Thoracic

Question 1

Where does breast cancer metastasis?

Answer 1

• thoracic spine most commonly

Question 2

Who get compression fractures due to osteoporosis?

Answer 2

Older patients with stopped posture

Question 3

What can cause viscerosomatic referral to thoracic?

Answer 3

• GI (palpate abdomen - esophageal, gallbladder, pancreas)
• heart (acute coronary syndrome - auscultate heart)
• lung (cancer - auscultate lungs)

Question 4

Where can heart and esophageal issues refer?

Answer 4

Between shoulder blades - esophageal more narrow

Question 5

Where can the gallbladder refer

Answer 5

Just distal to the inferior border of the scapula and on superior aspect of shoulder (upper traps)

Question 6

Where can the pancreas refer

Answer 6

Thoracolumbar area

Question 7

Where can and ulcer refer

Answer 7

Lower left rib cage wrapped from from to back

Question 8

What is schepelmann’s sign?

Answer 8

Patient seated arms fully abducted and raised over head. Instruct patient to laterally flex thoracic spine to the left and right

positive
= pain on concave = intercostal neuritis
= or convex side = pleuritis (fibrous inflammation of the pleura), or intercostal myofascitis (MFTP)

Question 9

What is shingles? What causes it? Who is at highest risk?

Answer 9

Painful rash typically in a dermatomal distribution (usually unilateral)

Viral infection - herpes zoster

Patients > 50 and immunocompromised patients

Question 10

What is the progression of signs/symptoms for shingles?

Answer 10

Itching or tingling, then pain (often severe, burning, stabbing, or shock-like) in the area 1-5 days BEFORE the blisters develop

The rash lasts 7-10 days, the vesicles become yellowish, flatten and dry out. Complete healing in 2-4 weeks

Question 11

About one in _____ people will have an episode of shingles during their lifetime

Answer 11

Four

Question 12

What is the possible complication of shingles? Who is more at risk?

Answer 12

Postherpetic neurologia

Damaged nerves cause severe pain after the rash clears, lasting for weeks, months or years.

The risk of PHN increases with age

Question 13

How is shingles treated? (4)

Answer 13

1. Cover the rash with clothing or non-adherent dressing. Calamine lotion may help relieve the itching. The rash is contagious until the last blister has scared over
2. Medical treatment for pain: paracetamol, ibuprofen or codeine
3. Antiviral medication (acyclovir 800mg 5X/d for 7-10 days) if administered within 72 hours of onset, can shorten the duration and lower the risk of PHN
4. Patients >50 should consider getting the vaccine for prevention

Question 14

What is Scheuermann’s disease? Where is it located in the spine?

Answer 14

Results in progressive structural thoracic hyperkyphosis (<40-45 degrees) in children

The hyperkyphosis does not correct with flexion or hyperextension

75% thoracic, 25% thoracolumbar

Question 15

What does sheuermann’s disease look Ike on xray?

Answer 15

Calcification of vertebral epiphysis characterized by

1) notching of vertebral endplates
2) wedging of vertebral bodies

Question 16

When is the onset of sheuermann’s disease? Who gets it more M/F? What percent of general pop?

Answer 16

Puberty 13-17 yo

M>F

4-8.3% of population affected depending on type of diagnosis (clinical vs radiograph)

Question 17

_____% of patients with sheuermann’s have an associated scoliosis

Answer 17

30-40

Question 18

What should you do the the physical exam for sheuermanns disease?

Answer 18

• Have child supine on bolster/foam roller under the apex of the deformity and assess for reducibility
• neuro screen for evidence of spinal cord involvement (DTRs, pathologic reflexes, superficial abdominal reflexes, presence of hypertonia, lower extremity sensory abnormalities, muscle weakness, altered sphincter function)

Question 19

When should you consider non-surgical treatment of a sheuermann’s patient?

Answer 19

• curvature >40 but <65 degrees
• curve is reducible
• there is >1 year of spinal growth remaining

Question 20

How do you manage a patient with sheuermann’s?

Answer 20

• bracing/ casting/ physical therapy
• CMT and mobilize to promote extension
• In acute phase -(LIMIT WEIGHT BEARING ACTIVITY AND CONTACT SPORTS)
• postural training (brueggers)
• home care - enhance extension and core strength
• stretch hamstrings (may aggravate symptoms)
• reduce myospasm with STM, heat, possible electro therapy
• Traction or distractions therapies
• assess nutrition

Question 21

What are mechanisms of injury for the thoracic spine?

Answer 21

• trauma, repetitive trauma/overuse, etc.
• forward head carriage (especially overloading T5)
• Push/pull activities
• rotational activities

Question 22

What are causes of nerve root lesion for the thoracic spine?

Answer 22

• stenosis,
• Tumor
• disc herniation (super rare so in third place)

Question 23

What are lesions of the intercostal neural (intercostal neuritis) of the thoracic spine?

Answer 23

Trauma, neuritis, shingles

Question 24

What are lesions of the thoracic cord of the thoracic spine?

Answer 24

• stenosis
• tumor
• disc herniation (rare so number 3 on the list)

Question 25

What is the low neuro screen for the thoracic spine? When do you do a low neuro screen?

Answer 25

- when the patient has localized pain Light touch on the back bilaterally *no sharp dull, muscle testing, reflexes

Question 26

What is a high index neuro screen of the thoracic spine? When do you need to do a high neuro screen?

Answer 26

If the pain is over a wider area or wrapping around the ribs anterior/posterior or worried of spinal cord - Light touch & sharp/dull along dermatome - vibration on sternum (maybe) (do it at the end of the dermatome - the sternum) - reflex: Beevor’s sign, superficial abdominal reflex

Question 27

How do you perform beevor’s sign? What can does it tell you is wrong?

Answer 27

Partial sit up - look for umbilicus deviation - nerve root OR spinal cord

Question 28

How is the superficial abdominal reflex done? What can it tell you?

Answer 28

Lightly brush along abdomen and navel, look for skin twitching or umbilicus deviation - nerve root OR spinal cord issue

Question 29

If you suspect tumors, stenosis or disc herniation, what does the neuro screen involve in the lower extremity?

Answer 29

- sensory (sharp/dull, vibration/position sense/Romberg) - reflex (DTR’s, Babinski/clonus) - motor (lower extremity strength (include hip flexors))

Question 30

What the ddx for nerve root lesion of thoracic?

Answer 30

Stenosis, tumor, disc herniation

Question 31

What is the ddx for spinal cord for thoracic?

Answer 31

Stenosis, tumor, disc herniation

Question 32

What is the ddx for intercostal nerve for thoracic spine?

Answer 32

Herpes zoster, intercostal neuritis (other viral infection), trauma (rib fracture, intercostal muscle strain)

Question 33

What is the ddx for trauma to the thoracic spine?

Answer 33

- thoracic sprain/strain (or facet syndrome/ disc derangement but not as common) - costovertebral sprain, rib fracture) - spinal fracture or contusion - intercostal sprain *there is a diagnostic code for a bruise so list it too!

Question 34

What is the ddx for repetitive stress injuries?

Answer 34

- scapulocostal syndrome (SICK) snapping scapula - thoracic joint dysfunction - rib joint dysfunction - facet syndrome, disc herniation, postural sprain/syndrome - intercostal/scapular MFTPs

Question 35

What are causes for pleuritic pain (pain with inspiration) associated with ribs, spine, intercostal muscles, lungs)

Answer 35

- ribs (fracture, sprain, joint dysfunction) - thoracic spine (fracture, sprain, joint dysfunction) - intercostal muscles (strain, spasm) *MFTP not common to cause pain with breathing* - lungs (pleuritis, pulmonary embolism)

Question 36

What can cause referred pain to between the shoulder blades from the cervical spine?

Answer 36

- Cervical dorsalgia (joint problems in neck causing pain between the shoulder blades) - visceral: Heart, lung, esophagus, ulcer,

Question 37

How can doorbell sign, or rotation with overpressure into extension, help you if it causes referred pain between the shoudler blades?

Answer 37

Just tells you the referred pain is coming from something in the neck

Question 38

The rate of vertebral body fractures begins to steadily increase as patients reach their mid _____ (due to ______)

Answer 38

Mid 60s | Osteoporosis

Question 39

LBP and deformity can be the results of __________

Answer 39

Compression fractures

Question 40

How does a patient get a compression fracture?

Answer 40

- possible trauma with sudden pain and “snapping” sound - spontaneous compression fracture in patients over 70 with sudden non-traumatic LBP - in patients over 50 with only low or moderate old especially if peri or post menopausal or or other indications of possible osteoporosis *order radiographs for these patients

Question 41

Almost _____ of spinal compression fractures are never diagnosed because many patients think their back pain is just _________

Answer 41

2/3 | A sign of aging and arthritis

Question 42

Pain due to a compression fracture is aggravated by what? Relieved by what?

Answer 42

- standing, walking, with activity | - rest or lying down

Question 43

Your patient who has a compression fracture may experience _________ for ____days, causing digestion issues. What can you recommend to help them with this?

Answer 43

Paralytic ilium (a temporary stoppage of intestinal peristalsis) for 2-3 days - liquid diet and especially no bulky foods

Question 44

Corticosteroids are a risk for ______. The most rapid period of this occurs within the first ______ months

Answer 44

Osteoporosis | - most rapid bone loss occurs in the first 6 months (10-20% loss)

Question 45

What are findings in a physical exam for a compression fracture? (3)

Answer 45

- AROM all decreased (especially flexion, and standing straight may be difficult as well) - muscle guarding/splinting in the beginning - tenderness to palpation or sharp lingering pain with spinal percussion over involved segment * do a neuro exam to rule out nerve root or spinal cord damage

Question 46

If you suspect a fracture when should you order a radiograph? What can you do before ordering a radiograph?

Answer 46

Before joint plays or orthopedic tests! - AROM, neuro screen

Question 47

Are compression fractures stable or unstable?

Answer 47

- most are stable and heal on their own

Question 48

How do you manage a compression fracture?

Answer 48

- refer to orthopedist for medicolegal reasons although management is primarily conservative - after the acute phase, co-treat for subsequent joint dysfunction and myospasm avoiding the fracture

Question 49

A compression fracture collapse of _____% is a surgical case

Answer 49

``` >50% = surgical <50% = conservative ```

Question 50

What is a schmorl’s node? Is it usually painful?

Answer 50

Thoracic intervertebral disc herniated through vertebral endplates, directly into adjacent vertebral bodies - usually does not cause symptoms but an inflammatory, foreign body-type reaction can occur causing severe pain

Question 51

What is the criteria for a T4 syndrome diagnosis? What other symptoms may the patient have?

Answer 51

- rule out TOS, carpal tunnel syndrome, cervical radiculopathy CRITERIA - joint dysfunction around T4 level - glove paresthesia in upper extremity (NON DERMATOMAL) (may be accompanied by hyperalgesia to pin prick) (may be in hands and even up to elbow) EXTRA - pain generalized in upper back, scapula, arms and or forearms (may be reproduced by thoracic P-A glide) - skin near joint dysfunction may be hypersensitive - sometimes generalized headache in “helmet” distribution (sometimes occipital) - may report grip weakness (but muscle tests are normal), temp changes in hands, and Raynaud’s like phenomenon - may wake up at night with symptoms or worse in the morning (shaking involved extremity may offer temporary relief)

Question 52

What can happen to ribs?

Answer 52

- sprain (trauma or overuse) - fracture/contusion (trauma or minimal trauma if osteoporosis) - joint dysfunction

Question 53

How does a rib fracture occur

Answer 53

- Blunt trauma (MVA, slip and fall, sports) or strenuous Repetitive activities (rowers, discus throwers, golfers) - secondary to pathology/osteoporosis (may be triggered by coughing)

Question 54

What is a sign that the rib is fractured?

Answer 54

- pain aggravated by inspiration/coughing | - pain with palpation, tuning fork or percussion

Question 55

What are the radiographs ordered for a fractured rib? What is the sensitivity? When would a fractured rib show up on an xray? What is the next step?

Answer 55

- AP and lateral - 50% - non-displaced fx may not show up for 3 weeks - need to follow up with another xray in 3 weeks or and immediate CT (which is more sensitive)

Question 56

What are you worried about with a fractured rib? What additional exam procedures should you do to screen for each?

Answer 56

Displaced fracture may puncture kidney (UA), spleen (palpate abdomen) or puncture lung (auscultate)

Question 57

What can cause a rib sprain or joint dysfunction?

Answer 57

- trauma or overuse

Question 58

What are rib sprain or joint dysfunction signs?

Answer 58

- sharp pain with point sensitivity | - may be significantly aggravated by breathing, especially a deep breath

Question 59

How to you manage a rib sprain or joint dysfunction

Answer 59

- manipulation of joint can be very effective but painful (use light force, especially in osteoporotic patients) - sprains can be taped with kinesiotape, but should NOT be braced!

Question 60

What is scapulocostal syndrome? What can cause it?

Answer 60

Myofascial syndromes involving soft tissue between the scapula and rib cage (scapulocostal interspace) - traumatic or mechanical irritation the soft tissue contained within the scapular interspace (scapularis muscle and decreased viscosity of the serous fluid minimizing friction in the interface to lubricate the movement)

Question 61

What are symptoms of scapulocostal syndromes?

Answer 61

- local pain along vertebral border and deep to the scapula - pain commonly referred down the posterior shoulder and arm - dysesthesia in arm & forearm common

Question 62

What are exam findings of scapulocostal syndromes? (4)

Answer 62

- possible painful tenderness and decreased shoulder abduction - MFTP and tenderness along the vertebral border of the scapula - associated costotransverse joint dysfunction - predisposed postural distortions (forward head carriage, rolled shoulders)

Question 63

What is SICK scapula?

Answer 63

- a scapulocostal syndrome - acronym to look for scapular malposition - Scapular malposition - Inferior/medial border winging - Coracoid tenderness - dysKinesis (aberrant movement)

Question 64

What is the ddx for neuropathy in the thoracic spine? What are the symptoms and the part of the nervous system causing it?

Answer 64

- T4 syndrome (symptoms in arms, ANS) - herniated disc, spinal stenosis, tumor (Sx in legs, CORD) (intercostal Sx, NRs) (abdominal wall signs such as beevors sign or superficial abdominal reflex, CORD or NRs) - thoracic OR rib fracture (sx in legs, CORD) (intercostal sx, NRs) (abdominal wall sx, CORD or NRs) - intercostal neuritis (intercostal sx, INTERCOSTAL NERVES)