Diagnosis of osteochondrosis of the thoracic spine

Diagnosis of osteochondrosis of the thoracic spine is based on examination of the chest

A. Front view:

• the shoulder girdle and pelvic girdle should be at the same level and symmetrical;
• the ratio of the length of the trunk and lower limbs (in patients with spinal curvature, this ratio is usually disturbed);
• standing of the shoulders, presence of obesity, posture defects;
• state of the muscular system.

B. Inspection from behind:

• position of the shoulder girdle, position of the shoulder blades, upper limbs;
• position of the spine and pelvic axis;
• condition of the muscular system (interscapular region, paravertebral muscles).

B. Lateral inspection:

• examination of the curves of the spine and posture in general;
• state of the muscular system;
• chest shape.

Palpation and percussion of the back area determine the disorders revealed during external examination:

• the chest and shoulder blade area are palpated to detect pain, asymmetry, deformations and other disorders;
• The spinous processes are palpated from the level of Th1 to L1: each process should be located on the midline.

ATTENTION! Any deviation of the spinous processes to the side indicates rotational pathology (for example, in scoliosis);

• palpation of the interspinous spaces:
  • examination of the distance between the articular processes (normally it is approximately the same);
  • an increase in this distance may indicate a stretching of the ligament-capsular apparatus, instability of the PDS;
  • a decrease in the interspinous space occurs with subluxations or injuries;
• palpation of each of the spinal joints, which are located on both sides between the spinous processes approximately 2.5 cm outward from them. The joints are located under the paravertebral muscles.

ATTENTION! Pain and spasm of the paravertebral muscles upon palpation indicate pathology of these structures;

• by percussion, starting from Th1, examining each spinous process in the caudal direction, it is possible to differentiate the pain in this part of the spine from a deeper source of pain (for example, the lungs, kidneys);
• palpation of the supraspinous ligament, which attaches to the spinous processes of each vertebra, connecting them together:
  • damage (stretching) of the posterior ligament complex is determined by the expansion of the intervertebral spaces;
  • when the supraspinous (and interspinous) ligaments are damaged (stretched), the doctor’s finger penetrates between the adjacent spaces deeper than normal;
• Palpation of the paravertebral muscles of the thoracic region also includes examination of the lumbar and sacral spine, since the presence of muscle spasm is also possible in areas remote from the primary pathological focus:
  • unilateral or bilateral muscle spasm may be a consequence of spinal deformation (scoliotic spinal alignment, etc.);
  • trigger points in the paravertebral muscles;
  • muscle asymmetry (for example, lengthening of the paravertebral muscles on the convex side of the spinal curvature and spasm on the concavity side).

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Study of the range of motion of the chest

Although the patient may complain of pain in a specific area of the back, it is always necessary to examine the mobility of both parts of the spine - thoracic and lumbar, because:

• specific disorders may manifest as a decrease in the range of motion in a certain direction;
• symptoms in one area may be a manifestation of a disorder in another (for example, thoracic kyphosis increases lumbar lordosis).

ATTENTION! A patient with primary thoracic pathology may have symptoms in the lumbar spine.

Movements in the thoracic and lumbar spine include:

• bending;,
• extension;
• side bends;
• rotation.

A. Study of active movements

Flexion:

• patient's initial position - standing, feet shoulder-width apart;
• Normally (when viewed from the side), the patient's back is a single, flat, smooth curve; the lumbar lordosis is either smoothed out or slightly kyphosis.

ATTENTION! Preservation of lumbar lordosis during flexion indicates pathology. It is necessary to remember that the main flexion occurs in the lumbar region.

• The most accurate study of flexion is achieved by measuring the distance between the spinous processes from the level of Th1 to S1 in the patient's initial position - standing and during flexion.

ATTENTION! If the increase is less than normal, it is recommended to measure the distance between the Th1-Th ₁₂ and Th12-S1 levels in order to determine in which section the decrease in mobility occurred.

• normally this distance increases by approximately 10 cm;
• in healthy people the difference in the thoracic region is 2.5 cm, and in the lumbar region - 7.5 cm;
• Limitation of flexion is determined by damage to the posterior longitudinal ligament in the lumbar region, stretching of the interspinous ligaments and myofascial syndromes.

Extension:

• patient's initial position - standing, feet shoulder-width apart,
• the examination should be carried out from the side, using the spinous processes of Th1-S1 as landmarks,
• Normally, the patient is able to straighten up to 30°.

ATTENTION! Disorders that limit extension include dorsal kyphosis, ankylosing spondylitis, osteochondrosis of the spine (acute and subacute stages).

Lateral bends:

• patient's initial position - standing, feet shoulder-width apart;
• normally, the vertical line connecting the spinous processes Thj-Sj deviates by 30-35° from the vertical;
• in extreme positions, it is recommended to measure and compare the distance between your fingers and the floor;
• Patient's initial position - sitting. Bends to the sides (right and left).

False unlimited lateral mobility may be detected when fixing the lower thoracic and upper lumbar regions; significant mobility in the lower lumbar region masks the rigidity of the overlying regions.

Rotation:

• patient's initial position - standing, feet shoulder-width apart;
• the patient should turn the shoulders and torso to the right, then to the left; the pelvis should be fixed:
  • by the hands of a doctor;
  • patient's initial position - sitting on a chair,
• A rotation of 40-45° is normal, but any asymmetry should be considered pathological.

B. Study of passive movements

Patient's initial position: sitting on the edge of the couch, legs apart, hands behind the head, elbows extended forward.

Extension: the doctor smoothly lifts the patient's elbows up and back with one hand, while palpating the interspinous spaces of the thoracic region with the other hand.

Flexion: the doctor gently lowers the patient's elbows down with one hand, exerting a certain amount of pressure; with the other hand, he palpates the interspinous spaces of the thoracic region.

Rotation: With one hand placed on the patient's shoulder, the doctor smoothly performs rotation, and with the index and middle fingers of the other hand, located on the spinous processes, controls the movement in each segment.

Lateral tilts: the physician stands behind the patient, whose head is tilted in the direction of the tilt being examined. One hand of the physician is on the patient's crown, the thumb of the other hand is on the lateral side (of the paravertebral motor segment being examined), between the adjacent spinous processes.

After this, it is necessary to make an additional lateral push so that the thumb can feel the resistance and elasticity of the tissues in this motor segment. To perform a more pronounced lateral tilt in the lower thoracic spine, the doctor's axillary region can be used as a lever. To do this, the doctor presses on the patient's shoulder with his axillary region; moving his hand in front of his chest to the opposite axillary region of the patient, controlling the amplitude of movement of each tested motor segment with the thumb of the other hand, located between the spinous processes, paravertebrally.

In the presence of an immobilized PDS, the following violations are observed:

• violation of the smoothness of the arc of the spinous processes;
• the appearance of the “phenomenon of one half of the back running away”;
• change in the prone position of the respiratory wave according to the phenomenon of "plateau-like freezing"/

Examination of the chest and ribs

The thoracic spine is functionally integral with the rib cage. Any limitation of mobility in the thoracic spine causes a corresponding limitation of the mobility of the ribs, which must also be eliminated to normalize the function of the spine as an axial organ. When breathing, the rib cage moves as a single whole.

A. Stoddard (1979) divides the movement of the ribs during breathing into three types.

1. Rocking movements of the "yoke" type, when during inspiration the sternum with the ribs rises as a single unit, and the ventral sections of the ribs follow it, leading to the fact that the diameter of the apex of the chest increases. With this sternocostal type of movement, the ribs relative to each other remain almost parallel.
2. A "bucket handle" type movement where the "trunk" (spine and sternum) stays in place and the ribs swing up and down between the anterior and posterior fixation points.
3. Lateral swing type movements in which the sternal end of the ribs is moved laterally from the midline, this movement stretches the costal cartilages and widens the angle of the ribs.

Most dysfunctions of the ribs are caused by spasms of the intercostal muscles, which result in a decrease in the normal excursion (approach and movement) between two ribs. This may be a consequence of a violation of central regulation, irritation of the intercostal nerve, protrusion of the intervertebral disc in the thoracic spine, constant tension of the corresponding muscle, etc. If the muscle is in constant tonic tension, this can lead to pain that intensifies with deep breathing, coughing, etc. With prolonged spasm of the intercostal muscle, fusion of the ribs may occur. Since the scalene muscles are attached to the 1st and 2nd ribs, any tension of these muscles disrupts the functioning of the ribs. In this case, the size of the sternocostal triangle is reduced, and the palpable, superficial bundles of the brachial plexus are tense. Dysfunction and pain in the area of the XI-XII ribs may be the result of a spasm of the fibers of the quadratus lumborum muscle attached to them.

A. Stoddard (1978) identifies three types of rib dysfunction.

1. Fixation of the ribs in the lower parts of the sternum as a result of degenerative age-related changes. In this case, the normal anterior-posterior swinging movement in the hinge joint of the xiphoid process disappears.
2. Dislocation of the osteochondral part of the rib. Very often there is a pathology that occurs as a result of trauma or discoordination of the fixing muscles. The patient complains of strictly defined pain, corresponding to the projection of the osteochondral ligament of the corresponding rib.
3. Opening of the cartilaginous ends of the XI and XII ribs where they approach each other to form the costal arch. In this case, the patient may experience pain every time the XI and XII ribs touch each other.

The study of passive rib movements is carried out in order to determine the degree of remoteness and proximity of two adjacent ribs, since they move interrelatedly during full tilt back, forward, to the sides, during rotation, the patient's position is sitting on the edge of the couch, legs are shoulder-width apart. When studying passive rib movements during flexion and extension, the patient's arms are placed behind the head, elbows are extended forward. With one hand, manipulating the patient's elbows, the doctor carries out maximum flexion and extension in the thoracic spine, with the index and middle fingers of the other hand controlling the amplitude of movements in the examined intercostal spaces. When studying passive rib movements during rotation, the patient's position is the same, only one doctor's hand is on his shoulder, gradually producing maximum rotation, and the index and middle fingers of the other hand are on the examined intercostal spaces, controlling the amplitude of rib movement. To check the passive movements of the ribs when bending to the side, the doctor presses on the patient's shoulder with his axillary region, moving his hand in front of the patient's chest to the opposite axillary cavity of the patient, controlling the amplitude of movement of the ribs being examined with the index and middle fingers of the other hand.

The active mobility of the ribs is studied with the patient lying on his stomach: first, the chest excursion and functional activity of the intercostal muscles are determined visually, then the intercostal space (between the 6th and 7th ribs) is measured with a measuring tape during inhalation and exhalation. A difference of 7.5 cm during inhalation and exhalation is normal.

The diameter of the chest is measured with a large caliper. The most prominent lateral point on the acromial process of the scapula (acromial point) is used to measure the width of the shoulders. The ratio of this size to the shoulder arch (the distance between the acromial points, measured along the back of the body) serves as a guideline for determining such a posture defect as stooping and is called the shoulder index:

I = (shoulder width / shoulder arch) x 100.

For example, if this indicator decreases in a person engaged in exercise therapy or health-improving physical training during the training process, then it can be judged that they are developing a stoop. Apparently, this is due to the fact that strong pectoral muscles "pull" the acromial processes forward, and the muscles located behind (the interscapular region) are poorly developed and do not resist the pull of the pectoral muscles.

When measuring the anteroposterior (sagittal) diameter of the chest, one leg of the caliper is placed on the middle of the sternum (the place where the 4th rib is attached to the sternum), and the other on the corresponding spinous process of the vertebral body.

The transverse (frontal) diameter of the chest is measured at the same level as the sagittal. The legs of the calipers are set along the mid-axillary lines on the corresponding ribs.

Chest circumference is determined during inhalation, exhalation, and during a pause. The tape measure is placed at the back at a right angle to the shoulder blades, and at the front for men and children along the lower edge of the areolas, and for women - under the mammary glands at the attachment point of the 4th rib to the sternum (at the level of the midsternal point). It is recommended to first measure the chest circumference during the maximum possible inhalation, then during a deep exhalation and during a pause during normal calm breathing. The patient should not raise his shoulders during inhalation, or bring them forward during exhalation, bend over, or change body position. The measurement results are recorded in centimeters. The difference between the readings during inhalation and the readings during exhalation is calculated and recorded, which characterizes the chest excursion - an important functional value.

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