The Thoracic Spine & Ribs

Anatomy
Function: Main area of adaptation Facilitates respiration Provides attachment for the shoulder girdle, to enhance stability and allow absorption of torque and momentum. In particular it provides an attachment point for the muscles and tissues controlling the postural orientation of the shoulder girdle and hand. Provides attachment sites for muscles and tissues connecting the csp and the trunk to allow transmission and dissipation of forces generated in these areas. Allows rotation of the trunk by virtue of its facet direction T/L junctional area between UEXX and LEXX Provides protection and support for viscera and CNS. Structural fulfilment: The spinous process is longer and overhangs the body below The pedicle is long, allowing a larger vertebral canal, so stenosis is less likely in the dorsal spine The TPs are directed posteriorly to encourage rotation by attachment of the rotators The facets are nearly vertical allowing some s/b, rotation, but limited flexion and extension. The rib facets limit s/b. Together with the vertebrae they provide a large area for muscular attachment and a volume of musculo-skeletal units to allow in force dissipation. The tsp has certain ligaments exclusive to it: o The radiate ligament which runs to the disc, sup and inf aspect of the vertebral body o The sup, inf and lat costotransverse lig. Which reinforce the costo-transverse lig o The costotransverse joints are close to the sympathetic ganglia and any irritation of the joint may have sympathetic repercussions. th Ribs are deformable and contain a high volume of collagen particularly until the 5 decade, so aiding force dampening and absorption. Nerve Supply 12 thoracic nerves: o Posterior primary ramus: lat sensory brach to the skin and motor branch for deep back muscles and joints o Ant primary ramus: Forms the INTERCOSTAL NERVES. Communicates with the sympathetic ganglia o Gives collateral branch (intercostals muscles, parietal pleura, periostium of the ribs), lateral cutaneous branch (pec, lat dorsi, scapula), ant cutaneous branch. o 1st intercostal nerve joints the brachial plexus (no lat cutaneous branch)

Structure

2nd intercostal nerve joins the medial cutaneous nerve of the arm (INTERCOSTOBRACHIAL NERVE: branch of the ulnar nerve). Supplies the infraclavicular area and lat and upper border of the breast. th th o The 7 -11 intercostals nerves- gives rise to thoracoabdominal nerves o 12th intercostal nerve- subcostal nerve Sympathetic chain (T1 to L2). o T1 go up to the head and neck (via cervical ganglia) o T2 neck and upper limb o T3-6 the thorax(heart & lungs) o T7-T11 the abdomen o T12 & below pelvis and lower limb Level Body TP T1 2 sup facets for rib 1 +2 inf 2 facets for rib 1 demifacets for rib 2 T2 T9 2 supe + 2 inf demifacets 2 facets for ribs 2-9 T10 2 facets for rib 10 2 facets for rib 10 T11 2 facets for rib 11 T12 2 facets for rib 12 12 ribs + sternum (manubrium, body, xyphoid process) st True ribs (1-7), connect directly to sternum by a costal cartilage (1 is fibrocartilagenous; 2 to 7 synovial) False ribs (8- 10), connect to the sternum via the costal margin Floating ribs (11-12), the anterior end is encased in the abdominal mm. Intercostal spaces we have 11 between the ribs Intercostal mm (intimus, internus & externus) Intercostal nerves and vessels (in costal groove) Costal cartilage: more flexible in youth, tend to ossify with age leading to loss of thoracic flexibility and respiratory efficiency Shortest & most curved. Superior surface has: 1. Anterior groove (subclavian vein)-more medial 2. scalene tubercle (scalenus anterior) 3. Posterior groove (subclavian artery) 4. Scalenus medius more lateral Att. to T1 body and Manubrium (is fibrocartilagenous) Typical rib. Att. to manubrio-sternal joint (sternal angle)(2 compartments) Typical ribs. Att. to Sternum Typical rib. Att. to Sternum/Xiphoid process Typical ribs. Att. to costal cartilage (at interchondral joints) Articulates to T10 only and costal cartilage (at interchondral joint) Articulate to own bodies, have no tubercle (for TP articul.), no neck, and short, little curve, and pointed anteriorly.

Ribs Components

Rib 1

Rib 2 Ribs 3 - 6 Rib 7 Ribs 8 9 (False) Rib 10 (False) Ribs 11- 12 (Floating)

Function Joints

Upper ribs pump handle ( increase A-P diameter) Lower ribs bucket handle (increase lateral ) Costo-vertebral joints: Synovial plane. The head of the rib articulates with the sup costal facet of the corresponding vertebra, the inf costal facet of the vertebra sup to it, and adjacent IVD uniting the two vertebrae. Costo-transverse joints : Synovial plane. Costal facets on the tranverse facets. Except for the inf 23 thoracic vertebra Manubrio-sternal joint: Symphysis Xiphisternal: Synchondrosis Sternocostal joints (upper 7 costal cartilages--- sternum) o 1 is fibrocartilagenous: synchondrosis o 2 to 7 are synovial: synovial plane Inter-chondral joints (between costal cartilages 6/7,7/8,8/9,9/10) ---are synovial plane

Sternoclavicular: Saddle joint. Ant + post sternoclavicular lig+cotoclavicular lig. The joint is divided into two compartments by an articular disc. Costovertebral lig.: a) costo-transverse lig (between rib tubercle and TP) 3 bands: Lateral (tip of TP to costal tubercle) o Interosseous (TP to underlying rib) o Superior (TP to posterior neck of same rib) b) radiate lig (between ribs head and vertebrae): Divides the enclosed space between 2 synovial cavities o 3 bands: Superior (to superior vertebral body) Inferior (to inferior=same level vertebral body Intermediate ( to annulus fibrosus of disc) Radiate sternocostal lig. (between ribs 1 to 7 and sternum) Interchondral lig.(reinforce the thin fibrous capsules of interchondral joints)

Ligaments

Blood supply

Arterial supply: Thoracic aorta >Posterior Intercostal a. (supreme) + subcostal a. >give lateral and collateral branches Subclavian > Internal Thoracic artery > anterior perforating branches+ sup epigastric + musculophrenic Venous Drainage: Left Intercostal veins - left brachiocephalic vein - SVC Right intercostals veins - azygos vein - right brachiocephalic vein - SVC Thoracic wall parasternal nodes bronchomediastinal trunks thoracic duct Head &necks of ribs upper intercostal nodes bronchomediastinal trunks thoracic duct Lower intercostal nodes thoracic duct Diaphragm diaphragmatic nodes Superficial thoracic wall -axillary lymph nodes or parasternal nodes SPS, SPI, levator costarum, external intercostals, internal intercostals, innermost intercostals, subcostal, transverses thoracic, diaphragm (nerve supply) Pectoral fascia, clavipectoral fascia, endothoracic fascia becoming into a sibsons fascia in the apical part

Lymph

Muscles Fascia

VINDICATER Vascular Inflammatory Neurological Neoplasm Degenerative Infection Congenital Autoimmune Trauma Endocrine Rheumatologic
Sys/Referred (Thoracic/Scap pain)

Aortic aneurysm, angina pectoralis, pulmonary embolism, TOS, subclavian steal syndrome Teitzes syndrome, Costochondritis, interchondritis, scapula-costal sndrome, cholecystitis, pleuratic pain, Magner syndrome Myasthenia gravis, Sympathetic chain irritation/stimulation, intercostobrachial nerve 2ries, Neurofibroma, multiple myeloma O/A, Spondylosis, Spondyloarthrosis Osteomyelitis , TB, Herpes zoster, osteochondritis Scheurmans, Pectus carinatum, Pectus excavatum, scoliosis, cervical rib, Sprengels syndrome Sarcoidosis Rib/ vertebra # Pagets disease(40+), Hyperthyroid / Hypothyroid, Diabetes, Cushings, Addisons Ankylosing spondylitis, R/A, Reiters, PM (60+)
Cardiac (MI or AA) Location: Mid-thoracic, T/L Pulmonary (Pneumonia, Empyema, Pleurisy, Pneumothorax) Location: Right upper back, Scapula Renal (Acute pyelonephritis)

Location: costovertebral angle GI (Oesophagitis, Peptic ulcer, Gallbladder,Biliary colic, Pancreatic carcinoma) Location: Interscapular area

Common extrinsic cause of SS

Heart ( to the Left shoulder & occasionally to arm, neck or jaw) Diaphragm ( to the shoulder and C4 dermatome) Abdominal disorders (Spleen to Left shoulder area ; Gall bladder to Right shoulder area) Lung / pleura ( Pancoast tumour to the thoracic outlet area Renal disorders ( to 12th rib area)

Inflammatory
Tietzs syndrome Def: clinical syndrome, usually of a tender, painful mass (perichondrial swelling with round cell nd infiltration) over a single costal cartilage. (50% 2 rib). It may also occur over the sternomanubriem junction as well. D.D: Tietzs syndrome implies swelling, costochondritis refers to pain alone Incidence: >50; female . Signs:Unilateral, upper ribs usually, swelling, R2-R5, manubrium junction Cause: Torsion of the rib, secondary to a maintained post rib lesion, with a stimulation of a maintained somato-visceral reflex. Def: inflammatory process of one or more costal cartilage that causes localized tenderness and pain in the anterior chest wall. D.D: Tietzs syndrome implies swelling, costochondritis refers to pain alone. Onset/Progression: often self-limited, it can be a recurring condition that can appear to have little or no signs of onset. Insidious onset Cause: NAR, direct injury, strenuous lifting, bouts of coughing, seat-belt trauma, post chest surgery wiring, secondary to costo-vertebral/costo-transverse joint dysfunction, AS,seronegatives (enthesopathy involvement), RA, OA, infection of the affected joint, tumours (benign or cancerous). Incidence: between 20 and 40, typically female, and tends to affect the third, fourth, fifth, or sixth costosternal joints Signs: local pain, TTP, BUT THERE IS NOT SWELLING of the bone-cartilage junction at R1-5 and of inter-chondral junction of R6-10. Interchondral joints may detach, as well as displace, producing a characteristic click, on sitting, twisting to the side. Unilateral/Bilateral, middle ribs Moderate to severe sharp/shooting ant chest wall pain Well localised pain, but may radiate to chest, upper abdomen or back

Costochondritis// Interchondritis

Agg: coughing, deep breathing, or physical activity, arm movements Rel: Ice, rest, heat Investigation: Vital signs: t, pulses, auscultation, breathing rate Observation: symmetry of the chest wall Palpation of the affected joint usually causes pain Swelling is common in Teitzs syndrome Lack of warmth and erythema rules out an infective process Arm movements may limited due to costosternal pain. Ttt: rest, analgesics, or anti-inflammatory medications, cortisone injection

Scapulocostal syndrome

Def: Snapping of the scapula-thoracic interface at the sup-medial corner of the scapula. Signs and symptoms:pain and tenderness along the medial side of the scapula, fine crepitus on passive and active movements of the scapula Cause:Degenerative ST nodules of the subscapularis, which may further affect shoulder mechanics, thining of the subscapularis/serratus ant muscles, irregularities from old rib #, or altered posture. Sharp, stabbing pain, mainly in deep breath in. Reduced breath sounds in the affected side and pleural rub Neurologycal Related to issues in the costotransverse joints. Honers syndrome: Ptosis, anhidrosis, miosis (constriction), sunken eye (enopthalmus), bloodshot (redness of the conjunctiva) Cause: Hyperflexion-hyperextension (whiplash), pulling activities, entrapment at the serratus ant. Signs and symptoms: pain in the upper tsp, spreading across the scapula, under the axilla, and radiating down the post/medial aspect of the arm, often to the elbow. Agg: extension tsp (when lying prone), strong expiration Neoplasm Def: Common site for metastatic disease (breast, kidney, uterus, ovaries, testes, thyroid) and secondaries Prevalence: 50% of male deaths from cancer are from lung cancer, age: 50-75. 40times more frequent among cigarette smokers Pathophysiology: narrowing of the bronchus, reducing airflow to the lung. No pain unless it reaches the chestwall Symptoms: Cough (dry or with sputum,changes in quality or relative new, lasting more than 3 weeks), dyspnoea (obstruction, collapse, pneumonia/infection due to obstruction), weight loss, chest pain (pleurisy, spread to the chest wall), haemoptysis (breakdown of the tissue in the centre of the bronchial tumour) Pleuratic spread direct or by lymphatic spread affecting intercostals nerves, brachial plexus (C8T1) Mediastinal spread affecting phrenic nerve (diaphragmatic paralysis) and recurrent laryngeal nerve (vocal chord- usually unilateral) Metastasic spread (liver, brain: changes in mental or emotional behaviour, bone pain(pain during the night, unrelated to mvmt or position)) Test: X-Ray Primary malignant tumours: of the spine are uncommon and make up less than 5% of bone neoplasms, which account for only 0.2% of the overall human tumour burden Secondary malignant tumours: in spine affect about 30% of patients with cancer (in terminal phase is up to 90%). Metastatic tumours to the spine commonly from breast and lung adenocarcinomas, prostate, renal and gastric carcinomas. Symptoms: Gradually develop with constant BP the most frequent (extradural lesions aggravated by coughing/straining). Bone pain (usually localised ti the area of the deposition) Bone weakness leading to # (osteolytic metastasis) Neurological symptoms range from slight weakness / abnormal reflexes to complete paraplegia. Bowel or bladder incontinence can occur from 1or 2lesion. Complications: Anaemia: due to extensive replacement of bone narrow Hypercalcemia: released Ca from the bone Nerve and spinal cord compression

Cholecystitis Pleuretic pain

Myasthenia gravis Sympathetic chain irritation Intercostobrachial nerve

Bronchial carcinoma

2ries

neurofibroma

Def: A neurofibroma is a benign nerve sheath tumor in the peripheral nervous system. It may derive from Schwann cells or fibroblasts. Cause: autosomal dominant (usually)

myeloma

Degenerative
Spondylosis This is most common in the mid-thoracic area. Here the spine is more distant to the line of wb wich magnifies the forces. Internal disc mechanics and nutrition may be poor due to limited use of middle ribs in normal respiration, leading to early degenerative changes Signs: stiffness, kyphosis, scoliosis. Periodic, dull and intermittent pain with associated myofascial pain, compensatory rib lesion. Occasional episodes of acute ligamentous pain lasting a couple of days. MRI studies have shown that disc protusion is common but is of clinical significance. Long thoracic pedicles offer a wide spinal canal and IV foramen.

Disc protusion Spondyloarthrosis

Infection
TB Pott's disease= infection of the vertebral bodies secondary to a pulmonary tuberculosis RARE occurring in 1-2% of patents being usually secondary to haematogenous spread of tuberculosis from other sites (pulmonary). Unfortunately 60-90% of patients have no evidence of extraspinal tuberculosis. mainly affects low thoracic / upper lumbar Symptoms: include constant LBP, fever, weight loss, loss of appetite, imbalance, clumsiness and sometimes even paralysis. If adjacent vertebrae affected will result in disc and vertebral collapse so sudden change in curves with neurological symptoms related to affected area (UML or LML) Herpes zoster Def: Herpes zoster, commonly known as shingles, is an infection of a nerve and the skin around it. It is caused by the herpes varicella-zoster virus, which also causes chickenpox. Onset: The initial infection with varicella zoster virus causes the acute, short-lived illness chickenpox which generally occurs in children and young adults. Once an episode of chickenpox has resolved, the virus is not eliminated from the body and can go on to cause shingles. Pathophysiology: After the initial episode of chickenpox resolves, the varicella zoster virus remains latent in the nerve cell bodies ,dorsal root or ganglia, cranial nerve or autonomic ganglia, without causing any symptoms. Years or decades after the initial infection, the virus may break out of nerve cell bodies and travel down nerve axons to cause viral infection of the skin in the region of the nerve. The virus may spread from one or more ganglia along nerves of an affected segment and infect the corresponding dermatome. Incidence: people who are over 50 years of age. Shingles is much less common in children. Progression: Resolution usually in 2 weeks Signs and symptoms: -Promodal: headache, fever, and malaise. Feeling unwell before the rash appears -An episode of shingles usually lasts two to four weeks. The first sign of the condition is a tingling sensation in the affected area, followed by pain (stabbing, constant, burning, sharp) and then a rash (develops into itchy blisters). -Affects a specific area on either the left or right side of the body and does not cross over the midline of the body. Dermatomal distribution -Trigeminal nerve (ophthalmic:conjunctivitis, uveitis), CN VIII (hearing loss, vertigo) Complications: postherpetic neuralgia. This is where severe nerve pain lasts for more than three months after the rash has gone.

Congenital
Scoliosis Cervical rib -Failure of ossification Rib arising usually from C7. It is normally bilateral. This may vary in size from a small rudimentary rib to a complete rib extending forward to articulate with the sternum on the costal cartilage of the 1stR. st Where the rib is underdeveloped a fibrous band may extend from its outer extremety to the 1 R normally attaching near the scalene tubercle. The brachial plexus, subclavian artery and vein must pass over a higher barrier before passing

Pectus scavatum Pectus carivatum Scheuermans disease

down the arm and are therefore stretched. Congenital deformity where the chest is pushed posteriorly by overgrowth of the ribs. Can displace the heart laterally.

localized prominence of the sternum/asymptomatic/pigeon chest/severe and poorly controlled childhood asthma or Osteomalacia/rickets
Def: It is a osteochondrosis of the ts Pathophysiology: Interruption of a blood supply of a bone, in particular to the epiphyseal end plates, followed by localized bony necrosis and later regrowth of the bone. Incidence: Teenager boys Progression: Self limiting Cause: Multifactorial: Hormonal imbalance, dietary imbalance, hereditary, trauma Signs and symptoms: Significantly worse deformity than postural kyphosis. Patients suffering with Scheuermanns kyphosis cannot consciously correct their posture. The apex of their curve, located in the thoracic vertebrae, is quite rigid. Lower and mid-level back pain Pain at the apex of the curve, stiff apex of the curvature Agg by physical activity, long periods of standing or sitting Usually affects T7-T10 Sometimes silent progression Test:X-ray: 3 adjacent wedged vertebra, each angled by atleast 3 Increased AP diameter of the body Vertebral bodies wedge-shaped anteriorly Irregular an narrow disc space Loss of lordosis, frank kyphosis Schmorls nodes Flatenned areas on the sup surface of the bodies, near the epiphyseal ring Detached epiphyseal ring, irregularly ossified end plate Complications: Compromissed internal organs space, spinal cord damage Surgical ttt: Internal fixation

AI
Sarcoidosis