Chapter 10 Thoracic and Lumbar Spine

1. Chapter 10Thoracic and Lumbar Spine

2. Cervical Spine- Lordotic, greatest ROM Curves in the Spine Thoracic Spine- Kyphotic, greatest protection of spinal cord at expense of ROM Lumbar Spine- Lordotic, equal balance between protection and ROM

3. Characteristics of Vertebrae

4. Joints • Costovertebral Joint • Rib and thoracic vertebrae • Zygopopheseal Joint • Superior and inferior articulating facets • Intervertebral Joint • Vertebral bodies

8. Ligamentous Support

10. Sacrum and Coccyx

12. Spinal Nerves

15. Extrinsic Muscles

17. Intrinsic Muscles of the Spine

18. History • Key Questions • ADLs • Time of day • Postural positions • Location of Pain • Pain radiating into extremities, peripheral parasthesia (numbness) • Impingement- pressure on a nerve root exiting the intervertebral foramen • Dural irritation- proximal to site of pain • Pain around PSIS, radiating pain into hip/groin • SI joint pathology • Sciatic nerve dysfunction/irritation • Piriformis spasm

19. History • Onset of Pain • Acute • Patients may be capable of describing a singular incident • Chronic • Accumulation of repetitive stress, macrotrauma • Insidious • Being a disease that progresses with few or no symptoms to indicate its gravity

20. History • MOI • Direct blow • Contusions • Hyperextension sports • Gymnastics, Offensive line (FB), Cheerleading, Diving, Crew (Rowing), Weightlifting • Compressive forces • Shear forces

21. History • Consistency of pain • Constant • No change in pain level with change in posture • Chemical- Dural sheath irritation • Intermittent • Symptoms inc and dec with repositioning • Mechanical- Compression/stretching of nerve root • Bowel/Bladder signs • Incontinence or urinary retention • Lower nerve root lesion (Cauda equina syndrome) • Spinal cord injury

22. History • History of spinal injury • Structural degeneration • Predispositions • Changes • Activity • Level • Intensity • Duration • Surfaces • Footwear • Training shoes • Competition shoes • Sleeping location/habits

23. Inspection- General

24. Postural Malalignments

25. Frontal Curvature

26. Test for Scoliosis • Patient position- Standing with hands held in front with arms straight • Examiner- Seated in front or behind patient • Procedure- Patient bends forward, sliding hands down front of legs • Positive test- Asymmetrical hump observed along lateral aspect of thoracolumbar spine and rib cage • Implications • Functional scoliosis- disappears during flexion • Structural scoliosis- present at rest and during flexion

27. Inspection- General • Gait • Altered running or walking gait • Slouching • Shuffling • Shortened gait • Skin Markings • Cafe-au-lait spots • Neurofibromatosis 1 • Increased cell growth of neural tissues • Normally benign • Painful with pressure of local nerves

28. Inspection- Thoracic Spine • Breathing patterns • Irregular, shallow breathing • Injury to T vertebrae, pressure on T nerve roots, trauma to costal cartilage or ribs • Bilateral comparison of skin folds • Asymmetry, unevenness • Bilateral muscle imbalance, kyphosis, scoliosis • Shape of chest • Vertebral rotation causing rib prominence posteriorly • “Rib hump”

29. Inspection- Lumbar Spine • General movement and posture • Improper standing or sitting • Improper lifting mechanics • Lordotic curvature • Reduced curve • Acute pain, muscle spasm, hamstrings tightness • Increased curve • Hip flexor tightness, abdominal muscle weakness • Standing posture • Lateral shift in trunk or pelvis • Impingement

30. Inspection- Lumbar Spine • Erector muscle tone • Unilateral hypertrophy or atrophy • Weak muscles • Poor, abnormal posture • Faun’s beard • Tuft or hair in lumbar or sacral spine • Spina bifida occulta

31. Palpations- Thoracic Spine • Spinous processes • Supraspinous ligaments • Costovertebral junction • Trapezius • Paravertebral muscles • Scapular muscles

32. Palpations- Lumbar Spine • Spinous processes • Step-off deformity • Paravertebral muscles

33. Palpations- Sacrum and Pelvis • Median sacral crests • Iliac crests • Posterior superior iliac spine • Gluteal muscles • Ischial tuberosity • Greater trochanter • Sciatic nerve • Pubic symphysis

34. Palpations- Sacrum and Pelvis • Iliac crest • Tensor fascia latae • Gluteus medius • Iliotibial band • Greater trochanter • Trochanteric bursa

35. Palpations- Pelvis • Pubis • Anterior superior iliac sine • Anterior inferior iliac spine • Sartorius • Rectus femoris

36. ROM- Goniometric Measurements • Patient position- standing with knees extended, spine in neutral position • Procedure • Initial- measure distance between C7 and S1 • Motion- trunk fully flexed or extended • Final- measure distance between C7 and S1

37. ROM- Goniometric Measurements • Patient position- standing with knees extended and spine in neutral position • Procedure • Fulcrum- Aligned over S1 SP • Stationary arm- Aligned over median sacral crest • Movement arm- Aligned with C7 SP

38. ROM- Goniometric Measurements • Patient position- seated with feet firmly planted on floor • Procedure • Fulcrum- Aligned over the center of patient’s head • Stationary arm- parallel to line formed by iliac crests • Movement arm- parallel to line formed by acromion processes