Thoracic Spine. Anatomy, Kinesiology and Pathology of the Thoracic Spine. Thoracic Spine. Function of the Thoracic Spine.

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1 Anatomy, Kinesiology and Pathology of the Thoracic Spine Beth K. Deschenes, PT, MS, OCS Thoracic Spine Consists of thorax, rib cage and sternum 12 vertebrae and 12 ribs Function of the Thoracic Spine Support head and internal organs Attachment of ligaments, bones, muscles Links upper and lower extremities Allows mobility of the trunk for respiration Protects spinal cord Thoracic Spine 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 Spinal canal is narrower Less flexible than cervical and lumbar Common site for CA metastases Rule out nonmusculoskeletal problems Osteology of the Thoracic Spine 1

2 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 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 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 Ribs 1-7 are true ribs Ribs 8-10 articulate with costal cartilage Ribs floating with no attachment with the sternum 1 st rib atypical articulates only T1 disc Osteology of the Rib Ligaments of the Thoracic Spine 2

3 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 Radiate and capsular ligaments are present at the costovertebral joint Costotransverse and superior costotransverse unite the rib to the transverse process Joints of the Thoracic Spine 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 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

4 Costoverterbral Joint Costotransverse Joint Articulation between head of rib and two demi-facets Plane synovial joint Attaches by radiate ligaments to IVD Motion: rotation and gliding 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 Physiologic Movement of the Thoracic Spine AROM of the Thoracic Spine Flexion: degrees Extension: degrees 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

5 Rotation: limited by rib cage and ossification of costal cartilage with aging Sidebending: limited by ribcage and facet joints Effects of ROM on IVF and VF Closing: extension, ipsilateral sidebending and ipsilateral rotation Opening: flexion, contralateral sidebending and contralateral rotation Movement of the Ribs 2-10 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 Movement of the Ribs First rib is the stiffest can be most restricted All ribs elevates during inspiration Pathologies of the Thoracic Spine 5

6 Pathologies of the Thoracic Spine Inflammatory Structural affecting bone Joint: facet, costotransverse or costovertebral Disc Herniation Thoracic Outlet Pathologies of the Thoracic Spine Inflammatory Costochondritis Inflammation of the costal cartilages Unknown etiology Characterized by sharp pain that radiates to shoulder/arm Local tenderness Pain with AROM/PROM Herpes Zoster (shingles) Reactivation of the chicken pox infection Affects spinal gangliag Usually occurs during episodes of immune suppression Radicular pain, itching, parathesia and rash frequently dermatomes T5-10 Pathologies of the Thoracic Spine Structural Schuermann s Disease Accented kyphotic curve; fixed Anterior wedging of vertebrae Painless and slow progressing 6

7 Anklyosing Spondylitis Ankylosing Spondylitis Progressive form of arthritis Fusion of SIJ and spine to ossification Characterized by diffuse LBP AM stiffness that decreases with movement May include costovertebral joints Spinal stiffness with negative neuro exam Ankylosing Spondylitis Scoliosis Deformity often in thoracic spine that affects all 3 planes 80-90% idiopathic Remaining cases seen in CP, MD, Polio, SCI Scoliotic posture Rib Fractures History trauma Difficulty breathing Pain increases with movement + Tap test 7

8 Compression Fracture Often in osteoporotic patients Trauma or flexion injury History of steroids Anterior wedging + tap test Flexion most pain 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 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 Pain and fear of fracture often results in the what can help the patient the most; physical activity 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. Pathologies of the Thoracic Spine Joint 8

9 Joint Dysfunction Facet Rib: Costotransverse or costovertebral Degenerative Joint Disease Age > 50 ROM loss in capsular pattern Stiff in AM Facets joints frequently affected Rib Dysfunction Costotransverse and costovertebral joints motion is gliding and rotation Rib can become subluxed Localized pain Responds well to manipulation Pathologies of the Thoracic Spine Disc Disc Herniation Very rare Most common in lower thoracic spine C/O bandlike pain Flexion most painful Slump test reproduces symptoms Pathologies of the Thoracic Spine Thoracic Outlet 9

10 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 Bony Tunnel Floor-ribs 1-5 Anterior wall-clavicle Posterior wallscapula Medial bordercervical spine Lateral border-gh joint Muscular Tunnels Contents of the Thoracic Outlet Medial Anterior/middle scalene Lateral Pectoralis minor Brachial plexus C 5 - T 1 Stellate ganglionneck of 1 st rib Subclavian artery/vein Axillary artery/vein Thoracic Outlet Syndrome Entrapment of the neurovascular structures within the thoracic outlet May affect: Brachial plexus-lower trunk Subclavian vessels Axillary vessels Common Age x s more likely in females Thoracic Outlet Syndrome: Risk Factors with the Bony Tunnel Large transverse process of C 7 Cervical rib Callus formation following clavicle fracture Degenerative hypertrophy of arthritic GH joint Elevated 1 st rib 10

11 1 st Rib Elevation 1 st Rib Elevation Primary Sudden powerful contraction of scalenes Secondary Excessive scalene tone, Poor posture C 3/4 joint dysfunction Abnormal breathing patterns Post traumatic scarring & shortening of scalenes Increased distance the T 1 root must travel up and over the 1 st rib to join C 8 space between clavicle and 1 st rib effecting the subclavian artery subclavian vein Thoracic Outlet Syndrome Risk factors within the muscular tunnels 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) Compression of subclavian or axillary artery Ischemic changes Coldness Pain Diminished pulse Supraclavicular/infraclavicular bruits Diagnosis confirmed by arteriogram Thoracic Outlet Syndrome (Venous) Compression of subclavian or axillary vein UE swelling Feeling of heaviness Cyanotic discoloration Diagnosis confirmed by venogram 11

12 Only 10% of TOS Cases are Vascular Thoracic Outlet Syndrome- True Neurogenic Compression of the lower trunk of the brachial plexus Cervical rib/elongated transverse process confirmed by x-ray Pain/parasthesia C 8 -T 1 Positive EMG of the C 8 -T 1 musculature Thoracic Outlet Syndrome- Nonspecific Neurogenic Most controversial No conclusive objective tests 85% of TOS patients Dysfunction in the pressure gradient in the muscular and bony tunnels Thoracic Outlet Syndrome- Nonspecific 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 Syndrome- Nonspecific Neurogenic Thoracic Outlet Body Chart Lateral neck/supraclavicular pain Parasthesia, numbness, pain and or burning in the ulnar nerve distribution (most common), although may additionally be experienced in the median and radial nerve distributions 12

13 Thoracic Outlet Syndrome- Nonspecific 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 Examination Findings Poor posture/protective posture Minimal limitations with cervical ROM Tension in the scalene with contralateral t l sidebend 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 C 8 - T 1 distribution 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 Traditional tests Adson s test Exaggerated military 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