THORACIC SPINE

CHAPTER SEVEN THORACIC SPINE

INTRODUCTION

Thoracic spinal pain and dysfunction present a particularly challenging clinical dilemma. Thoracic spinal pain may arise from somatic and visceral origins. Pain felt along the thoracic spine may arise from the ribs, the abdomen, or the vertebral column.

The thoracic spine is the part of the vertebral column that is most rigid because of the rib cage. The rib cage, in turn, provides protection for the heart and lungs.

Thoracic pain can occur as a referred visceral symptom, radiating from the chest and abdomen. The pain may also appear as a symptom of musculoskeletal origin. Sudden pain in the thoracic region occurs less often than in the more mobile cervical and lumbar spines.

The structure of the thorax as a whole is such that overall motion of this portion of the spine is limited.

TABLE 7-1 THORACIC SPINE CROSS-REFERENCE TABLE BY ASSESSMENT PROCEDURE

TABLE 7-2 THORACIC SPINE CROSS-REFERENCE TABLE BY SYNDROME OR TISSUE

Ankylosing spondylitis	Amoss sign Chest expansion test Forestier bowstring sign Rib motion test
Fibrositis	Sponge test
Fracture	Spinal percussion test
Intercostal syndrome	Rib motion test Schepelmann sign
Intervertebral disc syndrome	Amoss sign Spinal percussion test
Myelopathy	Beevor sign
Rib injury	Rib motion test Schepelmann sign Sternal compression test
Scoliosis	Adams positions
Sprain	Amoss sign Spinal percussion test
Strain	Spinal percussion test
T1–T2 nerve root	First thoracic nerve root test Passive scapular approximation test
Tuberculosis	Anghelescu sign

ORTHOPEDIC GAMUT 7-2 MECHANICAL SPINAL SYNDROME CLASSIFICATIONS

Adapted from Hefford C: McKenzie classification of mechanical spinal pain: profile of syndromes and directions of preference, Man Ther 13(1):75–81, 2008.

1. Posture syndrome. Pain arises as a result of mechanical deformation of normal soft tissues from prolonged end-range loading of periarticular structures.

2. Dysfunction syndrome. Pain occurs as a result of mechanical deformation of structurally impaired tissues (scarred, adhered, or adaptively shortened tissue).

3. Derangement syndrome. Pain occurs as a result of a disturbance in the normal resting position of the affected joint surfaces.

4. Other. Patient exhibits signs and symptoms of other known abnormality (i.e., spinal stenosis, hip disorders, sacroiliac disorders, low back pain in pregnancy, zygapophyseal disorders, spondylolysis and spondylolisthesis, and postsurgical problems).

ORTHOPEDIC GAMUT 7-3 THORACIC SPINE

Stabilizing influences for the thoracic spine include the following:

• The first element is the vertebral articular process. The interlocking arrangement of the thoracic facets prevents anterior displacement of the vertebra and forms the imbrication of the thoracic spine.

• The second primary stabilizing influence of the thoracic spine is the vertebral body. At the posterior of the vertebral bodies, the height of the body is greater than in the anterior. This circumstance contributes to the thoracic spine kyphosis.

• The third stabilizing influence is the structure of the ribs and their attachments to the spine. The ribs help stiffen the thoracic spine.

• The fourth primary stabilizing influence for the thoracic spine is the structure of the intervertebral disc. The thoracic spine intervertebral discs are more narrow and thin than in the cervical or lumbar spines. They are also less elastic than all the other disc tissues of the spine.

ORTHOPEDIC GAMUT 7-4 THORACOLUMBAR SPINE

To assess range of motion of the thoracolumbar spine, the patient is directed to do the following:

1. Slowly bend forward at the waist and try to touch the toes (while observed for scoliosis) (Figs. 7-1 and 7-2).

2. Bend back as far as possible (hyperextending the spine) (Fig. 7-3).

3. Bend to the right and left side as far as possible (lateral bending with the pelvis stabilized) (Fig. 7-4).

4. Turn to the right and left in a circular motion (with the pelvis stabilized) (Figs. 7-5 and 7-6).

FIG. 7-1 Flexion range of motion in the thoracic spine is 20 to 45 degrees.

FIG. 7-2 For testing flexion with an inclinometer, the patient is seated or standing. (A). The thoracic spine is flexed forward so as not to involve lumbar spine motion (B). Both instrument readings are recorded. The T12 value is subtracted from the T1 value to arrive at the thoracic flexion angle.

FIG. 7-3 Extension in the thoracic spine is normally 25 to 35 degrees.

FIG. 7-4 Lateral flexion is approximately 20 to 40 degrees to the right and left.

FIG. 7-5 Rotation in the thoracic spine is approximately 35 to 50 degrees.

FIG. 7-6 When an inclinometer is used to assess thoracic spinal rotation, the patient is standing. The patient is flexed forward. The T12 measurement is subtracted from the T1 measurement to arrive at the thoracic rotation angle.

ESSENTIAL MUSCLE FUNCTION ASSESSMENT

In addition to te bony and discal stabilizing influences of the thoracic spine are muscles that support the spinal column. The thoracic spinal column serves as the attachment for many of the muscles of the trunk, shoulder, and arm.

During the trunk extension test, the latissimus dorsi, quadratus lumborum, and trapezius assist back extensors. The head and neck extensor muscles and the hip extensors should be tested before the back extensors are tested (Fig. 7-7).

FIG. 7-7 The patient is prone. The patient then attempts trunk extension.

ADAMS POSITIONS

Assessment for Pathologic or Structural Scoliosis

Comment

The spinal column centers the mass of the torso and head in a line along the vertical axis that falls through the pelvis. Disturbances of the spine, such as the curvatures associated with scoliosis, may significantly alter the normal balance and coordination of the spine (Table 7-3).

TABLE 7-3 THORACIC SPINE SYNDROMES

Scoliosis is also classified as either structural or nonstructural. Structural curves are fixed and nonflexible and fail to correct with side bending. Nonstructural curves, on the other hand, are flexible and readily correct with side bending. The Lenke Classification System helps examiners develop a more complete picture of the patient’s condition by understanding the scoliosis as multidimensional and considering it from more than one view. The Lenke classification method also gives more detailed shorthand for communicating about scoliosis in professional settings, using a widely understood set of criteria (Table 7-4).

TABLE 7-4 LENKE SCOLIOSIS CLASSIFICATION

The Lenke Classification System is simple, accurate, and easy to reproduce and communicate between health care providers. It relies on measurements taken from standard radiographs (X-rays). In this method, the examiner evaluates X-rays of the patient from the front, the side, and in bending positions. Each scoliosis curve is then classified in three steps by the region of the spine, the degree or angle of the curve, and the relationship of the side-to-side curve to the sagittal plane. For example, many scoliosis curves affect the presence or absence of kyphosis, which is the outward or convex curve normally found in the upper back. In addition, each aspect of the curve is evaluated for its relative stiffness or flexibility.

From Dr. Lawrence Lenke, Washington University School of Medicine, St. Louis, Missouri. Available at: www.spinal-deformity-surgeon.com.

PROCEDURE

• If the patient has an S or C scoliosis, the curvature may straighten when the spine flexes forward.

• A curvature that does straighten is a negative sign, indicating evidence of functional scoliosis.

• A positive sign occurs when the scoliosis does not improve after flexing forward.

• A positive sign is evidence of pathologic or structural scoliosis, and it indicates altered morphologic abnormality, pathologic condition, trauma, and subluxation.

• A posterior Adams position requires the examiner to be behind the patient (Fig. 7-8).

• An anterior Adams position requires the examiner to be in front of the patient.

FIG. 7-8

When the scoliotic curvature disappears in the Adams position, the curves are mild to moderate, or less than 25 degrees. These curves have more of a functional component than a structural component and are amenable to conservative management.

AMOSS SIGN

Assessment for Ankylosing Spondylitis, Severe Sprain, or Intervertebral Disc Syndrome

Comment

Ankylosing spondylitis (AS), an ascending disease, affects the thoracic region after the lumbar. Patients with this condition experience back pain, but the anterolateral chest pain and the limited chest expansion bother them the most. In some patients, these symptoms may occur rather early in the life of the disease, but they usually become bothersome after 6 years of illness. Chest pain, which usually occurs during inspiration, and limited chest expansion are caused primarily by involvement of costovertebral and manubriosternal joints, as well as the costochondral junctions and the clavicular joints. The girdle-like restriction may cause a sense of anxiety and dyspnea, particularly during exertion. However, respiratory problems are surprisingly uncommon, although restricted ventilatory volumes are detected by pulmonary function studies (Table 7-5). Of course, should concomitant disease result in impaired diaphragmatic breathing, a problem is likely to develop.

TABLE 7-5 MODIFIED NEW YORK CRITERIA FOR ANKYLOSING SPONDYLITIS DIAGNOSIS

Clinical criteria	Low back pain and stiffness for more than 3 months that improves with exercise but is not relieved by rest Limitation of motion of the lumbar spine both the sagittal and the frontal planes Limitation of chest expansion relative to normal values corrected for age and sex
Radiological criterion	Sacroiliitis grade 2 bilaterally or sacroiliitis grade 3–4 unilaterally

Adapted from Moll JMH: New criteria for the diagnosis of ankylosing spondylitis, Scand J Rheum 16(suppl 65):12-24, 1987.

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Jun 5, 2016 | Posted by admin in ORTHOPEDIC | Comments Off

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