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 1
2 Objectives Discuss red flag signs for the thoracic region Apply key concepts from the thoracic anatomy/kinesiology self-study to aid in differential diagnosis for the following: Thoracic neuropathic pain Thoracic disc and joint disorders Thoracic stiffness 2
3 3 RED FLAGS
4 Upper Thoracic Pathology 4 Pancoast tumor Cigarette smokers Age >50 Nagging shoulder/periscapular pain progressing to burning in the C8 distribution of the arm May have wheezing May have Horner s syndrome Drooping eyelid Sweat disturbance Constricted pupil SC joint septic arthritis Insidious onset History of IV drug use, diabetes, trauma, or infection Tender and swollen SC joint Limited shoulder ROM
5 Vertebral Compression Fracture 5 Most common at T7, T8, T11, L1 Female Female Age > 70 Age > 52 Significant trauma No leg pain Prolonged corticosteroid BMI 22 use ¾ = + LR of 218 No regular exercise Henschke et al, Arthritis 4/5 = + LR of 9.6 Rheum /5= - LR of 0.16 Roman et al, JMMT 2010
6 Spinal Tumor 6 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 Prostate, t Thyroid, Breast, Liver, Kidney
7 7 NERVE
8 Pathophysiology of Somatic Nerves Radiculopathy rare due to high exit point of roots in IVF Myelopathy possible due to small cord and canal T4-T9 Intercostal neuralgia Thoracic outlet syndrome 8
9 Pathophysiology of Autonomic Nerves 9 Tension on sensory branches and sympathetic ganglion, most commonly T2-T4T4 Sizer et al, Pain Practice, 2001 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 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 10
11 Evidence of T10 Syndrome? 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
12 Differential Diagnosis 12 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
13 13 LOCAL THORACIC PAIN
14 Pathophysiology of Local Thoracic Pain Disc disorders Disc Protrusion Disc Prolapse Joint disorders Zygapophyseal joint Ribs Costotransverse joint Costovertebral joint Costochondral joint 14
15 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
16 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
17 Regional Interdependence 17 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
18 Z-Joint Dysfunction 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,
19 Rib Joint Dysfunction 19 Ribs 1-4 Often seen in MVA/whiplash 2-3 Costochondritis Women>men, Left>right 3-5 Disc narrowing leads to CV joint arthrosis 8-10 Slipped rib tip Hyperkyphotic posture or direct trauma
20 Differential Diagnosis 20 Disc (Sizer et al 2001) Dural irritationit ti Joint PLL/posterior annulus attached to dural sac Production of positive dural signs Neck flexion at end range thoracic rotation Thoracic slump Zygapophyseal Primary restriction into 3-D rotation Ribs Primary restriction into sidebending
21 21 MOBILITY
22 Pathophysiology 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 22
23 Differential Diagnosis 23 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 Rotation DSM 24 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 Flexion DSM Young: worse pain with prolonged flexed sitting Older: Pain with reversal of flexion/walking/standing Pain/Increased thoracic flexion Limited thoracic extension Thoracic kyphosis, swayback Weak intrinsic thoracic paraspinals, p scapula retractors, TRA, and external obliques Stiff lumbar paraspinals, rectus abdominus, internal obliques 25
26 Extension DSM 26 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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