
True ribs?
* ribs 1-7
* attach directly to lateral border of sternum via 7 sternocostal joints
62
# Which ones, attachment
False ribs?
* ribs 8-10
* attach to sternum by fusing to the cartilage of the immediate superior rib
63
# which ones, attachment
Floating ribs?
* ribs 11-12
* free floating because they do not attach to the sternum
64
# Overview, orientation, attachment, stiffness, movement
Ribs 1-7
* true ribs
* transverse plane orientation
* direct sternal attachment
* more flex/ext stiffness
* lots of rotation
65
# Overview, orientation, attachment, stiffness, movement
Ribs 8-10
* false ribs
* indirect sternal attachment
* more rotation stiffness
* lots of flex/ext
* oblique orientation
66
# Overview, attachment, mobility
Ribs 11-12
* no sternal
* very mobile
67
How many vertebrae are ribs 2-8 connected to?
2 each
68
How many vertebrae does ribs 1, 9-12 connect to?
1
69
Major restrictor of sidebending?
ribs --> pain
| stress rib in SB --> pain likely from ribs
70
# Rib Ring Motions
Thoracic Flexion: ipsilateral and contralateral rib ring?
* IR (anterior rotate), forward
* IR (anterior rotate), forward
71
# Rib Ring Motions
Thoracic Extension: ipsilateral and contralateral rib ring?
* ER (posterior rotation), backward
* ER (posterior rotation), backward
72
# Rib Ring Motions
Thoracic Sidebend: ipsilateral and contralateral rib ring?
* approximation, IR (anterior rotation), forward
* separation, ER (posterior rotation), backward
73
# Rib Ring Motions
Thoracic Rotation: ipsilateral and contralateral rib ring?
* ER (posterior rotation), backward
* IR (anterior rotation), forward, contralateral translation
74
See images on slides 34-36
75
If you rotate L what are the ribs doing?
* L rib ER and moves back
* R rib IR moves forward
76
# Movement, see image slide 38
Ribs 2-6 (5 ribs)
* pump handle movement
* superior and anterior movement of sternum
* middle costotransverse joint spins/rotates, little more rotation
77
# Movement, see image slides 39-40
Ribs 7-10 (4 ribs)
* bucket handle movement
* glides at lower costotransverse joints
78
# path, movement, combined movement, volume
Rib Motion on Inspiration
* during inspiration, the shaft elevates in a path perpendicular to the axis of rotation that lies generally parallel with the associated transverse process
* on inspiration, the rib rotates upward and outward, increasing intrathoracic volume
* on inspiration, the movement of the ribs is combined with slight extension of the thoracic spine
| see image on slide 41
79
# path, movement, combined movement, pressure
Rib Motion on Expiration
* During expiration, the shaft depresses in a path perpendicular to the axis of rotation that lies generally parallel with the associated transverse process
* On expiration, the rib rotates downward and inward, decreasing intrathoracic pressure
* On expiration, the movement of the ribs is combined with slight flexion of the thoracic spine
80
# Movement, see image slide 43, what happens on inspiration and expiration
Ribs 11-12
* caliper
* inspiration - separation of ribs from midline
* expiration - approximation of ribs toward the midline
* keep in mind that motion will occur in 3D
81
# Rib ring motions during breathing
Expire
* Ipsilateral ring IR (anterior rotation), forward
* associated thoracic motion is flexion
82
# Rib ring motions during breathing
Inspire
* ER (posterior rotation), backward
* associated thoracic motion is extension
83
# what does it test, what is a positive test, how to test
Seated Rib Position Test
* have pt SB and rotate towards you
* test ribs from superior to inferior after breathing out to find rib stuck in inspiration
* inspiration: positive test is a prominent superior border
* test ribs from inferior to superior after breathing in to find a rib stuck in expiration
*expiration: postive test is prominent inferior border
84
# when does it occur
Quiet Ventilation
occurs during sedentary activities with low metabolic demand
85
# when does it occur
Forced Ventilation
occurs during strenuous activities that require rapid and voluminous exchange of air = exercise
86
Mechanics of Inspiration
* intrathoracic voulme is increased by contraction of the muscles attached to the ribs and sternum
* the expansion increases the negative pressure drawing air into the lungs
87
Mechanics of Expiration
* intrathoracic volume is decreased
* pressure is increased and air is drawn out of the lungs
88
# Muscular Actions During Ventilation
Diaphragm
flattens to increase the vertical diameter of the thorax
89
# Muscular Actions During Ventilation
Scalenes
elevate the ribs and sternum to increase intrathoracic volume
90
# Muscular Actions During Ventilation
External Intercostals
elevate the ribs to increase intrathoracic volume
91
# Muscular Actions During Ventilation
Internal Intercostals
assists in forced expiration
92
Forced Expiration
contraction of "abdominal" muscles, transversus thoracis, and intercostales interni (interosseous fibers) increases intrathoracic and intra-abdominal pressures
93
# orientation, thickness, endplate, disc:vertebral body ratio, restrictor
Thoracic Discs
* very thin and oriented below nerve root
* thin vertebral endplate = common to have schmorl's nodes
* 1:5 to 1:7 disc to vertebral body ratio
* Major restrictor of rotation = pain due to torsion on disc
94
Cervical has more ... stress, while thoracic has more... stress.
* sagittal movement
* rotation
| see slide 50
95
Schmorl's Node
common spinal disc herniation in which the soft tissue of the intervertebral disc bulges out into the adjacent vertebrae through and endplate defect
96
Disc/Dura primary controls?
* rotation
* extension (as you move down)
97
Disc/Dura minor controls?
* flexion
* SB
98
What is unlikely in t-spine and why?
* radicular/nerve root impingment
* high foramen
* rare radicular symptoms due to high foramen
99
Dura involvement due to ....leading to ... pain
* narrow canal
* posterior diffuse
100
Disc are major restrictor of ... can lead to pain.
rotation
101
Rotation increased by ... degrees after .... percent disc resection.
* 12
* 70
* large increase in extension
102
If I SB, I am mostly testing the ...
ribs
103
If I do 3D motion, I am mostly testing..
facets
104
If I rotate, I am mostly testing...
discs
105
# incidence of asymptomatics, referral patterns
Thoracic Disc Pathology
* incidence of asymptomatic thoracic disc protrusions is approximately 37%
* referral patterns of thoracic discs are unclear as no studies have directly investigated them
106
# Disc Pain, location, how common
Posterior Disc Lesion
* local thoracic pain
* most common
107
A majority of the thoracic disc herniations are ...
asymptomatic
108
Symptoms of disc herniation can present as ...
chest wall pain, epigastric pain, upper extremity pain, and sometimes, a pain in the groin or the lower extremity causing the clinician to think of a more common problem than a disc herniation
109
# Capsuloligamentous, what ligaments, population
General predisposition to ossification
* especially in Asian population
* both of PLL and flaval ligament
110
# Capsuloligamentous, referral, how likely pain, why
ZAJ Capsule
* thin, no meniscus, very voluminous
* 3D movements are needed to stress it
* Mechanoreceptors present
* Low number of nociceptors = ZAJ is not likely the main t-spine pain generator
* ZAJ does not refer pain in the midline
111
# Nerve, Ventral Rami, 12 pair
Intercostal nerves innervate:
* pleura
* CT and CV joints
* intercostal muscles
* skin on ventral trunk
* abdominal muscles from T6 down = altered abdominal reflex
112
See image on slide 57
113
What do the dorsal rami innervate?
* CV joints
* lateral ZAJs
* sacrospinal muscles
* skin on dorsal trunk
114
What do recurrent sinuvertebral nerves/Nerves of Von Luschka innervate?
* PLL
* Vetrebral body
* disc
* ventral and lateral dura
* vascular supply
115
Pathology and dysfunction has implication on ... actions.
sympathetic
116
# Sympathetic influence
Eyes
dilates
117
# Sympathetic influence
heart
increases rate and force of contraction
118
# Sympathetic influence
lungs
dilates bronchioles via circulating adrenaline
119
# Sympathetic influence
blood vessels
dilation in skeletal muscle (in animals)
120
# Sympathetic influence
gastrointestinal
constricts in organs
121
# Sympathetic influence
sweat glands
activates sweat secretion
122
# Sympathetic influence
digestive tract
inhibits peristalsis
123
# Sympathetic influence
kidney
increases renin secretion
124
The sympathetic nervous system is a division of the ... nervous system.
autonomic
125
See image of sympathetic chain on slide 60.
126
# where does it lie, how might it present, relationship to scoliosis
Aorta
* lies on L side of anterior thoracic vertebrae
* may present with osteophytes on the R > L side
* possible relationship with idiopathic scoliosis - most common is R sided convexity = L SB
127
A weakening of the aortic wall can lead to...
an abdominal aortic aneurysm
128
See image on slide 62.
129
Muscles of the Anterior-Lateral Trunk (abdominal muscles)
* rectus abdominus (RA)
* external oblique (EO)
* internal oblique (IO)
* transverse abdominis (TA)
130
# Hyperkyphosis, see image slide 64
Osteoporosis may lead to...
anterior wedge compression fractures and anterior disc degeneration
131
Medical Causes of Kyphosis
* Scheuermann's disease: excess anterior wedging in adolescents
* Osteoporosis: chronic metabolic in primary postmenopausal (estrogen component) women (not just aging)
* Trauma related spinal changes
* Tumor
* Infection
* Vertebral fractures
* Degenerative disc disease diagnostic procedures/examination
132
# See slides 66-67 and video
Define scoliosis curve off of ...
convexity
133
# see slide 68 image
Excessive Kyphosis
* leads to excessive anterior shear forces
* increased thoracic flexion torque
* resultant extensor muscle elongation
134
# Quotes about
Thoracic Outlet Syndrome
* "A controversial cause of neck and shoulder pain due to complex mechanisms involving muscular dysfunction and nerve compression"
* "A group of disorders that occur when there is compression, injury, or irritation of the nerves and/or blood vessels in the lower neck and upper chest"
* "The most underrated, overlooked, misdiagnosed and probably the most important and difficult to manage peripheral nerve compression in the upper extremity'
135
# as relating to ribs
Scalenes
* anterior and middle scalenes are relevant contributing factors to dysfunction of the first rib because they both can elevate the first rib when the c-spine is fixed
* posterior scalene can potentially elevate the 2nd rib when c-spine is fixed
136
How many dynamic compartments are there?
4
137
# Compartments
Anterior Triangle Borders
* SCM
* anterior scalene
* first rib
138
# Compartments
Anterior triangle contents
* subclavian vein
* lymph vessels
* phrenic nerve
139
# Compartments
Posterior Triangle Borders
| see image on slide 71
* anterior scalene
* middle scalene
* first rib
140
# Compartments
Posterior triangle contents
| see image on slide 72
* subclavian artery
* brachial plexus
141
# Compartments
Costo-clavicular borders
* dorsal: scapula, subscapularis
* ventral: clavicle, subclavius muscle
* caudal: first rib, upper serratus
* cranial: clavicle
142
# Compartments
Costo-clavicular contents
| see image on slide 73
* brachial plexus
* subclavian artery and vein
143
# Compartments
Thoraco-coraco-pectoral borders
* ventral: pectoralis minor
* medial: thoracic wall
* cranial/lateral: coracoid process
144
# Compartments
Thoraco-coraco-pectoral contents
* brachial plexus
* subclavian artery and vein
145
# Anatomical Considerations of TOS
Cervical Rib
* only symptomatic 10% of the time
* vascular consequence
* with or without fibrous bands
* rudimentary 1st rib (off of C7) with postfixed plexus
146
# Anatomical Considerations of TOS
Tension or Compression?
* tension is more common, travel longer distance
* occurs with cervical rib, 1st rib elevation, scalene hypertonicity (MVA), decreased costoclavicular space, decreased thoraco-coraco-pectoral space
* objectifiable findings are elusive
* difficult differential diagnosis - multiple abnormalities, varying s/s, no root involvement (symptoms are non-radicular)
147
# Etiology of TOS
Congenital
* cervical rib
* fibrous bands
* muscle anomalies
* elongated transverse process
148
# Etiology of TOS
Acquired
* whiplash
* clavicle fracture
* ligamentous laxity
* overhead work
* posture
149
# %, what vessel types, due to
What percentage of TOS is true vascular?
* 1.5%
* venous and arterial
* more likely to be due to anatomical variation
150
What percentage of TOS is likely to be neurogenic?
98.5%
151
What percentage of TOS is likely to be true neurogenic?
3.5%
152
Why might someone with true neurogenic TOS not do well with PT?
True compression on nerves
153
What percentage of neurogenic TOS is disputed neurogenic?
95%
