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Cook, Orthopedic Manual Therapy: an Evidence-Based Approach, 2/E © 2012 by Pearson Education, Inc., Upper Saddle River, NJ Osseous Structures THORACIC SPINE ANATOMY The thoracic spine is unique from the cervical and lumbar spine because of the size and extent of the region and the articulations with the rib cage. The articulation with the rib cage leads to regional variations in movement patterns and function (1). The upper thoracic spine mimics the movement and to some extent, the anatomy of the cervical spine and the lower thoracic vertebra mimics the lumbar spine. Table 7.1: General Information Regarding the Thoracic Spine Region. Concept Information Bones Twelve primary vertebrae, 24 individual ribs, 1 manubrium Number of dedicated 101 joints, 20 (synovial) costotransverse articulations, 24 (synovial) Joints costovertebral articulations, 20 costochondral articulations, 24 (synovial) facet articulations, and 13 intervertebral articulations. Scapulothoracic is considered a joint of the shoulder complex Anatomical regions 3 distinct regions: upper thoracic (C7-T1 toT3-4), mid-thoracic (T3-4 to T9-10; lower thoracic (T9-10 to T12-L1) Useful landmarks T5 = Nipple level T7-8 = Epigastric level T10-11 = Umbilical level Palpation: rule of threes • T1-3 SPs are in the same plane as its own transverse processes (TP) • T4-6 SPs are halfway between its own TP and the TP of the vertebra below • T7-9 SPs are in a plane with the TP of the vertebra below • T10 SP is in the plane of the TP below • T11 SP is halfway between its own TP and the TP of the vertebra below • T12 SP is in the same plane as its own TP Opening movements Flexion (both sides), side flexion (on the side away), rotation (on the side away) Closing movements Extension (both sides), side flexion (toward), rotation (toward) Theoretical resting Midway between Flexion and Extension Position Theoretical close-pack Extension Position Theoretical capsular Side bend and rotation equally limited pattern Cook, Orthopedic Manual Therapy: An Evidence-Based Approach, 2/E © 2012 by Pearson Education, Inc., Upper Saddle River, NJ Osseous Structures The thoracic vertebrae can be subdivided anterior to posterior into three specific regions— the body, the pedicles, and the posterior structures, such as the transverse and spinous processes (2). Joint articulations occur at the body of the vertebra and at the posterior structures (Table 7.1). Figure 7.1: Typical Thoracic Vertebra The thoracic vertebral body is primarily made of cancellous bone and progressively is wider from the upper thoracic segments to the lower segments (3,4). The inclination of the end plates remains constant throughout the thoracic spine even though the posterior height of the vertebral body increases slightly with caudal progression (3). Kothe et al. (2) reported that the average pedicle height demonstrated greater variability in the lower thoracic spine than in the middle thoracic spine. The pedicle is a complex three- dimensional structure that is filled mostly with cancellous bone (62–79%) for structural rigidity. The Cook, Orthopedic Manual Therapy: An Evidence-Based Approach, 2/E © 2012 by Pearson Education, Inc., Upper Saddle River, NJ outer cortical shell showed different thickness throughout its perimeter and variations in trabeculae at disparate levels. The posterior structures include the transverse processes and the articulations, the facets, and the spinous processes. The spinous processes angle inferiorly and progressively from the upper thoracic spine to the mid- to lower thoracic spine. The transverse processes angle posteriorly and provide the contact points for the facets (5). The ribs are long, thin bones that are commonly fractured during trauma to the thoracic region (6) and connect to the thoracic spine anteriorly and posteriorly. Each rib has a convex head that articulates with the concave facets of the vertebral body (costovertebral joint) and transverse processes of the thoracic spine (costotransverse joint). The anterior connection is called the costo- sternal attachment and identifies the two separate articulations of the sternum to the costal cartilage and the costal cartilage to the rib. The anterior articulation is a flattened, concave depression. The Intervertebral Disc The intervertebral disc plays a major role in movement control of the thoracic spine, a much more significant role than the posterior structures (7). With respect to height, the disc in the thoracic spine demonstrates less height in ratio to the vertebral body than the cervical and lumbar spines (8). Additionally, the thoracic disc has a relatively small nucleus pulposus (9). It is expected that the compliance of the thoracic disc is lost much earlier than the cervical or lumbar disc (13). Disc space narrowing is common from the third decade of life and disc degeneration, osteophytes, and subsequent degenerative changes are frequent findings in the mid- thoracic segment (16). With respect to intradiscal pressures, Polga et al. (11) found that the positions of standing upright with 10-kg weights in each arm display the highest pressure versus other positions such as prone lying, sidelying, sitting with and without flexion, and other variations of standing including twisting. Cook, Orthopedic Manual Therapy: An Evidence-Based Approach, 2/E © 2012 by Pearson Education, Inc., Upper Saddle River, NJ Joints Table 7.2: Joints of the Thoracic Spine. Joint Information Intervertebral disc Not frequently studied. High incidence of asymptomatic herniated discs and can be a pain generator Zygapophyseal (facet) Synovial, planar, diarthrodial joints. All thoracic joints are in the frontal joints plane and vary between 0° and 30° from vertical. This allows significant movement in all 3 planes A synovial joint that allows rolling and gliding. The heads of ribs 2–9 Costovertebral (and occasionally the 10th) articulate with 2 vertebral bodies and the disc A synovial joint and is shaped differently according to the thoracic level. In the upper thorax, there is a concave/convex articulation between the convex costal surface and concave TP surface. The costotransverse joints gradually flatten and are more planar in the lower thorax. This change in joint shape allows for more rotation and torsional movement above rib 7 and more planar gliding movement Costotransverse below that level During inspiration, the upper chest wall rises (flexes) in the sagittal plane, whereas the lower ribs widen (abduct) in the frontal plane. During spinal flexion, the rib rotates anterior (posterior elements move superiorly and anterior elements move inferiorly)—an internal torsional movement. During spinal extension, the rib rotates posteriorly (posterior elements move inferiorly and anterior elements move superiorly) There are variations in the zygapophyseal joints (facets) throughout the length of the thoracic spine. In general, the superior facets face anteriorly but are not completely aligned in the frontal plane (12). This angulation is reduced as the thoracic spine descends, culminating at T12. At T12, the facets face both an inferior and superior a similar orientation of the lumbar spine (12). Cook, Orthopedic Manual Therapy: An Evidence-Based Approach, 2/E © 2012 by Pearson Education, Inc., Upper Saddle River, NJ Figure 7.2: Zygapophyseal Joints of the Thoracic Spine The architecture of the facets changes throughout the upper, mid- and lower thoracic segments. In the mid-thoracic region, the superior and inferior articular processes are curved in both the transverse and sagittal planes, thus permitting multidirectional movement (13,14). However, the facet architecture does not dictate or guide a specific, directional coupling movement of the mid- thoracic region. Within the transverse plane, the superior facet demonstrates near-sagittal angulation as compared to inferior facet (12). In the coronal plane, the sagittal angulation of the superior facets demonstrates a steeper degree with respect to the inferior facets (12). Each facet demonstrates fibrous annular menisci, which may originate medially from the ligamentum flavum or laterally from the joint capsule (15). These meniscal folds are hypothesized as the culprits during an acute thoracic facet lock (16). Additionally, each facet demonstrates asymmetry from right to left at nearly all levels (12). This may produce abnormalities in range of motion between the right and the left, although in most cases the differences are small (17). Cook, Orthopedic Manual Therapy: An Evidence-Based Approach, 2/E © 2012 by Pearson Education, Inc., Upper Saddle River, NJ Rib Cage Joints There are three primary joints associated with the rib cage—the costovertebral joints, the costotransverse joints, and the costosternal joints. The costovertebral joint is formed by a convex rib head with two adjacent vertebral bodies, superiorly and inferiorly. The concave inferior costal demi- facet of the superior vertebral body and the concave superior costal construction of the inferior vertebral body provide a synovial attachment to the rib head. The rib head articulates with the lateral aspect of the intervertebral disc in addition to the two separate vertebral connections. The joint has two synovial cavities separated by an intra-articular ligament (13). This joint also houses meniscoids that may be involved during acute costovertebral pain (18). Figure 7.3: The Costovertebral Joint Peculiarities regarding the costovertebral joint exist throughout the thoracic spine, specifically the facet orientation for the articulation of the costovertebral joint. The first thoracic vertebra has an articular facet for the head of the first rib and a demi-facet for the upper half
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