Thoracic Spine: Anatomy & Differential - PowerPoint Presentation

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Thoracic Spine: Anatomy & Differential Dx

The Manual Therapy Institute

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AnatomyLess mobile… Why?Typical & Atypical Levels (T1 & T12)

Narrowing of the spinal canal T4-T9

Tension Point = T6

Articulations with ribs

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Thoracic Facet OrientationOrientation of Facets

– 60 degrees to transverse; 20 degrees to frontal

Coupling

–

sidebending

is coupled with rotation

ipsilateral

in upper and to the opposite side in lower; controversial with differing opinions regarding upper thoracic and lower thoracic couplingRange of Motions – i. flexion = 40oii. extension = 35oiii. sidebending = 20o iv. rotation = 35o

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Thoracic Facet Orientation

If the facets were inscribed on the periphery of a circle, the center of the circle would be in the middle of the vertebral body. This orientation allows for a good amount of rotation and

sidebending

despite the fact that much of the range has been lost due to the ribcage.

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Facet Pain Patterns

Dreyfuss

P. Thoracic

zygapophyseal

joint pain patterns. Spine. 1994;19:807-811.

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Rule of 3’sSpinous processes are longer and have more variability in the thoracic spine

Longest from T5-8, caution when palpating!

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Rule of 3’s

T 1 - T 3

Spinous

processes level with respective vertebral body.

T 4 -T 6

Spinous

processes level with the inferior disc.

T 7 - T 9 Spinous processes one segment below the repsective transverse process.T 10 - T 12 gradually decreasing inclination to where at T 12, the spinous process and transverse process are close to being on the same horizontal plane.

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Ribs and Rib MovementUpper RibsLower Ribs

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Costovertebral & Costotransverse

McMinn, Hutchings. Color Atlas of Human Anatomy. Year Book Medical Publishers, Inc: Chicago; 1988

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Sympathetic InnervationAll spinal nerves have a sympathetic component

Anatomically = just in front of the

costotransverse

joint

Sympathetic

innervation

of:

head T1-2upper extremities T3-7trunk T1-12lower extremities T7-12

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Other T-Innervation Considerations

Course of the lateral branch of the dorsal

rami

…

When patient’s present with

s&s

in these regions do NOT forget to look back at the respective level of the T-spine and assess function

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Medical ScreenMost issues dealt with in your Home study course

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Definition of Constitutional S&S: symptoms associated with a multitude of different systemic conditions; are NOT definitive diagnostic indicators in and of themselves, but function as signals to “dig deeper” and possible reasons to refer…

Examples of Constitutional S&S

: fever, fatigue, malaise, nausea, vomiting, diarrhea, night sweats, pallor, diaphoresis, HA and dizziness.

So what does that really mean?

Example: dizziness could indicate any of the following

Dehydration

Vestibular condition

Low blood sugarLow blood pressureSidenote on Constitutional S&S:

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FractureCompression fracturesRib fracture

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Compression FractureMagee 462

Usually occur in the lower thoracic area

Hx

of trauma

Hx

of osteoporosis

Increased risk of decreased bone density

Renal failureChronic GI disordersLong-term corticosteroidsPain with vibration and percussion

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Rib fractureMust have hx

of trauma

If not, suspect serious pathology

Fracture of sternum

Result from direct trauma

Case study

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Structural DefectsScoliosis

Kyphosis

Ankylosing

Spondylitis

(

Bechterews

disease)

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ScoliosisCharacterized by both lateral curvature and axial rotation of the vertebrae

Idiopathic

Cases where cause remains obscure

90% are probably genetic

7x more frequent in females

Classification depends on the well defined peak period of onset:

InfantileJuvenileAdolescent

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Idiopathic ScoliosisDoes not come to a sudden stop

once full maturity is reached->

opposite of previous thought

Reasons for adult progression:

Strong genetic component

If curve pattern throws the body off balance

If person has poor muscle tone

Common Rx: bracing and ex, or surgery and exCave: a lateral shift in the t-spine-> usually a sign of serious pathology

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Kyphosis Genetics

Osteoporosis

Spondylosis

Pathological fractures

Scheuermann’s

disease

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Scheuermann’s Disease

The vertebral version of

Perthes

or Osgood

Schlatter’s

Osteochondritis

of the vertebrae

Prevalent between 10 and 20 years of ageMore of a degenerative process than inflammatoryProblem occurs where the disc and the vertebrae connectDefects in the endplate lead to protrusion of the nucleus, causing disturbance of the growth plate anteriorly, making the vertebra wedge shaped

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Scheuermann’s DiseasePain usually starts a few years after the deformity becomes visible

Patients usually complain of slowly increasing pain, never severe, brought on by heavy labor, increasing as the day goes on

Frequent c/o fatigue in the mid back

T-L problems can develop later in life as a result of overcompensation

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Scheuermann’s Disease

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Characteristics:Non-infectious

Inflammatory

Erosive Rheumatic disease

Targets:

SI joints

Connections

bw

disc & boneFacet joints Results in: progressive fibrosisDiagnostics: negative RA factor; positive HLA-B27Most Common s/s: “backache”Characteristics of

Spondyloarthopathies

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Inflammation of the fibrous part of the joint capsule & ligaments (via the synovium) that leads to fusion.PT’s will assess any pt (particularly young male) with onset LB/SI pain, or hip pain with no trauma or overuse especially if also has s/s of fatigue, fever, or respiratory compromise

Osteoporosis Common: use same precautions

Associated Problems:

Cardiopulmonary problems (T-

kyphosis

)

Cauda

EquinaPT should address: postural training (emph extension & rotation), breathing exercises, stretchingAnkylosing Spondylitis

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Sites Affected by

Ankylosing

Spondylitis

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Ankylosing

Spondy

X-Ray

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ASAvg age = 25

Men > women

Hereditary factor

 20x higher than in

avg

population

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DiscS&S = anterior chest pain that can be sudden with radiating symptoms in the

intercostal

region.

Neuro

eval

doesn’t give clear information (too much overlap).

Aggs = increased symptoms with coughing or sneezing, repetitive movements and weight bearing.Incidence = highest T7-8T-spine disc lesions occur mostly in patients 40-60 y/oMcKenzie: all derangements posterior and posterolateral-> suitable for extensionSince IVF is bigger and each nerve root responsible for much smaller area, disc lesion in t-spine cause fewer problems than in c-spine or l-spine

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Thoracic DJDMost often at C7-T1, T4-5 and lower T spine. Bone spurring usually doesn’t lead to clear incidence of nerve root interference as it does in the cervical and lumbar spine.

S&S = palpable loss of movement and signs of joint irritation. The CV joints share in localized and painful loss of movement

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CostochondralMOI = direct trauma S&S = pain and swelling at the bone/cartilage junction, 1-inch lateral to the lateral margin of the sternum.

Acute

costochondrosis

is a benign inflammatory process also known as

Tietze’s

syndrome.

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Thoracic Facet DysfunctionS&S = Unilateral limitation & asymmetrical segmental mobility findings, asymmetrical

palpatory

findings (pain, tissue texture abnormalities, positional faults)

Aggs

= pain in rotation most pronounced

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Costovertebral DysfunctionS&S = intense sharp pain unilaterally

Movement restriction =

sidebending

Aggs

= deep breathing, sneezing and coughing

Rule out: pneumonia,

pleuritis

, fractured ribs, triggerpoints, cardiac problems and herpes zoster

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First RibMOI = powerful pushing/pulling, FOOSH, cervical facet dysfunction (C3-4 increases scalene tone)

S&S = restricted mobility of the rib in inhalation/exhalation or both; no

neuro

signs, but

paresthesia

in C8, T1

dematome

; can irritate the stellate ganglion (C7-T2).R/O = cervical rib before you do any form of mobilization. Higher than 1 cm, suspect joint dysfunction. Difference > 2 cm, suspect cervical rib. X rays will tell.

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Segmental Mobility: FlexionC-T Flexion

Thoracic Flexion

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Segmental Mobility: ExtensionC-T Extension

Thoracic Extension

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Segmental Mobility: RotationC-T Rotation

T-Rotation

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Segmental Mobility: SidebendingC-T

Sidebending

T-

Sidebending