Thoracic Spine Applied Anatomy. Jason Zafereo, PT, OCS, FAAOMPT

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1 Thoracic Spine Applied Anatomy Jason Zafereo, PT, OCS, FAAOMPT Clinical i l Orthopedic Rehabilitation ti Education

2 Objectives Discuss concepts relevant to thoracic pain of red flag origin Discuss concepts relevant to pathophysiology and differential diagnosis for neuropathic pain originating from the thorax Discuss concepts relevant to pathophysiology and differential diagnosis for disc and joint disorders of the thorax Discuss concepts relevant to pathophysiology and differential diagnosis for mobility of the thorax

3 RED FLAGS

4 Vertebral Compression Fracture Female Age > 70 Significant trauma Prolonged corticosteroid use ¾ = + LR of 218 Henschke et al, Arthritis Rheum 2009 Female Age > 52 No leg pain BMI 22 No regular exercise 4/5 =+LR of 9.6 2/5= - LR of 0.16 Roman et al, JMMT 2010

5 Spinal Cancer Age > 50 Previous hx cancer Failure to improve in 1 mo of therapy Unexplained weight loss Sens = 1.0; Spec =.60 Deyo and Jarvk, Ann Intern Med 2002

6 NERVE

7 Pathophysiology of Neural Structures Radiculopathy rare due to high exit point of roots in IVF Myelopathy possible due to small cord and canal T4-T9 Tension on sensory branches and sympathetic ganglion, most commonly T2 to T4 Sizer et al, Pain Practice, 2001

8 Pathophysiology of T4 Syndrome Intercostobrachial nerves contribute to Posterior brachial cutaneous branch of radial nerve Medial cutaneous nerve of the arm and forearm T2 sympathetic ganglion (Fraser, J Orthop Med, 1993) Extremity swelling Weakness of grip Difficulty breathing

9 Pathophysiology of Sympathetic/Somatic Pain Extensive branching between systems Close proximity to heads of ribs, ventral aspect of vertebral column (Nathan, Spine, 1987) Sympathetic ganglion Head and neck C8-T5 UE T2-T10 LE T10-L2

10 Evidence of T10 Syndrome? 52-year old female with low back and B LE symptoms Unremarkable exam except T10-12 stiffness Positive sympathetic slump Longsitting slump with contralateral thoracic sidebend/rotation and Grade 4 AP pressure e on ribs corresponding to sympathetic ganglia referral distribution Cleland and McRae 2002 Geerse 2012

11 Differential Diagnosis of Neural Structures Radiculopathy Spinal levels in relation to Sensory/motor levels 2 segments above for T1-6 3 segments above for T7-10 Abdominal weakness T6-12 Myelopathy y Mild paraparesis of LEs Positive Babinski Wide-based gait Occasional sensory disturbances

12 LOCAL THORACIC PAIN

13 Pathophysiology of Local Thoracic Pain Disc disorders Disc Protrusion Disc Prolapse Joint disorders Zygapophyseal joint Ribs Costotransverse joint Costovertebral joint Costochondral joint

14 Pathophysiology of Disc Disorders Protrusion More common than once believed Commonly seen in midthoracic segments 11% of documented lesions on MRI were symptomatic on discography (Errico et al 1997)

15 Pathophysiology of Disc Disorders Prolapse Tend to occur in mid to lower thoracic More flexion/extension available Increased load bearing (Edmondston and Singer, Manual Therapy, 1997) 33% of body weight at T8 47% of body weight at T12

16 Pathophysiology of Joint Disorders Zygapophyseal joint T1-4 Morphologically similar to cervical spine Moves with cervical motion T5-8 UE elevation creates movement down to T5/6 T9-12 Morphologically similar to lumbar spine LE motion creates movement up to T8

17 Pathophysiology of Joint Disorders Zygapophyseal arthropathy often associated with secondary disc disorder Most common sites C7-T1 T3-5 T11-L1 Sizer et al, Pain Practice, 2001 Shore, British J Surg, 1985

18 Pathophysiology of Joint Disorders Ribs 1-4 Often seen in MVA/whiplash 2-3 C t h d iti Costochondritis Women>men, Left>right 3-5 Disc narrowing leads to CV joint arthrosis 8-10 Slipped rib tip Hyperkyphotic posture or direct trauma

19 Differential Diagnosis of Disc Disorders Disc (Sizer et al 2001) Uniplanar rotation ti or flexion provocative Breathing provocative Dural irritation PLL/posterior annulus attached to dural sac Production of positive dural signs Neck flexion at end range thoracic rotation Thoracic slump

20 Differential Diagnosis of Joint Disorders Zygapophyseal Joint 3-D motion testing ti most provocative, but coupling is variable Rib Joints Uniplanar sidebending di most provocative Breathing provocative

21 MOBILITY

22 Pathophysiology of Mobility Posture and ROM Non-contractile til determinants Vertebral body/disc shape Tension in associated ligaments Contractile determinants Deep one joint muscles and thoracic long extensors

23 Differential Diagnosis Mobility Age predictive of impairment Old likely related to anatomical changes Postural correction not likely except through cervical and lumbar spine Young likely related to postural muscle weakness/stiffness Poor correlation between thoracic kyphosis angle and thoracic extension ROM (Edmondston et al 2011) Thoracic postural correction possible Flexion-rotation syndrome most common Sahrmann 2011

24 Differential Diagnosis Mobility Rotation syndrome Pain/asymmetry with rotation/sidebend Pain with unilateral shoulder flexion SB/rotation postural deviation around area of pain (possibly scoliosis) Weak intrinsic thoracic paraspinals, lower scapula, and obliques Stiff ribs, lats

25 Differential Diagnosis Mobility Flexion syndrome Young: worse pain with prolonged flexed sitting Older: Pain with reversal of flexion/walking/standing g Pain/Increased thoracic flexion Limited thoracic extension Thoracic kyphosis, swayback Weak intrinsic thoracic paraspinals, scapula retractors, TRA, and external obliques Stiff lumbar paraspinals, rectus abdominus, internal obliques

26 Differential Diagnosis Mobility Extension syndrome Pain with extension or return from flexion Limited thoracic flexion, tilted/winged scapulae Military posture Weak abdominals (rectus and IO) and serratus Stiff thoracic extensors and scapular adductors

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