Thoracic spine

Objectives

  • Demonstrate understanding of clinical anatomy & biomechanics of thoracic spine

  • Describe & discuss common causes & prevalence of thoracic region pain & dysfunction & appropriate orthopedic management

  • Perform safe & effective examination, evaluation, & interventions for thoracic region pain & dysfunction

  • Demonstrate clinical reasoning in differential diagnostic process of thoracic region pain & dysfunction

Anatomy & Biomechanics of Thoracic Spine

  • Transitional Zones

    • Cervicothoracic and thoracolumbar regions serve as transitional areas within the spine.

  • Structure

    • Most rigid portion of the spine due to rib articulations, essential for organ protection.

    • Each vertebra has 6-13 articulations, allowing flexibility and stability.

    • It plays a significant role in load transfer from the upper to lower limbs.

    • Structural kyphosis is prevalent, with the apex at the T6-T7 region.

    • Wedge-shaped vertebrae contribute to its unique biomechanical function.

Joints & Ligaments

  • Major ligaments involved include:

    • Radiate ligament

    • Costovertebral joint

    • Costotransverse ligaments

    • Costotransverse joint

    • Costochondral and sternocostal joints

  • Understanding the interconnections of these joints is essential for diagnosis and treatment.

Position of Processes (Rule of 3’s)

  • 1-3, 12: SP same level as TP.

  • 4-6, 11: SP located between TPs (same to TP below).

  • 7-10: SP at the level of TP below.

Diaphragm Functionality

  • Inhalation: Contracts and moves caudally.

  • Exhalation: Relaxes and moves cephalad.

  • Key muscles contributing include:

    • Diaphragm, Intercostals, and Pec Minor.

Mechanical Behavior

  • Influenced by load with axial load increasing stiffness and decreasing mobility.

  • Modified by cage-like ribs and the kyphotic curve, leading to posterior tension and anterior compression that may result in vertebral wedging and kyphosis.

Rib Movements

  • Various motion patterns:

    • Pump Handle (T1-T6): Primarily anterior-posterior movement.

    • Bucket Handle (T7-T10): Motion resembling a bucket handle in its elevation and depression.

    • Caliper Action (T11-T12): Free floating movements without rigid attachment.

Pathomechanics

  • Limited research on motion in individuals with thoracic disorders.

  • Motion impairments often refer to facet joint mobility; however, no universal language exists for describing these impairments.

Common Conditions in Thoracic Spine

  • Postural Dysfunction

    • Prevalence of thoracic spinal pain is 15-20% over a lifetime.

    • Maigne’s syndrome presents as thoracic pain of cervical origin.

  • Disc & Joint Disorders

    • Thoracic disc dysfunction comprises <4% of symptomatic disc protrusions.

    • Facet joint dysfunction identified by movement restrictions.

  • Soft Tissue Conditions

    • Conditions like Tietze Syndrome involve inflammation of the costosternal cartilage.

    • Intercostal strain and costochondritis are also significant.

Ankylosing Spondylitis

  • Chronic systemic rheumatic disease leading to ossification of joints, affecting mainly young individuals (15-40 years old).

  • Symptoms include night and morning stiffness, lower back pain, and eventual loss of lumbar lordosis.

Scoliosis

  • Lateral curvature of the spine with specific characteristics:

    • Structural (irreversible) vs. non-structural (reversible).

    • Significant curves (>40°) can lead to additional health issues, including pain and cardiopulmonary complications.

Examining the Thoracic Spine

  • Comprehensive Evaluation Process

    • Initial patient observation, subjective history, and physical examination.

    • Use of follow-up assessments and evaluations to inform ongoing care.

  • Importance of Clinical Reasoning

    • Formulating a diagnosis based on the comprehensive examination, interactions, and understanding the patient’s personal history and goals.

Referral Patterns in Thoracic Disorders

  • Symptoms above T4 tend to be cervical in origin, while those at T5-T12 are more likely thoracic.

  • Differentiating between musculoskeletal and non-musculoskeletal symptoms is crucial for proper management.

Patient Management Principles

  • Develop individualized care strategies based on a variety of diagnostic tests and patient interaction results.

  • Focus on therapeutic exercises and manual techniques to aid recovery and improve functionality.