Thoracic

How many articulations are present in a typical thoracic vertebra?

12- Upper and Lower intervertebral, 2 superior facet, 2 inferior facet, 2 superior costal articular facet, 2 inferior costal articular facets, 2 transverse costal facets

5. Trunk deviation to the right during ROM testing for flexion indicates: A. A restriction of the right facet joint to up glide. B. A restriction of the left facet joint to up glide. C. A restriction of the right facet joint to down glide. D. A restriction of the left facet joint to down glide.

A. A restriction of the right facet joint to up glide.

2. In the thoracic spine, the most common differentiation between pain originating from a facet joint versus pain originating from a costo-vertebral joint is: A. The facet joint refers pain out laterally while the costo-vertebral joint creates a shooting pain from posterior to anterior. B. The facet join refers pain posterior to anterior while the costo-vertebral joint refers pain laterally. C. There is no difference in pain perception originating from a facet joint or a costo-vertebral joint and differentiation between the two types of joints should be done with MRI, CT or bone scan. D. The costo-vertebral joint produces pain only with respiration while the facet joint produces pain only with thoracic motion.

A. The facet joint refers pain out laterally while the costo-vertebral joint creates a shooting pain from posterior to anterior.

14. The posterior longitudinal ligament attaches to all BUT the following sites: A. The posterior vertebral body. B. The vertebral end plate/rim. C. The axis. D. The anulus fibrosus.

A. The posterior vertebral body.

7. The spinous processes of the thoracic vertebrae at different levels are characterized as follows: A. The spinous processes of the middle 4 thoracic vertebrae are long, overlapping and nearly vertical. Those of 1,2 and 11,12 are nearly horizontal. The spinous processes of 3,4 and 9,10 are oblique. B. The spinous processes of the middle 4 thoracic vertebrae are oblique. Those of 1,2 and 11,12 are nearly horizontal. The spinous processes of 3,4 and 9,10 are long, overlapping and nearly vertical. C. The spinous processes of the middle 4 thoracic vertebrae are nearly horizontal. Those of 1,2 and 11 and 12 are long, overlapping and nearly vertical. The spinous processes of 3,4 and 9,10 are oblique. D. All thoracic spinous processes are similar in shape and direction.

A. The spinous processes of the middle 4 thoracic vertebrae are long, overlapping and nearly vertical. Those of 1,2 and 11,12 are nearly horizontal. The spinous processes of 3,4 and 9,10 are oblique.

4. Coupling forces of the thoracic vertebrae are: A. The upper thoracic spine (T1-T4) as having the same coupling characteristics as the cervical spine, with lateral flexion and rotation occurring to the same side in the erect spine. In the mid (T4-T8) and lower (T8-T12) thoracic spine rotation can be in the same or in the opposite direction as lateral flexion, but this coupling pattern is inconsistent. B. The coupled forces of the thoracic spine follow the coupled forces of the cervical spine throughout the entire thoracic spine. C. The coupled forces of the thoracic spine follow the coupled forces of the lumbar spine throughout the entire thoracic spine. D. Coupled forces in the thoracic spine change from morning to evening.

A. The upper thoracic spine (T1-T4) as having the same coupling characteristics as the cervical spine, with lateral flexion and rotation occurring to the same side in the erect spine. In the mid (T4-T8) and lower (T8-T12) thoracic spine rotation can be in the same or in the opposite direction as lateral flexion, but this coupling pattern is inconsistent.

10. Which one of the following signs and symptoms is NOT part of Scheuermann's Vertebral Osteochondritis: A. The patient is usually between 13 and 16 years old. B. The male:female ratio for the thoracic spine is 2:1. C. There is an increase in the thoracic kyphosis. D. X-ray findings will show Schmorl's nodes.

B. The male:female ratio for the thoracic spine is 2:1.

12. The medial branch of the posterior primary rami in the thoracic spine innervates: A. The disc. B. The multifidus muscles. C. The costotransverse joint. D. The dura.

B. The multifidus muscles.

13. The anterior longitudinal ligament attaches to all BUT the following sites: A. The margins of the vertebral body. B. The vertebral endplate/rim. C. The anterior surface of the vertebral body. D. The front of the anulus fibrosus.

B. The vertebral endplate/rim.

. The number of articular joint surfaces in a mid thoracic spine segment is: A. 8 B. 10 C. 12 D. 14

C. 12

9. According to Cyriax, if AROM and PROM testing of the thoracic spine produce pain and/or restriction in the same directions the lesion is said to be: A. A muscular lesion. B. A non-organic pain presentation. C. An arthrogenic lesion. D. No hypothesis can be made.

C. An arthrogenic lesion

1. The ribs in the mid thoracic spine are connected to the vertebrae by joint articulations with: A. Its adjoining vertebral segment on the body and the transverse process. B. The vertebral body of the lower segment and the transverse process of the upper segment. C. Both vertebral bodies of the vertebral segment and the transverse process of the upper vertebrae of that vertebral segment. D. Both vertebral bodies of the vertebral segment and the transverse process of the lower vertebrae of that vertebral segment.

D. Both vertebral bodies of the vertebral segment and the transverse process of the lower vertebrae of that vertebral segment.

3. An elevation of the first rib contributes to: A. Thoracic outlet pathologies. B. Shoulder pathologies by restricting the sternoclavicular joint through a shared joint capsule. C. Positive neural tension findings of the brachial plexus. D. Respiratory dysfunctions. E. All of the above.

E. All of the above.

6. An increase in the thoracic kyphosis with a loss of extension mobility may contribute to: A. Respiratory dysfunction. B. Lower cervical spine mechanical pathologies. C. Shoulder impingement. D. Lumbar spine mechanical joint pathologies. E. All of the above.

E. All of the above.

8. The costo-vertebral and costo-transverse joints are mechanically linked by an axis through the center of both joints. The direction of this axis with respect to the sagital plane determines the direction of rib movement. Which of the following statement(s) is/are true. A. In the upper ribs this axis lies close to the frontal plane and rib elevation therefore increases the transverse diameter of the thorax. B. In the upper ribs this axis lies close to the frontal plane and rib elevation therefore increases the anterior-posterior diameter of the thorax. C. In the lower ribs this axis lies nearly parallel to the sagital plane and rib elevation increases the anterior-posterior diameter of the thorax. D. In the middle ribs the axis lies at a 45 angle to the sagital plane and therefore both diameters increases during rib elevation. E. B and D.

E. B and D.

The ribs act as a flexible ring attached to the thoracic spine as well as the sternum. Describe what happens in a rib pair (left and right rib of the same level) during rotation of the trunk.

a. Accentuation of the concavity of the rib on the side of rotation b. Flattening of the concavity of the rib on the opposite side c. Accentuation of the costochondral concavity on the side opposite to the rotation d. Flattening of the costochondral concavity on the side of rotation

Describe to motion of the ribs with respiration and how this varies as you move from the lower rips to the upper ribs.

a. Do to the angle that exists and the plane between the costotransverse joint and the costal head there is a specific rotation of the rib that takes place at each rib level. The angle of this plane/axis relative to the sagittal plane determines the direction of movement. The lower ribs moves closer to the sagittal plane so that elevation of the rib increases the transverse diameter of the thorax. The uipper ribs lie almost in the coronal plane, therefore, elevation of these ribs markedly increases the anteroposterior diameter of the thorax. b. Pump handle - is the upper thoracic ribs c. Bucket handle- is the lower thoracic ribs

Describe the motions of the thoracic facet joints during flexion and extension

a. During extension both the inferior process of the above segment are driven back downwards, and actually become more congruent on the inferior poles which is one of a few restraints to extension (others being above spinous process on below, and the ALL is stretched) b. During flexion the inferior processes of the above segment are driven upwards and can overshoot from above the superior processes of the underlying vertebra. Flexion is limited by the interspinous ligaments, the lig flav, the capsular ligs and the PLL.

Describe the motions of the rib at the costovertebral and costotransverse joints during thoracic flexion and extension.

a. Flexion you get an anterior rotation of the neck of the rib which causes an anterior rotation of the tubercle of the rib as well as a superior glide b. Extension you get a posterior rotation of the neck of the rib which causes a posterior rotation of the tubercle of the rib as well as a inferior glide

You have a patient who is performing a trunk extension exercise specifically to target the erector spinae muscles. The patient asks how far they should flex during the exercise what is your answer and why?

a. Relaxation phenomina- don't go to end-range because at this point they become electrically silent. Nordin text 271.

Describe the coupling pattern of rotation and side bending in the thoracic spine

a. Sidebending- Contralateral is just like Flexion of the facets, with limitations being lig flav and intertransverse lig. Ipsilateral side is just like Extension of the facet where the processes is the limiting factor b. Rotation- c. T1-T4 is similar to the cervical where rotation and sbing are the same d. The rest of the thoracic flexion and neutral is the same (sbing and rotation occur to the same side) where as extension (sbing and rotation occur to the opposite side) e. Its important to note that you CAN get pure sidebending and pure rotation, however there are coupled movements, and these coupled movements can add appeared increases in motions. For example sidebending in extension with rotation opposite will allow for more bend

What types of cancer commonly give metastases to the vertebrae of the spine?

a. Spinal metastasis is common in patients with cancer. The spine is the third most common site for cancer cells to metastasize, following the lung and the liver. Approximately 60-70% of patients with systemic cancer will have spinal metastasis; fortunately, only 10% of these patients are symptomatic. Approximately 94-98% of these patients present with epidural and/or vertebral involvement. Intradural extramedullary and intramedullary seeding of systemic cancer is unusual; they account for 5-6% and 0.5-1% of spinal metastases, respectively. b. Lung - 31% c. Breast - 24% d. GI tract - 9% e. Prostate - 8% f. Lymphoma - 6% g. Melanoma - 4% h. Unknown - 2% i. Kidney - 1% j. Others including multiple myeloma - 13% k. Predicting cancer for spinal - age over 50, history of cancer, unexplained weight loss, failure of conservative therapy. l. PH KTL - (lead kettle) - prostate, breast, kidney, thyroid, lung m. Metastatic cancer is the only one that is a contraindication towards manual therapy

As part of a mobility exercise program you ask your patient to try and squeeze all of the air out of his lungs at the end of expiration. What muscles are responsible for this forced expiration?

a. Sternocostalis, internal intercostals, abdomincal muscles (recuts, external oblique, internal oblique, iliocostalis thoracis, longissimus, serratus postiero inferior, quadrates lumborum, and ofcourse the costal cartilage stored energy from the inhalation causing a thoracic recoil effect

Your patient has a 4th rib that is "stuck" in the position of maximal inspiration. Which direction does the head of the rib need to glide at the costovertebral joint in order to return to normal resting position?

a. Superiorly, laterally, and posteriorly. b. Muscle energy rx rib 1: -- Use anterior and middle scalenes. c. Muscle energy rx rib 2: -- Use posterior scalenes. d. Muscle energy rx rib 3-5: -- Use pectoralis miniro. e. Muscle energy rx rib 6-9: -- Use serratus anterior. f. Muscle energy rx rib 10-11: -- Use latissimus dorsi. g. Muscle energy rx rib 12: -- Use quadratus lumborum h. OSTEOGENISIS IMPERFECTA is a lack of collagen in the bones, and ehlers denlers is the opposite end of the spectrum with too much collagen. Ehlers is going to needs strength and stability.

The thoracic vertebrae have long spinous processes. This makes identifying the level of facet articulation difficult. In general you can use the rule of 3's to identify the levels in the thoracic spine. Describe how you would use the rules of 3.

a. The "Rule of Threes" for the Thoracic Transverse Processes Leveling states: --1) T1-3 (and T12) transverse processes are at the level of the corresponding thoracic spine. --2) T4-6 (and T11) transverse processes lie superiorly between its level's spine and the spine of the thoracic segment above it. --3) T7-9 (and T10) transverse processes lie superiorly at the level of the superior segment's spine. --4) T10 transverse processes are at the level of the T9 spine. --5) T11 transverse processes are midway between the T10 and T11 spine. --6) T12 transverse processes are at level with its spine. b. Good to know that the rib comes in roughly at the level of the facet, so that's a helpful landmark. Very common also to have anatomical variances in the thoracic spine as opposed to an actual miss-alignment

What is the orientation of the thoracic facet joints

a. The superior facets are oval, flat or slightly convex transversely and face posteriorly and slightly superiorly and laterally. b. The inferior articular facets are oval, flat, or slightly transversly concave articular facets facing anteriorly and slightly inferiorly and medially. c. These are also 60 degrees oriented. The lower thoracic is around 75 as it gets to 90 in the lumbar, and then upper thoracic is closer to the 10 degrees that is found in the lower cervical.

You have a female patient with complaints consistent with thoracic outlet syndrome. She has a history of multiple abdominal surgeries including a caesarian, hysterectomy, and hernia repair. Examination reveals hypertonicity in the scalene, sternocleidomastoid, and pectorals. Describe the clinical relevance of these findings.

a. These muscles are considered excessory breathers for inhalation. Odds are is that the patient is not using her primary inhalation muscles which are the external intercostals, levatores costarum, and above all the diaphragm. Important to assess diaphragmatic breathing techniques with this patient

You are working with a patient on thoracic mobility and motor control. You want to facilitate the flexion and extension movement patterns with respiration. What are your instructions to the patient?

a. To breath in during extension, and exhale during flexion

Describe the ligamentous structure of the costovertebral and costotransverse joints

a. Two costovertebral joints that are supplied by powerful ligaments and cannot function one without the other mechanically linked b. Joint of costal head - head of the rib and the bodies of two adjacent vertebrae and the IV disc. -- Double synovial joint with two costal facets on the headof the costal -- These facets form a solid angle who base consists of the annulus fibrosus. The head of the ribs facets are slightly convex =- There is an interosseous ligament running from apex of costal head between the two articular facets (divides the joint)- surrounded by a single capsule =- Radiate ligament (3 ligs) reinforces the structure- superior band, inferior band (coming from adjacent vertebrae) and the intermediate band coming from the annulus fibrosus -- Costotransverse joint- synovial joint consisting of two oval articular facets (one on apex of transverse process and the other on the costal tubercle - 1 capsule =- Three costotransverse ligaments- very short and strong interosseous costotransverse ligament =- Posterior costotransverse ligament- apex of TP to the external border of the costal tubercle =- Superior costotransverse ligament- TP to the superior border of the neck of the underlying rib c. Conclusions: The costovertebral joints and rib cage play an important role in providing stability to the thoracic spine. The state of the costovertebral joints and rib cage should be assessed to evaluate the stability of the thoracic spine.

What makes the anterior portion of the vertebral body susceptible to wedge compression fractures?

b. Mechanical aspect is from the natural kyphosis and soft tissue reliance in front of it, as well as the mechanical arm. c. Also the structure of how the trabecuae are lined up is important. In these vertebral bodies form a V in the front, which means the front has less trabecuae and bone which then leads to increased fracture rate from anterior loading. CURRENT CONCEPTS PG 5

The diaphragm is able to increase the vertical, transverse, and anterior-posterior diameters of the thoracic cavity. Describe how this is possible

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