EXAMINATION OF THE THORACOLUMBAR SPINE (P1; THORACIC SPINE)

synovial plane joints located between the ribs and the vertebral bodies

Costovertebral joints

Which ribs articulate with one vertebra?

1, 10, 11, and 12

Which ribs articulate with 2 adjacent vertebra and IVD?

2 through 9

The main ligament of the costovertebral joint?

joins the anterior aspect of the head of the rib radiating to the sides of the vertebral bodies and disc in between

Radiate ligament

synovial joints found between the ribs and the transverse processes

costotransverse joints

Ribs with no costotransverse joints

11 and 12

This costal ligament runs from the lower border of the transverse process above to the upper border of the rib and its neck

Superior Costotransverse ligament

This costal ligament runs between the neck of the rib and the transverse process at the same level.

Costotransverse ligament

This costal ligament runs from the tip of the transverse process to the adjacent rib.

Lateral Costotransverse ligament

joints that lie between the ribs and the costal cartilage :

joints that are found between the costal cartilage and the sternum.

Costochondral joints

Sternocostal joints

• Joints 2 through 6 are synovial

• first costal cartilage is united with the sternum by a synchondrosis (cartilaginous jt.).

Components of the main trijoint complex of the thoracic spine:

• 2 apophyseal joints (facet joints)

  • aka zygapophyseal joints

• IV Disc between vertebrae

The superior facet of the T1 vertebra is similar to a facet of the cervical spine. Because of this, T1 is classified as a what type of vertebra?

Transitional vertebra

The superior facet faces up and back; the inferior facet faces down and forward.

The T2 to T11 superior facets face in what direction?

up, back, and slightly laterally (superoposterolaterally)

opposite for inferior facets

Angle of facet inclination for T2- T3:

Angle of facet inclination for T4- T9:

45° to 60°

90°

What movement do the thoracic facet joints limit?

What movement do they facilitate?

limit flexion and anterior translation

facilitate rotation

Aside from T1, which other vertebrae are considered transitional vertebrae?

T11 and T12

• The superior facets of these two vertebrae face up, back, and more medially; the inferior facets face forward and slightly laterally.

T7

• the point at which the lower limb axial rotation alternates with the upper limb axial rotation

Facet Joints of the Thoracic Spine

Resting position:

Close packed position:

Capsular pattern:

Facet Joints of the Thoracic Spine

Resting position: Midway between flexion and extension

Close packed position: Full extension

Capsular pattern: Side flexion and rotation equally limited, extension

Within the thoracic spine, there are 12 vertebrae, which diminish in size from _________ and then increase progressively in size to ______.

Within the thoracic spine, there are 12 vertebrae, which diminish in size from T1 to T3 and then increase progressively in size to T12.

Which thoracic vertebra has the greatest spinous process angulation?

Which thoracic vertebrae have spinous processes that face directly posteriorly?

T7

T1-3

TRUE OR FALSE:

the tips of the spinous processes of T4 to T6 are on a plane halfway between their own transverse processes and the transverse processes of the vertebrae below.

TRUE

TRUE OR FALSE:

the tips of the spinous processes of T7-10 are on a plane of the transverse processes of the vertebrae below.

TRUE

Matching type: T11, T12, T10

• spinous process is level with the transverse process of the vertebra below =

• the spinous process is level with the transverse process of the same vertebra=

• the spinous process is halfway between the two transverse processes of the vertebra=

Matching type: T11, T12, T10

• spinous process is level with the transverse process of the vertebra below = T10

• the spinous process is level with the transverse process of the same vertebra= T12

• the spinous process is halfway between the two transverse processes of the vertebra=T11

Which ribs articulate with the sternum directly and are classified as true ribs?

Ribs 1-7

Which ribs join directly with the costocartilage of the rib above and are classified as false ribs?

Ribs 8-10

Which ribs do not attach to either the sternum or the costal cartilage at their distal ends and are considered floating ribs

Ribs 11-12

True or False:

At the top of the rib cage, the ribs are relatively horizontal. As the rib cage descends, they run more and more obliquely downward.

True

True or False:

The first 4 ribs increase the anteroposterior dimension of the chest, mainly by rotating around their long axes.

False:

The first 6 ribs increase the anteroposterior dimension of the chest, mainly by rotating around their long axes.

Rotation downward of the rib neck is associated with depression, whereas rotation upward of the same portion is associated with elevation. accompanied by elevation of the manubrium sternum upward and forward. What is this movement called?

Pump handle action

Which ribs mainly increase in lateral, or transverse, dimension?

Ribs 7-10

the ribs move upward, backward, and medially to increase the infrasternal angle, or they move downward, forward, and laterally to decrease the angle, what is this movement called?

Bucket handle action

True or false

Ribs 7-10 can perform the bucket handle action but ribs 2-6 cannot.

False:

This action is also performed by ribs 2 through 6 but to a much less degree

Some ribs move laterally, in what is known as a caliper action, which ribs do this?

Ribs 8-12

In the anterior half of the chest, the ribs are ____________; in the posterior half, they are covered by ____________.

In the anterior half of the chest, the ribs are subcutaneous; in the posterior half, they are covered by muscles.

Scheuermann’s disease typically occur in young people between how many years of age?

13-16 years of age

True or False:

Idiopathic scoliosis is most commonly seen in adolescent males.

False":

Idiopathic scoliosis is most commonly seen in adolescent females

Most commonly, rib injuries are caused by ________

Trauma

True or False:

Thoracic spine problems may result from disease processes (e.g., scoliosis) and may have an sudden onset

FALSE

Thoracic spine problems may result from disease processes (e.g., scoliosis) and may have an insidious onset

Pain from true thoracic trauma tends to be _________ to the area of injury

Facet syndromes present as stiffness and local pain, which can be __________.

Pain from true thoracic trauma tends to be localized to the area of injury

Facet syndromes present as stiffness and local pain, which can be referred.

True or False

Thoracic spine pain and visceral pain can mimic each other.

True

Red Flags

True or False:

With thoracic disc lesions, because of the rigidity of the thoracic spine, passive movements do not often show the characteristic pain pattern, and sensory and strength deficits are easily detected.

FALSE:

With thoracic disc lesions, because of the rigidity of the thoracic spine, active movements do not often show the characteristic pain pattern, and sensory and strength deficits are difficult if not impossible to detect

This condition causes pain that follows the path of the ribs or a deep, “through-the-chest” pain.

Thoracic root involvement or spondylosis

which joints commonly refer pain along the rib.

Costovertebral, and costotransverse joints

ribs also refer pain to the ribs (no shit brh)

True or False:

Progressive abdominal pain preceding nausea, vomiting, diarrhea, fever, and loss of appetite in children is suggestive of chronic appendicitis.

FALSE:

Progressive abdominal pain preceding nausea, vomiting, diarrhea, fever, and loss of appetite in children is suggestive of acute appendicitis.

Pain related to breathing may signal pulmonary problems or may be related to movement of the ribs.

Pain referred around the chest wall tends to be _____________ in origin

Pain referred around the chest wall tends to be costovertebral in origin

If a breathing problem exists, it may be caused by a structural deformity (scoliosis), thoracic trauma or thoracic pathology

Thoracic Trauma that can cause difficulty in breathing:

• disc lesions

• fractures

• contusion

Thoracic Pathology that can cause difficulty in breathing:

• pneumothorax

• pleurisy

• tumors

• pericarditis.

Chest Pain Patterns

Thoracic nerve root pain is often severe and is referred in a sloping band along a/an ____________ space.

Thoracic nerve root pain is often severe and is referred in a sloping band along an intercostal space.

True or False:

It has been reported that any symptoms above a line joining the superior angles of the scapula should be considered of cervical origin until proven otherwise, especially if there is no history of trauma.

FALSE:

It has been reported that any symptoms above a line joining the inferior angles of the scapula should be considered of cervical origin until proven otherwise, especially if there is no history of trauma

What pain is accentuated by coughing, sneezing, or straining?

Dural Pain

True or False:

Active use of the arms sometimes irritates a thoracic lesion therefore pulling and pushing activities can be especially bothersome to a patient with thoracic problems.

True

True or False:

Costal pain is often elicited by breathing and/or underhand arm motion.

False:

Costal pain is often elicited by breathing and/or overhand arm motion.

True or False:

bracing the arms often makes breathing harder because this inhibits the action of the accessory muscles of respiration.

False:

bracing the arms often makes breathing easier because this facilitates the action of the accessory muscles of respiration.

What position may be painful for those with facet pathology?

sitting upright into full extension

What position may be painful for those with anterior vertebral compression fractures?

forward flexed postures

What type of pain tends to be vague, dull, and indiscrete and may be accompanied by nausea and sweating?

Visceral pain

Visceral pain tends to follow dermatome patterns in its referral:

• Cardiac pain is referred to :

• Stomach pain is referred to :

• Ulcers may be referred to :

Visceral pain tends to follow dermatome patterns in its referral:

• Cardiac pain is referred to : C4 (shoulder) and posteriorly to T2

• Stomach pain is referred to : T6–T8 posteriorly

• Ulcers may be referred to : T4–T6 posteriorly

True or False:

Conditions, such as herpes zoster, can cause unilateral, spontaneous pain.

True

Posteriorly, the medial edge of the spine of the scapula should be level with the ______ spinous process

the inferior angle of the scapula is level with the _________ spinous process

medial border of the scapula is parallel to the spine and approximately _____ cm lateral to the spinous processes.

T3

T7-9

5 cm

Normal kyphosis in the thoracic spine is ______________ and will depend on age (increases with age or decreases?)

20° to 40°

Increases

A kyphotic angle of greater than 40° is called?

What method is used to measure the kyphosis?

Hyperkyphosis

Cobb method

After what age does the thoracic kyphosis tend to increase?

Is the increase is higher in males or females?

40

Females

This is a deformity caused by a decreased pelvic inclination with a thoracolumbar or thoracic kyphosis.

How many degrees of pelvic inclination causes this?

Round back

20°

This kyphotic deformity is usually structural and often results from an anterior wedging of the body of one or two thoracic vertebrae.

Hump back

The wedging may be caused by a compression fracture, tumor, or bone disease.

The localized, sharp, posterior angulation of the hump back is called a?

Gibbus

True or False:

The pelvic inclination is usually normal (30°) in a hump back deformity

True

This deformity results from postmenopausal osteoporosis.

Dowager’s hump

True or False:

In the dowager’s hump deformity, anterior wedge fractures occur to several vertebrae, usually in the middle to lower thoracic spine, causing a structural scoliosis that also contributes to a decrease in height.

False:

In the dowager’s hump deformity, anterior wedge fractures occur to several vertebrae, usually in the upper to middle thoracic spine, causing a structural scoliosis that also contributes to a decrease in height.

Deformity caused by a decreased pelvic inclination (20°) with a mobile spine.

Flat back

Scoliosis in the cervical spine is called?

torticollis

Causes of Structural scoliosis:

• congenital problem

• wedge vertebra

• hemivertebra

• failure of vertebral segmentation

Causes of Non-structural scoliosis:

• Poor posture

• hysteria

• nerve root irritation

• inflammation in the spine area

• leg length discrepancy

• hip contracture

Enumerate the level of the apex in:

• cervical scoliosis, or torticollis =

• cervicothoracic curve =

• thoracic curve =

• thoracolumbar curve =

• lumbar curve =

• lumbosacral scoliosis =

Enumerate the level of the apex in:

• cervical scoliosis, or torticollis = C1-6

• cervicothoracic curve = C7-T1

• thoracic curve = T2-11

• thoracolumbar curve = T12-L1

• lumbar curve = L2-L4

• lumbosacral scoliosis = L5-S1

severe rotation of the vertebrae causes a rib deformity called?

Razorback spine

Structural scoliosis effects:

• vertebral bodies rotate towards the concavity or convexity of the curve?

• ribs on the convex side of the curve to push posteriorly or anteriorly?

• The thoracic cage narrows on the convex or concave side?

• The ribs move anteriorly on the convex or concave side?

• A “hollow” and a widening of the thoracic cage occurs on the convex or concave side?

Structural scoliosis effects:

• vertebral bodies rotate towards the convexity of the curve

• ribs on the convex side of the curve to push posteriorly

• The thoracic cage narrows on the convex

• The ribs move anteriorly on the concave side

• A “hollow” and a widening of the thoracic cage occurs on the concave side

True or False:

In idiopathic scoliosis, the rib contours are not normal, and there is asymmetry of the ribs. Muscle flaccidity resulting from injury may also be evident.

False

In idiopathic scoliosis, the rib contours are not normal, and there is asymmetry of the ribs. Muscle spasm resulting from injury may also be evident

Breathing patterns:

• Children =

• Women =

• Men =

• The aged =

Breathing patterns:

• Children = Abdominal

• Women = Upper thoracic

• Men = Upper and Lower thoracic

• The aged = Lower thoracic and abdominal

Muscles for respiration:

Chest deformity where the sternum projects forward and downward like the heel of a boot, increasing the anteroposterior dimension of the chest

Pigeon chest (pectus carinatum)

This congenital deformity impairs the effectiveness of breathing by restricting ventilation volume.

A congenital deformity that results from the sternum’s being pushed posteriorly by an overgrowth of the ribs.

The anteroposterior dimension of the chest is decreased, and the heart may be displaced.

funnel chest (pectus excavatum)

Affects respiration and can cause kyphosis

A deformity where the sternum projects forward and upward so that the anteroposterior diameter is increased.

barrel chest deformity

It is seen in pathological conditions, such as emphysema.

Active Movements of the Thoracic Spine:

• Forward Flexion =

• Extension=

• Side flexion=

• Rotation=

• Costovertebral expansion=

• Rib motions = (enumerate)

• Combined movements

• Repetitive movements

• Sustained postures

Active Movements of the Thoracic Spine:

• Forward Flexion = 20°–45°

• Extension= 25°–45°

• Side flexion= 20°–40°

• Rotation= 35°–50°

• Costovertebral expansion= 3–7.5 cm

  • Around the fourth intercostal space

• Rib motions = pump handle, bucket handle, and caliper

• Combined movements

• Repetitive movements

• Sustained postures

What is the normal range if we measure the C7 spinous process to the T12 (thoracic level) during forward flexion?

2.7 cm (1.1 inch) difference

What is the normal range if we measure the C7 spinous process to the S1 (thoracolumbar level) during forward flexion?

10cm (4 inch) difference

How much movement occurs between T12 and S1 (most movement in the thoracolumbar area)?

7.5 cm (3 inches)

True or false:

If the patient has an excessive kyphosis to begin with, increased forward flexion movement occurs in the thoracic spine.

False:

If the patient has an excessive kyphosis to begin with, very little forward flexion movement occurs in the thoracic spine

True or False:

Doing flexion while sitting to helps to decrease pelvic and hip movements.

True

True or False:

If symptoms arise from forward flexion on the spine with the neck flexed by the hands, the examiner should repeat the movement with the neck slightly extended and the hands removed. This will help to differentiate between cervical and thoracic pain.

True

During flexion, the ribs roll ________, their anterior aspect ______, and the facet joints glide ________.

During flexion, the ribs roll forward, their anterior aspect drops, and the facet joints glide superiorly.

Opposite for extension

Normal value for thoracic spine extension:

25° to 45° (Magee)

25° (Norkin; thoracolumbar extension)

True or False:

the normal kyphotic posture of the thoracic spine should disappear on passive extension with the spine becoming straight, but not in active extension.

False:

the normal kyphotic posture of the thoracic spine should disappear on active and passive extension with the spine becoming straight

What is the normal range if we measure the C7 spinous process to the T12 (thoracic level) during extension?

2.5-cm (1 inch) (norkin)

2.7cm(1.1 inch) (sir jose)

Side (lateral) flexion is approximately how many degrees to the right and left in the thoracic spine?

20° to 40° (Magee)

35° (Norkin; thoracolumbar side flexion)

During side flexion, if the ipsilateral paraspinal muscles tighten or their contracture is evident ankylosing spondylitis or pathology causing muscle spasm should be considered.

What sign is shown here?

Forestier’s bowstring sign

Rotation in the thoracic spine is approximately how many degrees?

35° to 50° (Magee)

45° (Norkin; thoracolumbar rotation)

What are the components of a thoracic ring?

How many are there in the human body?

• two vertebrae

• the adjacent two ribs and their attachments into the sternum

• intervertebral disc

• costal cartilage

• sternum

There are 10 thoracic rings

True or False

Because of the shape of the facets, there is more rotation in the lower thoracic spine than the upper thoracic spine

True or False

Because of the shape of the facets, there is more rotation in the upper thoracic spine than the lower thoracic spine.

A second method of measuring chest expansion is to measure at three different levels.

• under the axillae for apical expansion

• at the nipple line or xiphisternal junction for midthoracic expansion

• at the T10 rib level for lower thoracic expansion

If a rib stops moving relative to the other ribs on inhalation, it is classified as a?

Depressed rib

The highest restricted rib causes the greatest problem

If a rib stops moving relative to the other ribs on exhalation, it is classified as an?

Elevated rib

The lowest restricted rib causes the greatest problem