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Thoracic Cage and Thoracic Inlet

Professor Dr. Mario Edgar Fernández.

Parts of the body
The Thorax

Is the part of the trunk betwen the neck and abdomen. Commonly the term chest is used as a

synonym for thorax, but it is incorrect.

Consisting of the thoracic cavity, its contents, and the wall that surrounds it.

The thoracic cavity is divided into 3 compartments:

 The central mediastinus.  And the right and left pulmonary cavities.

Thoracic Cage

The thoracic skeleton forms the

osteocartilaginous

thoracic cage.

Anterior view.

Thoracic Cage

Posterior view.

Summary:

1. Bones of thoracic cage: (thoracic vertebrae, ribs, and sternum).

2. Joints of thoracic cage: (intervertebral joints,

costovertebral joints, and sternocostal joints)
3. Movements of thoracic wall.

4. Thoracic cage. Thoracic apertures: (superior thoracic

aperture or thoracic inlet, and inferior thoracic aperture).

Goals of the classes

 Identify and describe the bones of the thoracic cage.

 Identify and describe the joints of thoracic cage.

 Describe de thoracic cage.

 Describe the thoracic inlet and identify the structures

passing through.

Vertebral Column or Spine

 7 cervical.  12 thoracic.

 5 lumbar.  5 sacral

 3-4 coccygeal

Vertebrae

That bones are irregular, 33 in number, and received the names acording to the position which they occupy.

The vertebrae in the upper 3 regions of spine are

separate throughout the whole of life, but in sacral

anda coccygeal regions are in the adult firmly united in

2 differents bones: sacrum and coccyx.

Thoracic vertebrae

Each vertebrae consist of
2 essential parts:

 An anterior solid

segment: vertebral body.

 The arch is posterior an formed of 2 pedicles, 2

laminae supporting 7

processes, and

surrounding a vertebral foramen.

Thoracic vertebrae

The body is the largest part of the vertebra. Above and

bellow, it is flattened. Its

upper and lower surface are

rough, for the attachment of

the intervertebral fibrocartilages. In front , it is

convex from side to side,

concave from above

downwards.

Thoracic vertebrae

The thoracic vertebrae may bee at once

recognised by the

presence on the sides of

the body of 1 or more

half-facets for the heads of the ribs.

Thoracic vertebrae

The pedicles are 2 short, thick pieces of bone, which

projet backwards.

Thoracic vertebrae

The concavities above and below the pedicles

are the intervertebral

notches, they are 4 in

number, 2 on each side.

The inferior ones being generally the deeper.

Thoracic vertebrae

When the vertebrae are articulated, the notches

of each contigous pair of

bones form the

intervertebral foramina,

which communicate with the spinal canal and

transmit the spinal

nerves and blood-

vessels.

Thoracic vertebrae

 The laminae are 2 broad plates of bone which

complete the neural arch

by fusing together in the

middle line behind.

Thoracic vertebrae

 The laminae enclose a foramen, the vertebral or

spinal foramen, which

serves for the protection

of the spinal cord, and

are connected to the body by means of the

pedicles.

Thoracic vertebrae

The spinous process projects backwards from

the junction of the 2

laminae, and serve s for

attachment of muscles

and ligaments,

Thoracic vertebrae

 The spinous processes are long, triangular on

transverse section,

directed obliquely

downwards, and

terminate in a tubercular extremity.

Recommended publications

Ligaments of the Costovertebral Joints Including Biomechanics, Innervations, and Clinical Applications: a Comprehensive Review W

Open Access Review Article DOI: 10.7759/cureus.874 Ligaments of the Costovertebral Joints including Biomechanics, Innervations, and Clinical Applications: A Comprehensive Review with Application to Approaches to the Thoracic Spine Erfanul Saker 1 , Rachel A. Graham 2 , Renee Nicholas 3 , Anthony V. D’Antoni 2 , Marios Loukas 1 , Rod J. Oskouian 4 , R. Shane Tubbs 5 1. Department of Anatomical Sciences, St. George's University School of Medicine, Grenada, West Indies 2. Department of Anatomy, The Sophie Davis School of Biomedical Education 3. Department of Physical Therapy, Samford University 4. Neurosurgery, Complex Spine, Swedish Neuroscience Institute 5. Neurosurgery, Seattle Science Foundation Corresponding author: Erfanul Saker, [email protected] Abstract Few studies have examined the costovertebral joint and its ligaments in detail. Therefore, the following review was performed to better elucidate their anatomy, function and involvement in pathology. Standard search engines were used to find studies concerning the costovertebral joints and ligaments. These often- overlooked ligaments of the body serve important functions in maintaining appropriate alignment between the ribs and spine. With an increasing interest in minimally invasive approaches to the thoracic spine and an improved understanding of the function and innervation of these ligaments, surgeons and clinicians should have a good working knowledge of these structures. Categories: Neurosurgery, Orthopedics, Rheumatology Keywords: costovertebral joint, spine, anatomy, thoracic Introduction And Background The costovertebral joint ligaments are relatively unknown and frequently overlooked anatomical structures [1]. Although small and short in size, they are abundant, comprising 108 costovertebral ligaments in the normal human thoracic spine, and they are essential to its stability and function [2-3].
Of the Pediatric Mediastinum

MRI of the Pediatric Mediastinum Dianna M. E. Bardo, MD Director of Body MR & Co-Director of the 3D Innovation Lab Disclosures Consultant & Speakers Bureau – honoraria Koninklijke Philips Healthcare N V Author – royalties Thieme Publishing Springer Publishing Mediastinum - Anatomy Superior Mediastinum thoracic inlet to thoracic plane thoracic plane to diaphragm Inferior Mediastinum lateral – pleural surface anterior – sternum posterior – vertebral bodies Mediastinum - Anatomy Anterior T4 Mediastinum pericardium to sternum Middle Mediastinum pericardial sac Posterior Mediastinum vertebral bodies to pericardium lateral – pleural surface superior – thoracic inlet inferior - diaphragm Mediastinum – MR Challenges Motion Cardiac ECG – gating/triggering Breathing Respiratory navigation Artifacts Intubation – LMA Surgical / Interventional materials Mediastinum – MR Sequences ECG gated/triggered sequences SSFP – black blood SE – IR – GRE Non- ECG gated/triggered sequences mDIXON (W, F, IP, OP), eTHRIVE, turbo SE, STIR, DWI Respiratory – triggered, radially acquired T2W MultiVane, BLADE, PROPELLER Mediastinum – MR Sequences MRA / MRV REACT – non Gd enhanced Gd enhanced sequences THRIVE, mDIXON, mDIXON XD Mediastinum – Contents Superior Mediastinum PVT Left BATTLE: Phrenic nerve Vagus nerve Structures at the level of the sternal angle Thoracic duct Left recurrent laryngeal nerve (not the right) CLAPTRAP Brachiocephalic veins Cardiac plexus Aortic arch (and its 3 branches) Ligamentum arteriosum Thymus Aortic arch (inner concavity) Trachea Pulmonary
Unit 2 Lab 2

Unit 2, Lab 1 PTA/OTA 106 Regional A & P G. Blevins Updated: Fall 2011 SURFACE ANATOMY: VERTEBRAL COLUMN BONES [26] Jugular or suprasternal notch Vertebra (general features) Sternal angle Body Manubrium Neural arch Body of the sternum Pedicles Xiphisternal joint Laminae Costal margin Spinal (or vertebral) foramen Costal arch Transverse processes Anterior median line Spinous process Midclavicular lines Superior articulating processes Intermammary cleft Inferior articulating processes Axillary fossa Intervertebral foramen Anterior axillary line Intervertebral disc Anterior axillary fold Midaxillary line Thoracic vertebrae [12] Posterior axillary line Rib facets or demifacets Posterior median line Scapular lines Lumbar vertebrae [5] Epigastric fossa Lack rib facets and transverse Iliac crest foramina Umbilicus Linea alba Sacrum [1] Rectus abdominis Fused bone consisting of 5 Serratus anterior vertebrae Semilunar line Sacral promontory Sacral foramina (pelvic & dorsal) VERTEBRAL COLUMN- Auricular surface Special Features Coccyx [1] Normal Curves Fused bone consisting of 3-5 Primary: vertebrae Thoracic Sacral THORACIC BONES [25] Secondary: Sternum [1] Cervical Manubrium Lumbar Body (or gladiolus) Abnormal Curves Jugular (or suprasternal) notch Kyphosis Xiphoid process Lordosis Ribs [12 pair] Scoliosis Head Neck Tubercle Body (or shaft) Costal groove Costal cartilages Types of ribs True ribs False ribs Floating ribs PECTORAL (OR SHOULDER) GIRDLE Clavicles [2] Sternal extremity Acromial extremity Conoid tubercle Scapula [2] Borders: Superior
Chapter 21 Fractures of the Upper Thoracic Spine: Approaches and Surgical Management

Chapter 21 Fractures of the Upper Thoracic Spine: Approaches and Surgical Management Sean D Christie, M.D., John Song, M.D., and Richard G Fessler, M.D., Ph.D. INTRODUCTION Fractures occurring in the thoracic region account for approximately 17 to 23% of all traumatic spinal fractures (1), with 22% of traumatic spinal fractures occurring between T1 and T4 (16). More than half of these fractures result in neurological injury, and almost three-quarters of those impaired suffer from complete paralysis. Obtaining surgical access to the anterior vertebral elements of the upper thoracic vertebrae (T1–T6) presents a unique anatomic challenge. The thoracic cage, which narrows significantly as it approaches the thoracic inlet, has an intimate association between the vertebral column and the superior mediastinal structures. The supraclavicular, transmanubrial, transthoracic, and lateral parascapular extrapleural approaches each provide access to the anterior vertebral elements of the upper thoracic vertebrae. However, each of these approaches has distinct advantages and disadvantages and their use should be tailored to each individual patient’s situation. This chapter reviews these surgical approaches. Traditional posterior approaches are illustrated in Figure 21.1, but will not be discussed in depth here. ANATOMIC CONSIDERATIONS AND STABILITY The upper thoracic spine possesses unique anatomic and biomechanical properties. The anterior aspects of the vertebral bodies are smaller than the posterior aspects, which contribute to the physiological kyphosis present in this region of the spine. Furthermore, this orientation results in a ventrally positioned axis of rotation, predisposing this region to compression injuries. The combination and interaction of the vertebral bodies, ribs, and sternum increase the inherent biomechanical stability of this segment of the spine to 2 to 3 times that of the thoracolumbar junction.
Sacral Dimple – Tethered Cord Pathway V3.0: Diagnosis

Sacral Dimple – Tethered Cord Pathway v3.0: Diagnosis Approval & Citation Summary of Version Changes Explanation of Evidence Ratings REFERRAL AND DIAGNOSIS More Information Inclusion Criteria • PE056 Spina Bifida • All patients considered • PE589 Tethered Spinal Cord or referred in for • PE1999 Anesthesia for Radiology 1) cutaneous sacral, Tests coccygeal, and/or gluteal anomaly OR 2) closed spinal dysraphism Simple Sacral Dimple (radiographic) All 3 criteria must be met. A simple sacral dimple is: Exclusion Criteria • No more than 2.5 cm from anus • Patients with open • Less than 5 mm diameter spinal dysraphism • Localized in gluteal cleft Referral to Cutaneous anomaly Neurosurgery / Referral for MRI Neurodevelopment Review at Babies Further workup needed Conference Further workup needed Urgent? No intervention needed No Yes Not urgent Urgent Referring provider to Yes Age < 4 months? Age < 6 months? observe Age < 4 months (more info) (more info) Negative Referring provider No Yes No to order Age ≥ 4 months Age < 6 months Age ≥ 6 months spinal ultrasound Spinal • Imaging done at ultrasound Seattle Children’s if results possible • Imaging results reviewed by referring Referring provider provider to consult • (more info) Neurosurgery Positive Schedule MRI and Schedule MRI and Neurosurgery visit Neurosurgery visit Schedule MRI for when now age > 6 months Yes Positive or concerning MRI results MRI? No Treatment Phase Off Pathway For questions concerning this pathway, Last Updated: July 2021 contact: [email protected]
Anatomy of the Spine

12 Anatomy of the Spine Overview The spine is made of 33 individual bones stacked one on top of the other. Ligaments and muscles connect the bones together and keep them aligned. The spinal column provides the main support for your body, allowing you to stand upright, bend, and twist. Protected deep inside the bones, the spinal cord connects your body to the brain, allowing movement of your arms and legs. Strong muscles and bones, flexible tendons and ligaments, and sensitive nerves contribute to a healthy spine. Keeping your spine healthy is vital if you want to live an active life without back pain. Spinal curves When viewed from the side, an adult spine has a natural S-shaped curve. The neck (cervical) and low back (lumbar) regions have a slight concave curve, and the thoracic and sacral regions have a gentle convex curve (Fig. 1). The curves work like a coiled spring to absorb shock, maintain balance, and allow range of motion throughout the spinal column. The muscles and correct posture maintain the natural spinal curves. Good posture involves training your body to stand, walk, sit, and lie so that the least amount of strain is placed on the spine during movement or weight-bearing activities. Excess body weight, weak muscles, and other forces can pull at the spine’s alignment: • An abnormal curve of the lumbar spine is lordosis, also called sway back. • An abnormal curve of the thoracic spine is Figure 1. (left) The spine has three natural curves that form kyphosis, also called hunchback. an S-shape; strong muscles keep our spine in alignment.
Epithelia Joitns

NAME LOCATION STRUCTURE FUNCTION MOVEMENT Temporomandibular joint Condylar head of ramus of Synovial Diarthrosis Modiﬁed hinge joint mandible and glenoid fossa of Rotation and gliding temporal bone Biaxial Zygapophyseal joint Between articular processes of Synovial Diarthrosis Gliding 2 adjacent vertebrae Non axial Atlanto-Occipital joints Atlas and occipital condyle of Synovial Diarthrosis Ellipsoid occipital bone Biaxial Atlantoaxial joints Atlas and axis Synovial Diarthrosis Pivot Uniaxial Joints of vertebral arches Ligaments Fibrous Amphiarthrosis Syndesmoses Intervertebral symphyseal Intervertebral disk between 2 Cartilaginous Amphiarthrosis joints vertebrae Symphysis Costovertebral Head of ribs and body of Synovial Diarthrosis Gliding thoracic vertebra Non axial Costotrasnverse joints Tubercle of rib and transverse Synovial Diarthrosis Gliding process of thoracic vertebra Non axial Lumbosacral Joint Left and right zygopophyseal Laterally Synovial joint Intervertebral symphyseal joint Symphysis SternoclavicularJoint Clavicular notch articulates Synovial Diarthrosis Gliding with medial ends of clavicle Non Axial Manubriosternal Joint Hyaline cartilage junction Cartilaginous Synarthrosis Sternal Angle between manubrium and body Symphysis Xiphisternal Joint Cartilage between xiphoid Synchondrosis Synarthrosis process and body Synostoses Sternocostal Joint (1st) Costocartilage 1 with sternum Cartilaginous Synchondrosis Synarthrosis NAME Location Section Anterior longitudinal runs down anterior surface of vertebral body Vertebral column ligament Posterior longitudinal in canal, runs down posterior surface of vertebral body ligament Interspinous ligament Connects spinous processes Ligamentum ﬂavum Connects laminae ! Intra-articular Disc Between articulating surface of sternum and clavicle Sternoclavicular Joint Costoclavicular ligament 1st rib to clavicle !.
Ligamentum Flavum in Lumbar Spinal Stenosis, Disc Herniation and Degenerative Spondylolisthesis. an Histopathological Description

Acta Ortopédica Mexicana 2019; 33(5): Sep.-Oct. 308-313 Artículo original Ligamentum flavum in lumbar spinal stenosis, disc herniation and degenerative spondylolisthesis. An histopathological description Ligamento amarillo en estenosis lumbar espinal, hernia de disco y espondilolistesis degenerativa. Una descripción histopatológica Reyes‑Sánchez A,* García‑Ramos CL,‡ Deras‑Barrientos CM,§ Alpizar‑Aguirre A,|| Rosales‑Olivarez LM,¶ Pichardo‑Bahena R** Instituto Nacional de Rehabilitación «Luis Guillermo Ibarra Ibarra». ABSTRACT. Introduction: Changes in ligamentum RESUMEN. Introducción: Los cambios en el liga- flavum (LF) related to degeneration are secondary mento flavum (LF) relacionados con la degeneración to either the aging process or mechanical instability. son secundarios al proceso de envejecimiento o a la Previous studies have indicated that LF with aging inestabilidad mecánica. Estudios anteriores han indi- shows elastic fiber loss and increased collagen content, cado que LF con envejecimiento muestra pérdida de fi- loss of elasticity may cause LF to fold into the spinal bras elásticas y aumento del contenido de colágeno, la canal, which may further narrow of the canal. Material pérdida de elasticidad puede hacer que el LF se pliegue and methods: A total of 67 patients operated with the en el canal espinal, disminuyendo su espacio. Material surgical indications of lumbar spinal stenosis (LSS), y métodos: Se incluyeron 67 pacientes operados de es- lumbar disc herniation (LDH) and lumbar degenerative tenosis lumbar espinal (LSS), hernia de disco lumbar spondylolisthesis (LDS) were included. LF samples were (LDH) y espondilolistesis degenerativa (LDS). Se ob- obtained from patients who had LSS (39), LDH (22) tuvieron muestras de LF de pacientes que tenían LSS and LDS (6).
Axially Loaded Magnetic Resonance Imaging Identification of the Factors

Journal of Clinical Medicine Article Axially Loaded Magnetic Resonance Imaging Identification of the Factors Associated with Low Back-Related Leg Pain Tomasz Lorenc 1 , Wojciech Michał Glinkowski 2,* and Marek Goł˛ebiowski 1 1 1st Department of Clinical Radiology, Medical University of Warsaw, 02-004 Warsaw, Poland; [email protected] (T.L.); [email protected] (M.G.) 2 Department of Medical Informatics and Telemedicine, Center of Excellence “TeleOrto” for Telediagnostics and Treatment of Disorders and Injuries of the Locomotor System, Medical University of Warsaw, 00-581 Warsaw, Poland * Correspondence: [email protected] Abstract: This retrospective observational study was conducted to identify factors associated with low back-related leg pain (LBLP) using axially loaded magnetic resonance imaging (AL-MRI). Ninety patients with low back pain (LBP) underwent AL-MRI of the lumbar spine. A visual analog scale and patient pain drawings were used to evaluate pain intensity and location and determine LBLP cases. The values of AL-MRI findings were analyzed using a logistic regression model with a binary dependent variable equal to one for low back-related leg pain and zero otherwise. Logistic regression results suggested that intervertebral joint effusion (odds ratio (OR) = 4.58; p = 0.035), atypical liga- menta flava (OR = 5.77; p = 0.003), and edema of the lumbar intervertebral joint (OR = 6.41; p = 0.003) p were more likely to be present in LBLP patients. Advanced disc degeneration ( = 0.009) and synovial cysts (p = 0.004) were less frequently observed in LBLP cases. According to the AL-MRI examinations, the odds of having LBLP are more likely if facet effusion, abnormal ligamenta flava, and lumbar Citation: Lorenc, T.; Glinkowski, W.M.; Goł˛ebiowski,M.
OMM PRACTICAL EXAM Saroj Misra, DO, FACOFP Rachel Nixon, DO Marissa Rogers, DO Family Medicine Goals/Objectives

OMM PRACTICAL EXAM Saroj Misra, DO, FACOFP Rachel Nixon, DO Marissa Rogers, DO Family Medicine Goals/Objectives • Review Exam Day procedure • Understand scoring process • Discuss possible cases and 2 OMM techniques that may be used for each case Disclaimer: The material being presented is NOT necessarily identical to what will be tested upon. We are not afﬁliated with the actual exam. This is our approach to the practical exam material. EXAM DAY Exam day • You will be assigned a time slot based on your last name • You will select a partner within your time slot • May not partner with a spouse or relative • You will be asked to sign a waiver stating that if you choose to do HVLA you will not perform the corrective “thrust” • You will then stand in line with your partner and await entering the testing room Exam day • There will be two rooms - one in which you will review cases and the second where you will be tested • Once you enter the ﬁrst room you will not be able to leave • If you DO leave, both you and your partner will be given new cases Exam day • You will be given 3 cases: • Spine • Extremities • Systemic Disease • You will enter your name, ID number and your partners ID number on each case before turning them over Exam day • Each case will have the following information: • HPI • PMH • PSH • FHx • SocHx • There will be multiple choice for the best answer for your diagnosis • You will have 20 minutes to choose the best answer and plan a treatment strategy for each of your cases Exam day • After the 20 minutes are complete, you will
Chapter 02: Netter's Clinical Anatomy, 2Nd Edition

Hansen: Netter's Clinical Anatomy, 2nd Edition - with Online Access 2 BACK 1. INTRODUCTION 4. MUSCLES OF THE BACK REVIEW QUESTIONS 2. SURFACE ANATOMY 5. SPINAL CORD 3. VERTEBRAL COLUMN 6. EMBRYOLOGY FINAL 1. INTRODUCTION ELSEVIERl VertebraeNOT prominens: the spinous process of the C7- vertebra, usually the most prominent The back forms the axis (central line) of the human process in the midline at the posterior base of body and consists of the vertebral column, spinal cord, the neck supporting muscles, and associated tissues (skin, OFcon- l Scapula: part of the pectoral girdle that sup- nective tissues, vasculature, and nerves). A hallmark of ports the upper limb; note its spine, inferior human anatomy is the concept of “segmentation,” and angle, and medial border the back is a prime example. Segmentation and bilat l Iliac crests: felt best when you place your eral symmetry of the back will be obvious as you hands “on your hips”; an imaginary horizontal study the vertebral column, the distribution of the line connecting the crests passes through the spinal nerves, the muscles of th back, and its vascular spinous process of the L4 vertebra and the supply. intervertebral disc of L4-L5, a useful landmark Functionally, the back is involved in three primary for a lumbar puncture or epidural block tasks: l Posterior superior iliac spines: an imaginary CONTENThorizontal line connecting these two points l Support: the vertebral column forms the axis of passes through the spinous process of S2 (second the body and is critical for our upright posture sacral segment) (standing or si ting), as a support for our head, as an PROPERTYattachment point and brace for move- 3.
Vertebral Column

Vertebral Column • Backbone consists of Cervical 26 vertebrae. • Five vertebral regions – Cervical vertebrae (7) Thoracic in the neck. – Thoracic vertebrae (12) in the thorax. – Lumbar vertebrae (5) in the lower back. Lumbar – Sacrum (5, fused). – Coccyx (4, fused). Sacrum Coccyx Scoliosis Lordosis Kyphosis Atlas (C1) Posterior tubercle Vertebral foramen Tubercle for transverse ligament Superior articular facet Transverse Transverse process foramen Facet for dens Anterior tubercle • Atlas- ring of bone, superior facets for occipital condyles. – Nodding movement signifies “yes”. Axis (C2) Spinous process Lamina Vertebral foramen Transverse foramen Transverse process Superior articular facet Odontoid process (dens) •Axis- dens or odontoid process is body of atlas. – Pivotal movement signifies “no”. Typical Cervical Vertebra (C3-C7) • Smaller bodies • Larger spinal canal • Transverse processes –Shorter – Transverse foramen for vertebral artery • Spinous processes of C2 to C6 often bifid • 1st and 2nd cervical vertebrae are unique – Atlas & axis Typical Cervical Vertebra Spinous process (bifid) Lamina Vertebral foramen Inferior articular process Superior articular process Transverse foramen Pedicle Transverse process Body Thoracic Vertebrae (T1-T12) • Larger and stronger bodies • Longer transverse & spinous processes • Demifacets on body for head of rib • Facets on transverse processes (T1-T10) for tubercle of rib Thoracic Vertebra- superior view Spinous process Transverse process Facet for tubercle of rib Lamina Superior articular process