THORACIC SPINE:
CONDITIONS AND EVALUATION
BY: DR. STEVEN L. KLEINFIELD D.A.B.C.O.

• THORACIC FACTS:
• ASSESMENT OF THE THORACIC SPINE INVOLVES  EXAMINATION OF THE MOST RIDGID PART OF  THE SPINE. THIS IS DUE TO THE PRESENCE OF  THE RIB CAGE.
• THE RIB CAGE PROVIDES PROTECTION FOR THE  HEART AND LUNGS.
• THE THORACIC KYPHOSIS IS PART OF THE (1)  PRIMARY C CURVE.
• THERE ARE 12 VERTEBRAE IN THE THORACIC   SPINE WHICH DIMINISH IN SIZE FROM T1-T3  AND THEN THEY INCREASE AGAIN FROM  T4-12
• THE SPINOUS PROCESSES OF THE THORACIC  SPINE FACE OBLIQUELY DOWNWARD WITH  T7 HAVING THE GREATEST ANGULATION.
• SPINOUS PROCESSES OF T1-T3 ARE ALMOST   STRAIGHT POSTERIOR.
• THE RIBS HELP STIFFEN THE SPINE AND RIBS 2-9  HAVE DEMIFACETS WHILE RIBS 1 AND 10  HAVE FULL FACETS.
• RIBS 1-7 ARTICULATE WITH THE STERNUM   DIRECTLY AND ARE CALLED TRUE RIBS.
• RIBS 8-10 JOIN WITH COSTOCARTILAGE OF THE   RIB ABOVE AND ARE CALLED FALSE RIBS.
• RIBS 11-12 ARE CALLED FLOATING RIBS SINCE   THEY DON’T ARTICULATE WITH THE    STERNUM OR THE COSTALCARTLIAGE.
• AT THE TOP OF THE RIB CAGE, THE RIBS ARE   MORE HORIZONTAL.  AS YOU DESCEND,   THEY BECOME SHAPED  MORE OBLIQUELY   DOWNWARD.
• RIBS 1-6 INCREASE IN THE A-P DIRECTION UPON  INSPIRATION. RIBS 7-10 INCREASE IN THE   LATERAL DIRECTION UPON INSPIRATION.
• RIBS ARE VERY ELASTIC IN CHILDREN BUT   BECOME BRITTLE WITH AGE.
• THORACIC CONDITIONS:
• THORACIC SUBLUXATION
• OSSEOUS ANOMALY
• FRACTURE
• INTERCOSTAL NEURALGIA
• PLEURAL DISEASE
• ANKYLOSING SPONDYLITIS
• KYPHOSCOLIOSIS AND SCOLIOSIS
• SCHEUERMANN’S DISEASE
• DISCAL DISEASE
• MALINGERER

• EVALUATION:
• PHYSICAL CONSIDERATIONS
• PATIENT MOTIVE
• AGE OF PATIENT
• OCCUPATIONAL ERGONOMICS
• SPORTS HABITS
• PATIENT HISTORY:
• O.P.Q.R.S.T. APPROACH
• O= ONSET
• P=PAIN AND PROVICATION
• Q= QUALITY
• R= RADIATION
• S= SITE AND SEVERITY
• T= TIME
• PART OF YOUR QUESTIONING SHOULD INCLUDE  INFORMATION ABOUT THE DIGESTIVE   SYSTEM SINCE MANY ABDOMINAL CONDITIONS REFER TO THE THORAX.
• QUESTION THE PATIENT ABOUT THEIR BREATHING PATTERN AND IF THEY HAVE DIFFICULTY BREATHING OR NOT.  THIS MAY  INDICATE STRUCTURAL PROBLEMS OR   UNDERLYING PLEURAL DISEASE
• QUESTION THE PATIENT WHETHER COUGHING, SNEEZING OR STRAINING, AGGRAVATES THE  CONDITION. (CAN BE MUSCULAR SINCE   THORACIC DISC DISEASE IS RARE.)
• OBSERVATION/INSPECTION
• REMEMBER: THE BODY SHOULD BE SUITABLY   DRESSED FOR YOU TO OBSERVE THE SPINE AND ANTERIOR THORAX.
• OBSERVE THE KYPHOSIS:
• LOOK FOR GIBBUS
• LOOK FOR A DOWAGER’S HUMP
• OBSERVE FOR SCOLIOSIS:
• REMEMBER, SCOLIOSIS IS LISTED ON THE SIDE OF CONVEXITY. BODY ROTATION WILL DECIDE IF IT’S A LOVETTE + OR LOVETTE - SCOLIOSIS.
• IN A SITTING POSTURE, SEE IF THEY SIT STRAIGHT OR SAG.
• OBSERVE THE RIBS FOR SYMMETRY IN BOTH   INSPIRATION AND EXPIRATION.
• OBSERVE THE SKIN FOR BRUISING AND OR   SCARS.
• OBSERVE RATE AND DEPTH OF BREATHING:
• OBSERVE FOR PECTUS EXCAVATUM (FUNNEL   CHEST). THE STERNUM IS PUSHED    POSTERIORLY BY AN OVERGROWTH OF THE  RIBS.  THIS CAN DISPLACE THE HEART.  ON   INSPIRATION YOU WILL SEE A DEPRESSION  OF THE STERNUM.
• OBSERVE FOR PECTUS CARINATUM (PIGEON   CHEST). THE STERNUM PROJECTS    ANTERIORLY INCREASING THE A-P    DIMENSION.  THIS DEFORMITY WILL    RESTRICT BREATHING DUE TO RESTRICTION  IN VENTILLATION VOLUMN.
• OBSERVE FOR BARREL CHEST: THE STERNUM   WILL PROJECT FORWARD AND UPWARD.    THIS IS SEEN IN PATIENT’S WITH  EMPHYSEMA.
• PALPATION:
• PALPATION SHOULD BEGIN ON THE ANT. CHEST  WALL, MOVE LATERALLY AND THEN END UP  ON THE POSTERIOR CHEST WALL.
• PALPATE FOR TENDERNESS, MUSCLE SPASM,   TEMPERATURE ALTERATION AND SWELLING.
• PALPATE THE THORACIC SPINE AND RIBS FOR   THE FOLLOWING:
• JOINT PLAY AND MOTION OF THE    SPINAL SEGMENTS
• JOINT PLAY AND MOTION IN THE RIBS  AS   WELL.
• PALPATE FOR PROPER RIB EXCURSION ON INHALATION AND EXHALATION (CHEST EXPANSION TEST: 1.5-2” INCREASE IN  CHEST EXPANSION ON INHALLATION IS NORMAL).
• PALPATE FOR A DEPRESSED RIB: THIS OCCURS WHEN A RIB STOPS MOVING IN RELATION TO THE OTHER RIBS ON INHALLATION
• PALPATE FOR A ELEVATED RIB: THIS OCCURS WHEN A RIB STOPS MOVING IN RELATION TO THE OTHER RIBS ON EXHALATION.
• EXAMINATION
• RANGES OF MOTION
• ACTIVE VS PASSIVE
• ACTIVE AGAINST RESISTANCE
• NEUROLOGICAL EXAMINATION
• DERMATOME EXAMINATION
• ORTHOPAEDIC EXAMINATION
• RADIOGRAPHIC EXAMINATION
• THORACIC RANGES OF MOTION:
• NOTE** RANGES OF MOTION ARE USUALLY COUPLED WITH THAT OF OF LUMBAR SPINE AND CALLED THORACO-LUMBAR RANGES OF MOTION
• FLEXION=
• EXTENSION=
• ROTATION=
• LAT. FLEXION=
• DERMATOME TESTING:
• IN THE THORACIC SPINE, THE    DERMATOMES RUN RADIALLY AROUND THE BODY.  THINK OF   THE THORACIC DERMATOMES AS  BEING ONE DONUT STACKED   UPON ANOTHER.

REFERENCE POINT: T4 DERMATOME  IS AROUND THE NIPPLE LINE.
• ORTHOPAEDIC TESTING
• REMEMBER THAT ORTHOPAEDIC TESTING IS DESIGNED TO BE   PROVOCATIVE IN NATURE.
• PATIENT’S SHOULD BE ADVISED THAT THEY MAY FEEL WORSE POST EXAMINATION.
• ORTHOPAEDIC TESTING IS DESIGNED TO LOCATE THE INJURED TISSUE.
• TYPES OF PAIN:
• MUSCULAR STRAIN
• LIGAMENTOUS SPRAIN
• DEGENERATIVE BONE(ARTHRITIDES.)
• FRACTURE PAIN
• INTERCOSTAL NEURALGIA
• PLEURAL PAIN
• PAIN DESCRIPTION
• MUSCULAR:
• LIGAMENTOUS:
• DEGENERATIVE BONE:
• PAIN DESCRIPTION: CONT..
• FRACTURE:
• INTERCOSTAL NEURALGIA:

• RADIOGRAPHIC VIEWS:
• A-P:
• LATERAL:
• SWIMMER’S VIEW:
• A-P/P-A RIB:
• CHEST:A-P AND LATERAL:
• THORACIC SUBLUXATION:

• DEFINITION:

• FACTS/CLINICAL PEARLS:

• SIGNS:

• ORTHOPEDIC TESTING:

• RADIOGRAPHS:

TREATMENT:
• OSSEOUS ANOMALY:

• DEFINITION:

• FACTS/CLINICAL PEARLS:

• SIGNS:

• ORTHOPEDIC TESTING:

• RADIOGRAPHS:

TREATMENT:
• FRACTURE:

• DEFINITION:

• FACTS/CLINICAL PEARLS:

• SIGNS:

• ORTHOPEDIC TESTING:

• RADIOGRAPHS:

TREATMENT:
• INTERCOSTAL NEURALGIA

• DEFINITION:

• FACTS/CLINICAL PEARLS:

• SIGNS:

• ORTHOPEDIC TESTING:

• RADIOGRAPHS:

TREATMENT:
• PLEURAL DISEASE

• DEFINITION:

• FACTS/CLINICAL PEARLS:

• SIGNS:

• ORTHOPEDIC TESTING:

• RADIOGRAPHS:

TREATMENT:
• ANKYLOSING SPONDYLITIS

• DEFINITION:

• FACTS/CLINICAL PEARLS:

• SIGNS:

• ORTHOPEDIC TESTING:

• RADIOGRAPHS:

TREATMENT:
 
• SCOLIOSIS AND KYPHOSCOLIOSIS

• DEFINITION:

• FACTS/CLINICAL PEARLS:

• SIGNS:

• ORTHOPEDIC TESTING:

• RADIOGRAPHS:

TREATMENT:

• SCHEUERMANN'S DISEASE:

• DEFINITION:

• FACTS/CLINICAL PEARLS:

• SIGNS:

• ORTHOPEDIC TESTING:

• RADIOGRAPHS:

TREATMENT:

• THORACIC DISCAL DISEASE

• DEFINITION:

• FACTS/CLINICAL PEARLS:

• SIGNS:

• ORTHOPEDIC TESTING:

• RADIOGRAPHS:

TREATMENT:
 
• MALINGERER:

• DEFINITION:

• FACTS/CLINICAL PEARLS:

• SIGNS:

• ORTHOPEDIC TESTING:

• RADIOGRAPHS:

TREATMENT: