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Background and Anatomy

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Background and Anatomy BACKGROUND AND ANATOMY CASE REPORT BACKGROUND Painful musculoskeletal disorders in the region of the thoracic spine can be difficult to diagnose and treat. Imaging examinations are often negative or difficult to visualize, especially in instances of internal disc disruption, costovertebral arthropathies, and zygapophyseal joint problems.16,23,48,53,71 Knowledge of some of the distinctive anatomical features of this region, combined with information gathered in biomechanical studies2,6,11,15,35,43,44,55,61,62 can assist the clinician in isolating a painful structure (or structures) based on clinical examination. Because spinal metastases are most often seen in the thoracic spine,73,37 and because organic problems can cause musculoskeletal-like pain, it is important that the patient first undergo a thorough medical work up prior to visiting the physical therapist. When dealing with painful musculoskeletal conditions of the thoracic spine, there are a number of unique features to consider about this region. Anatomical construction of the thoracic spine makes it a rigid structure and, enhanced by the rib cage, it functions not only to protect the life-sustaining organs in the thorax, but it also serves as the foundation for movements of the head and extremities. The presence of the rib cage alone adds a number of possible sources of pain, such as pathology at the costovertebral (dorsal) and even cost-chondro-sternal (ventral) connections. The thoracic spine has the largest number of vertebrae of the three spinal regions. Morphological variation between the cranial and the caudal vertebrae is great, and this difference in morphology illustrates one of the primary functions of the thoracic spine, which is that of a transition “zone.” The cranial segments, (T1 to T4) and the caudal segments, (T8 to T12) have the appearance and the kinematic features similar to that of the cervical and lumbar spines, respectively. In regard to vertebral column mobility, the transition between axial rotation at the cervical level and flexion-extension at the lumbar level occurs through the thoracic spine. The intrinsic rigidity of the thoracic spine and ribs, and the relatively long lever system of the arms, allows for the absorption and transfer of tremendous forces47 through vigorous and/or repeated movements of the upper extremities. Numerous published case studies documenting stress fractures in the ribs, and spinous - as well as transverse - processes of the thoracic spine in golfers, elite rowers, water skiers, jockeys, and power lifters exemplify this phenomenon.18,26,27,32,36,40,41 This paper reviews the clinically significant pathoanatomy and kinematics of the thoracic spine and ribs, and then further discusses it in a case study. Given the interplay of the vertical and horizontal kinematic chains in this region, several afflictions that perpetuate an individual’s painful condition can be seen concurrently. This frequently encountered clinical picture is exemplified in the patient case report. CLASSIFICATION OF THE THORACIC SPINE The thoracic spine can be seen simply as that part of the vertebral column where the ribs are attached, however, on closer inspection three distinct parts can be observed: 1) the T1 to T6 vertebrae with ribs that have a direct attachment to the sternum, 2) the T7 to T10 vertebrae with ribs that have an indirect attachment to the sternum, and 3) the T11 and T12 vertebrae with ribs that have no sternal connection. In the segments where ribs connect directly to the sternum, there is less flexion-extension range of motion. With regard to sidebending mobility, the segments without the direct sternal connection have more sidebending. Rib connections have little influence on the axial rotation motion of the thoracic spine, and act mainly to limit sidebending. Thus, when testing trunk motions, rib pathology is most often provoked with thoracic sidebending. Morphologically seen, T1 to T4 are similar to cervical vertebrae except that in the thoracic region the endplate becomes thinner and the spinal canal narrows. At the caudal end, T11 and T12 begin to show features of increased spinal canal size and thicker endplates, similar to lumbar vertebrae. From T5 to T10, the vertebrae most closely resemble the “true” thoracic region, with thin endplates, narrowed spinal canal, and a critical zone of least vascularity in the spinal cord.21 Careful history taking can give the examining clinician an idea as to the localization of the patient’s problems: pain provoked by movement of the head or arms could indicate upper or mid thoracic pathology, respectively. Whereas, thoracic spine pain provoked by leg motions could be an indication of lower thoracic spine pathology. Kinematics During uniplanar movements, the greatest degree of axial rotation occurs at the T1 to T8 segments, with significantly decreased amounts at the last three segments. In contrast, the T9 to T12 segments have the most flexion-extension range of motion (similar to the lumbar spine). Sidebending is about equal throughout the thoracic spine, with a slight increase at the last two segments.59 Head movements create spinal motion that extends caudally to T4, while arm movements create spinal motion that occurs down to T6. Leg movement, such as during walking, creates movement of the spine cranially to about T7.28 When an individual performs a motion out of the sagittal plane, in other words performs a movement into sidebending or rotation, the spinal motions are paired with other, synkinetic, motions.66 For example, during sidebending at the T1 to T4 segments, an accompanying ipsilateral rotation occurs. The main motion out of the sagittal plane and its automatic accompanying synkinetic motion are termed “coupled” motion patterns. In the same way, when a rotation is performed, an automatic ipsilateral sidebending occurs as well. In the lower thoracic spine, T8 to T12 has an ipsilateral coupling during rotation or sidebend when the spine is flexed. When it is extended, however, the coupling tends to be a contralateral movement pattern. For instance, in an extended spine, when T8 to T12 rotates, the segments automatically sidebend in the opposite direction.60 The coupling pattern in the T4 to T8 segments of the thoracic spine is not as predictable, however, partly due to different methods of measurement by investigators, differing use of terminology, and partly due to the degree to which an individual can move out of their normal kyphosis. If the kyphosis is rather mobile, and there is movement toward extension, coupling during sidebending and during rotation in an “extended thoracic spine” is likely to be a contralateral movement pattern. In instances of a more rigid kyphosis, however, with minimal to no movement toward extension, as well as in positions of flexion, the coupling at T4 to T8 during sidebending and during rotation is ipsilateral.62 In general, when comparing with other levels of the spine, coupling at the T4 to T8 level, although present, is quite minimal. Synkinetic coupled motions of the spine are guided by spinal curve, joint orientation and soft tissue connective structures including the disc. These three-dimensional coupled movement patterns allow for maximal stretch on the zygapophyseal joint capsules. Of course, it is possible to introduce a motion into the spine that is opposite to the coupling, such as actively left rotating while in a position of flexion and right sidebend. This movement pattern is termed “combined” and is restricted by a “jamming” of the zygapophyseal joint surfaces. The principles of coupled and combined motions can be used not only in establishing diagnoses during interpretation of the physical examination, but also during the execution of manual therapy techniques in the treatment of joint or segmental dysfunction. Since the three-dimensional coupled movement patterns maximally stretch the zygapophyseal joint capsule, it is these that will be most painful in the incidence of capsule lesions or synovitis. On the other hand, combined motions, which jam the facet surfaces, will provoke the most pain in instances of articular chondropathy. During treatment, the clinician can ensure maximal stretch to the structures of that segment when mobilizing in a 3-dimensional coupled motion. On the other hand, when mobilizing the rib joints, the clinician can effectively “lock out” the thoracic spine by ensuring that it is in a combined position. PATHOANATOMY Bony structures Bony anatomy of the thoracic vertebrae differs from that of the cervical and lumbar regions in several ways. Vertebral body diameter is equal or larger in an anterior-posterior direction than in a transverse direction, functioning to carry the loads imposed on it more ventrally. Of clinical importance is the slightly wedge-shaped form of the vertebral body in the sagittal plane, approximately 3.8deg, that creates a 45deg angle of kyphosis when looking at the entire thoracic region.59 In the lumbar region, the vertebral bodies are more rectangular, whereas the discs are wedge-shaped. Thus, with disc aging and dehydration, the thoracic spine increases in kyphosis, whereas the lumbar spine becomes flatter. Endplates are thinnest in the thoracic spine, which explains why Schmorl’s nodes are seen most often here in spite of the fact that endplate disruptions are present throughout the spine. Frequently seen in the central or dorsal part of the endplate/vertebral body in lumbar spine, they often occur ventrally in the thoracic spine (again demonstrating the location of load through this area). Previously dismissed as insignificant, Schmorl’s nodes should be considered clinically important because the process of accelerated disc degeneration has been associated with endplate fractures.4,72 Partly due to the short, thick pedicles in this region, the spinal canal is small and round, particularly from the T4 to T9 segments. Furthermore, the pedicle is found at the upper half of the vertebral body, and so the intervertebral foramen lies quite high in relation to the disc.
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