CHAPTER 10
The Thoracic Spine
Introduction
Thoracic spine manipulation (TSM) mainly involves high-velocity, low-amplitude (HVLA) thrust techniques being applied at any segment of the thoracic region. The therapy has been practised for years by different professions to treat a number of musculoskeletal conditions, including non-specific neck disorders, subacromial pain syndrome, kyphosis, scoliosis and juvenile kyphosis (Ombregt, 2013).
Although clinical pain syndromes in the thoracic region are less common compared with the cervical and lumbar regions, regionally interdependent musculoskeletal disorders are very common in the thoracic spine (e.g. upper thoracic immobility is often associated with neck conditions) (Walser, Meserve and Boucher, 2013). However, it is not yet fully understood why regional interdependence exists between different segments of the spine (Wainner et al., 2007). Moreover, there is limited evidence in support of TSM in regions adjacent to the thoracic spine. Given the lack of high-quality literature, the benefits and risks associated with TSM are not yet fully explored (Lemole et al., 2002).
This chapter is written to describe common injuries to the thoracic spine, the red flags for serious pathology and appropriate special tests to diagnose serious pathology in the region. In addition, this chapter will also describe various thoracic joints and their range of motion.
The thoracic spine is located in the middle segment of the spinal column, between the cervical spine in the neck and the lumbar spine in the lower back. It is made up of twelve vertebrae (T1–T12), which caudally increase in size, reflecting the caudal increase in body load (McKenzie and May, 2006). These vertebrae are generally intermediate in size compared with vertebrae of other segments of the spine. The size and shape of the upper thoracic vertebrae closely resembles the cervical vertebrae. Conversely, the lower thoracic vertebrae are more similar to the lumbar vertebrae (White and Panjabi, 1978).
Table 10.1 The joints of the thoracic spine | ||
Joint name | Description | Function |
Costovertebral joint | •A synovial joint that connects the head of the rib with the costal facets of adjacent vertebral bodies and the intervertebral disc in between •Composed of a fibrous capsule, the fan-shaped radiate ligament and the interarticular ligament | •Serves to support spinal movement •Helps the ribs to work in a parallel fashion while breathing |
Costotransverse joint | •Forms when the tubercle of the rib articulates with the transverse process of the corresponding vertebra •Consists of a capsule, the neck and tubercle ligaments, and the costotransverse ligaments •Absent in T11 and T12 | •Helps the ribs to work in a parallel fashion while breathing |
Zygapophyseal joints | •A set of synovial joints that are formed by joining the articular processes of two neighbouring vertebrae | •Serve to restrain the amount of flexion and anterior translation of the vertebral segment •Guide and constrain the motion of the vertebrae •Facilitate rotation |
Sources: Duprey et al. (2010); Pal, Routal and Saggu (2001); Bontrager and Lampignano (2013) | ||
The thoracic spine is the least mobile segment of the vertebral column, because of its articulations with the rib cage. Moreover, it is technically difficult to measure thoracic movements. For this reason, unlike its other spinal counterparts, studies done to evaluate the movement of the thoracic spine are very limited.
Table 10.2 Range of motion in the thoracic spine | ||
Movement type | Motion unit | Range of motion |
Flexion | C7–T1 | 9° (approximately) |
T1–T6 | 4° | |
T6–T7 | 4–8° | |
T12–L1 | 8–12° | |
Lateral bending | T1–T10 | 6° (approximately) |
T11–L1 | 8° (approximately) | |
Sagittal | T1–T10 | Less than 5° |
T10–T12 | 5° (approximately) | |
Rotation | T1–T4 | 8–12° |
T5–T8 | 8° (approximately) | |
T9–T12 | Less than 3° | |
Sources: McKenzie and May (2006); Leahy and Rahm (2007) | ||
Common Injuries
Injuries to the thoracic spine usually occur when external forces applied on the vertebral column go beyond its strength and stability. Common causes of injuries include a fall, motor vehicle accident, violent activity, sport accident and penetrating trauma. Such injuries usually lead to a fracture in the thoracic vertebrae, and subsequently to pain and poor spinal functioning, depending on the severity of the injury.
Table 10.3 Common injuries of the thoracic joints | |
Injury | Characteristics |
Compression fracture | •Causes the anterior part of the vertebra to break and lose height •Usually a stable fracture, as it does not move the bones out of their places •Does not cause neurologic problems •Commonly occurs in osteoporosis patients |
Vertebral body fracture | •Most common in the thoracolumbar region •Often results from a high-energy accident or osteoporosis •May also occur because of an underlying disorder, such as ankylosing spondylitis, a vertebral tumour or infection •Symptoms include pain or the development of neural deficits such as numbness, weakness, tingling, spinal shock and neurogenic shock •More predominant in men than women |
Fracture-dislocation | •A severe injury in which a thoracic vertebra fractures and moves off an adjacent vertebra •Usually an unstable injury •Often causes compression of the spinal cord |
Transverse process fracture | •Usually results from rotation or extreme lateral bending •Often occurs due to a direct blow to the thoracic region •Does not affect the spinal stability |
Sources: Kostuik et al. (1991); Ombregt (2013) | |
Red Flags
Red flags help to identify serious pathology in patients with thoracic pain. If a red flag symptom is found in a patient, the practitioner should prioritise sound clinical reasoning and exercise utmost caution, so that the patient is not placed at risk of an undue adverse event following TSM.
Table 10.4 Red flags for serious pathology in the thoracic spine | |
Condition | Signs and symptoms |
Spinal tumours | •Greater than 50 years of age •Past history of cancer •Unintentional weight loss •Constant progressive pain at night •Pain lasting for more than a month •No improvement after a month of conventional treatment |
Spinal infection | •Greater than 50 years of age • Related posts: Stay updated, free articles. Join our Telegram channel
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