Download 1 Anatomy, Kinesiology and Pathology of the Thoracic Spine

Anatomy, Kinesiology and
Pathology of the Thoracic Spine
Thoracic Spine


Beth K. Deschenes, PT, MS,
OCS
Consists of thorax,
rib cage and sternum
12 vertebrae and 12
ribs
Function of the Thoracic Spine
Thoracic Spine
Support head and internal organs
 Attachment of ligaments,
g
, bones,, muscles
 Links upper and lower extremities
 Allows mobility of the trunk for respiration
 Protects spinal cord





Natural thoracic
kyphosis of about 45
degrees along the entire
length
Upper: T1-4 transition
from cervical
Middle: T5-T9 most rigid
Lower: T T10-T12
transition to lumbar
Important Points
Osteology of the Thoracic Spine




Spinal canal is
narrower
Less flexible than
cervical and lumbar
Common site for CA
metastases
Rule out nonmusculoskeletal
problems
1
Thoracic Vertebrae





Spinous process slope
inferiorly and overlap inferior
vertebra
Demifacets for ribs
12 ribs attach T1-12 which
make the thoracic spine less
mobile
Vertebrae increase in density
and size as move inferiorly
IVD thinner than in lumbar
Osteology of the Thoracic Spine




Facet joints in the
frontal plane
SP of sup vertebrae
is over the body of
the inferior
SP angle down to
level of inferior
vertebrae TP
TP are lateral of the
SP above
Osteology of the Rib
Thoracic Spine Facets


T1-9: lie in the
frontal plane
superior thin and flat;
face pos and sup/lat;
inferior face ant and
sup/med
T10-T11: lie in the
sagittal plane
superior facets face
pos/lat and inferior
facets face ant/lat
Osteology of the Thoracic Spine




Ribs 1-7 are “true ribs”
Ribs 8-10 articulate with
costal cartilage
Ribs 11-12 “floating”
with no attachment with
the sternum
1st rib atypical
articulates only T1 disc
Ligaments of the Thoracic Spine
2
Ligaments of the Thoracic Spine






Posterior longitudinal
Anterior longitudinal
Intraspinous
Supraspinous
Ligamentum flavum
Intertransverse
Ligament specifics in the Thoracic
Spine

Ligamentum flavum and anterior longitudinal
ligament are thicker as compared to the
cervical region
Thoracic Spine Ligaments


Facet Joints


Plane synovial joints
that are oriented
about 20 degrees off
the the frontal plane
ROM is greater into
frontal plane than
sagittal plane
Joints of the Thoracic Spine
Radiate and capsular
ligaments are present at
the costovertebral joint
Costotransverse and
superior costotransverse
unite the rib to the
transverse process
Costovertebral and
Costotransverse Joints




Allow movement of the
ribs and spine to during
ventilation
Costovertebral: joint
between rib and VB
Costotransverse: joint
between rib and TP
Can become a source
of pain if subluxed
3
Costoverterbral Joint
Costotransverse Joint
Articulation between
head of rib and two
demi facets
demi-facets
Plane synovial joint
Attaches by radiate
ligaments to IVD
Motion: rotation and
gliding
Physiologic Movement of the
Thoracic Spine
–
–
–
Articulation between
the costal tubercle of
the rib with the facet
on transverse
process on ribs 1-10
Costotransverse
ligament
Motion is gliding with
slight rotation
AROM of the Thoracic Spine
Flexion: 30-40 degrees
Extension: 20-25 degrees
g
 Rotation: 30 degrees to each side
 Side bending: 25 degrees to each side


Flexion:
limited by tension in PLL, lig
flavum, facet joint capsule
Extension: limited by bony structures and
tension in ALL and abdominals
4
Rotation:
Sidebending:
limited by ribcage and
limited by rib cage and
ossification of costal cartilage with aging
facet joints
Effects of ROM on IVF and VF
Movement of the Ribs 2-10
Closing: extension, ipsilateral
sidebending and ipsilateral rotation
 Opening: flexion, contralateral
sidebending and contralateral rotation

–
–
–
Movement of the Ribs
Upper ribs act as a
pump handle moving
A/P
Lower ribs act as a
bucket handle moving
M/L
Thoracic diameter
increases as rib
cages moves up and
out
Pathologies of the Thoracic Spine
First rib is the stiffest can be most
restricted
 All ribs elevates during inspiration

5
Pathologies of the Thoracic Spine
Pathologies of the Thoracic Spine
Inflammatory
Structural affecting
g bone
 Joint: facet, costotransverse or
costovertebral
 Disc Herniation
 Thoracic Outlet


Costochondritis





Inflammatory
Herpes Zoster (shingles)
Reactivation of the chicken pox infection
Affects spinal
p
g
ganglia
g
 Usually occurs during episodes of
immune suppression
 Radicular pain, itching, parathesia and
rash frequently dermatomes T5-10
Inflammation of the
costal cartilages
U k
Unknown
etiology
ti l
Characterized by
sharp pain that
radiates to
shoulder/arm
Local tenderness
Pain with
AROM/PROM


Schuermann’s Disease
Pathologies of the Thoracic Spine


Structural

Accented kyphotic
curve; fixed
Anterior wedging of
vertebrae
Painless and slow
progressing
6
Anklyosing Spondylitis



Progressive form of
arthritis
Fusion of SIJ and
spine to ossification
Characterized by
diffuse LBP AM
stiffness that
decreases with
movement
Ankylosing Spondylitis
Ankylosing Spondylitis


Scoliosis



Scoliotic posture
May include
costovertebral joints
S i l stiffness
Spinal
tiff
with
ith
negative neuro
exam
Deformity often in
thoracic spine that
affects all 3 planes
80-90% idiopathic
Remaining cases
seen in CP, MD,
Polio, SCI
Rib Fractures




History trauma
Difficulty breathing
Pain increases with
movement
+ Tap test
7
Compression Fracture






Often in
osteoporotic
patients
Trauma or flexion
injury
History of steroids
Anterior wedging
+ tap test
Flexion most pain
Osteoporosis




Ettinger et al study of 3000 white American
women between 65 to 70 yrs. 2/3 reported
back pain during past 12 months
60% had one vertebral deformity 24% had
more than 3 deformities
Severe vertebral deformities linked to
increased risk of back pain and height loss
Multiple fractures often result in acute and
chronic back pain, limitation of functional and
physical activity and height loss
Osteoporosis Management





Manipulation is contraindicated
Prone position needs support
Mobilization in sidelying may be indicated for
improved mobility and pain relief
Sitting techniques are safe if distraction
Exercise emphasizing weight bearing and
resistance, balance and flexibility help
decrease risk for falls.
Osteoporosis





Loss of bone density that can result in
compression fractures and/or excessive
thoracic kyphosis
Most common in post-menopausal women
Fracture rate is about 7% at age 50 to 78% at
age 90
Most common sites are T7, T8, T11 and L1
Estimated 2/3 of fractures are undiagnosed
Osteoporosis

Pain and fear of fracture often results in
the what can help the patient the most;
physical activity
Pathologies of the Thoracic Spine
Joint
8
Joint Dysfunction


Facet
Rib: Costotransverse or costovertebral
Rib Dysfunction
Costotransverse and costovertebral
joints’ motion is gliding and rotation
 Rib can become subluxed
 Localized pain
 Responds well to manipulation
Degenerative Joint Disease
Age > 50
ROM loss in capsular
p
p
pattern
 Stiff in AM
 Facets joints frequently affected


Pathologies of the Thoracic Spine

Disc Herniation
Very rare
Most common in lower thoracic spine
p
 C/O “bandlike” pain
 Flexion most painful
 Slump test reproduces symptoms
Disc
Pathologies of the Thoracic Spine


Thoracic Outlet
9
Edgelow (1997)
The anatomy of the thoracic outlet should
be considered as tunnels made up of
bones and muscles
 Bony tunnels
 Muscular tunnels
 Contain the neurovascular structures of
the upper extremity

Muscular Tunnels

Medial
–

Anterior/middle
scalene
Lateral
–
Bony Tunnel





Floor-ribs 1-5
Anterior wall-clavicle
P t i wallPosterior
ll
scapula
Medial bordercervical spine
Lateral border-GH
joint
Contents of the Thoracic Outlet


Pectoralis minor


Thoracic Outlet Syndrome
Entrapment of the neurovascular
structures within the thoracic outlet
 May affect:

–
–
–
Brachial plexus-lower trunk
Subclavian vessels
Axillary vessels
Common Age 25-40
 4x’s more likely in females
Brachial plexus C5T1
Stellate ganglionneck of 1st rib
Subclavian
artery/vein
Axillary artery/vein
Thoracic Outlet Syndrome: Risk
Factors with the Bony Tunnel
Large transverse process
of C7
Cervical rib
Callus formation following
clavicle fracture
Degenerative hypertrophy
of arthritic GH joint
Elevated 1st rib

10
1st Rib Elevation
1st Rib Elevation

Primary

Secondary
–
–

Sudden powerful contraction of scalenes

Excessive scalene tone,
 Poor
posture
joint dysfunction
 Abnormal breathing patterns
 C3/4
–
Post traumatic scarring & shortening of
scalenes
Thoracic Outlet Syndrome

‘Risk factors’ within the muscular tunnels
–
–
–
–
Increased distance the T1
root must travel up and over
the 1st rib to join C8
↓ space between clavicle
and 1st rib effecting the
– subclavian artery
– subclavian vein
Shortening of scalenes secondary to poor
posture or post traumatic scarring (whiplash)
Abnormal breathing patterns
Anatomic variations of scalenes
Pectoralis Minor tightness
Thoracic Outlet Syndromes
Classification
Arterial
Venous
 True neurogenic
 Non specific neurogenic


Thoracic Outlet Syndrome (Arterial)
Thoracic Outlet Syndrome (Venous)
Compression of subclavian or axillary
artery
 Ischemic changes


–
–
Coldness
Pain
Diminished pulse
Supraclavicular/infraclavicular bruits
 Diagnosis confirmed by arteriogram


Compression of subclavian or axillary
vein
 UE swelling
 Feeling of heaviness
 Cyanotic discoloration
 Diagnosis confirmed by venogram
11
Thoracic Outlet SyndromeTrue Neurogenic
Only 10% of TOS Cases
are Vascular
Compression of the lower trunk of the
brachial plexus
 Cervical rib/elongated transverse process
confirmed by x-ray
 Pain/parasthesia C8-T1
 Positive EMG of the C8-T1 musculature

Thoracic Outlet SyndromeNonspecific Neurogenic
Thoracic Outlet SyndromeNonspecific Neurogenic
Most controversial
 No conclusive objective
j
tests
 85% of TOS patients
 Dysfunction in the pressure gradient in
the muscular and bony tunnels






Thoracic Outlet SyndromeNonspecific Neurogenic


Edgelow (1997): it is the irritability of the
nervous system that is at the core of the
problem
Development of pathology at secondary sites
Altered axoplasmic flow (theoretical)
Upton & McCommas (1973)-115 patients with
CTS had neural lesions of the neck
Wood, et al. (1988)-CTS associated with TOS
in 21-30% of TOS cases
Thoracic Outlet Body Chart
Lateral neck/supraclavicular pain
Parasthesia,, numbness,, pain
p
and or
burning in the ulnar nerve distribution
(most common), although may
additionally be experienced in the median
and radial nerve distributions
12
Thoracic Outlet SyndromeNonspecific Neurogenic

Aggravating factors
–
–
–
–
–

Sleeping with arm over head
Overhead use of the arm
Carrying weighted objects
Contralateral sidebend
Repetitive use of arms
Easing factors
–
–
Arm adduction/Ir
Support for arm
Thoracic Outlet Syndrome
Nonspecific Neurogenic

Edgelow (1997)-there are four major
findings in patients with TOS
–
–
–
–
Positive ULTT
Paradoxical breathing
Scalene tenderness
Pectoralis minor tenderness
Thoracic Outlet Syndrome-Nonspecific
Neurogenic Examination Findings


Poor posture/protective posture
Minimal limitations with cervical ROM
–
–



Tension
T
i in
i th
the scalene
l
with
ith contralateral
t l t l sidebend
id b d
Radiating arm symptoms with contralateral
sidebend
Tenderness over scalenes and/or pectoralis
minor
Positive Upper Limb Tension Test
Mild muscle weakness and hypoesthesia in C8T1 distribution
Thoracic Outlet Syndrome
Traditional tests
– Adson’s test
– Exaggerated
gg
military
yp
position
– Hyperabduction test
– AER test
– Roos test
* Use of pulse obliteration only-high false positive rate
* Use of pulse obliteration and symptom reproduction more favorable

13