Diagnosis of the osteochondrosis of the thoracic spine

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

A. Front Inspection:

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

B. Rear Inspection:

• position of the shoulder girdle, standing of the shoulder blades, upper limbs;
• position of the spine and pelvic axis;
• the state of the muscular system (interblade area, near-vertebral muscles).

B. Side View:

• The study of flexural spine and posture in general;
• condition of the muscular system;
• shape of the chest.

Palpation and percussion of the back area is determined by violations revealed by external examination:

• the region of the thorax and the scapula are palpated for the purpose of revealing morbidity, asymmetry, deformations and other disorders;
• the spinous processes are palpable from level Th1 to L1: each process must be on the midline.

ATTENTION! Any deviation of the spinous processes towards the side indicates a rotational pathology (for example, in scoliotic disease);

• palpation of interstitial spaces:
  • the study of the distance between the articular processes (in the norm it is approximately the same);
  • an increase in this distance may indicate an extension of the ligament capsule apparatus, the instability of the PDS;
  • a decrease in the interstitial space occurs with subluxation or trauma;
• palpation of each of the joints of the spine, which are located on both sides between the spinous processes approximately 2.5 cm to the outside of them. The joints are located under the near-vertebral muscles.

ATTENTION! Soreness and spasm of the near-vertebral muscles during palpation indicate a pathology of these structures;

• percussion, beginning with Th1, examining each spinous process in the caudal direction, it is possible to differentiate the soreness of this part of the spine from a more deeply located source of pain (for example, lungs, kidneys);
• palpation of the bony ligament, which is attached to the spinous processes of each vertebra, connecting them with each other:
  • the damage (stretching) of the posterior ligamentous complex is determined by the widening of the intervertebral spaces;
  • with the damage (stretching) of the boring (and interstitial) ligaments, the finger of the doctor penetrates between adjacent spaces deeper than normal;
• palpation of the invertebral muscles of the thoracic region includes the study of the lumbar and sacral parts of the spine, since the presence of muscle spasm is possible in areas remote from the primary pathological focus:
  • one- or two-sided muscle spasm may be a consequence of deformity of the spine (scoliotic spine setting, etc.);
  • trigger points in the cortical musculature;
  • muscle asymmetry (for example, the elongation of paravertebral muscles on the convex side of the curvature of the spine and spasms - on the side of the concavity).

[1], [2], [3], [4]

The study of the volume of movements of the chest

Despite the fact that the patient can complain of pain in a certain area of the back, always should examine the mobility of the two parts of the spine - thoracic and lumbar, as:

• Specific violations can be manifested by a decrease in the volume of movements in a certain direction;
• Symptoms in one department may be a manifestation of a disorder, in another (for example, thoracic kyphosis strengthens lumbar lordosis).

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

Movements in the thoracic and lumbar spine include:

• bending; ,
• extension;
• slopes to the sides;
• rotation.

A. Research of active movements

Flexion:

• i.p. The patient is standing, legs are shoulder-width apart;
• in norm (when viewed from the side), the patient's back is a single, smooth, smooth curve; lumbar lordosis is either smoothed or slightly kyphosed.

ATTENTION! Preservation of lumbar lordosis with flexion indicates a pathology. It must be remembered 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 ips. Patient - standing and with flexion.

ATTENTION! If the increase is less than the norm, it is recommended to measure levels of Th1-distance TH ₁₂ and Th12-S1 to determine mobility reduction occurred in any of the departments.

• 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;
• restriction of flexion is determined when the posterior longitudinal ligament is afflicted in the lumbar spine, the interstitial ligament is sprained, and in myofascial syndromes.

Extension:

• i.p. Patient - standing, feet shoulder width apart,
• The examination should be carried out laterally, using the spinous processes of Th1-S1 as reference points,
• the patient is normally able to straighten up to within 30 °.

ATTENTION! To violations that limit extention, include dorsal kyphosis, ankylosing spondylitis, osteochondrosis of the spine (acute and subacute stage).

Lateral slopes:

• i.p. The patient is standing, legs are shoulder-width apart;
• in norm, the vertical line connecting the spinous processes of Thj-Sj deviates by 30-35 ° from the vertical;
• in extreme positions it is recommended to measure and compare the distance between the fingers and the floor;
• i.p. Patient - sitting. Tilts to the sides (right and left).

False unrestricted lateral mobility can be detected with fixation of the lower thoracic and upper lumbar regions; considerable mobility in the lower lumbar region mask the rigidity of the overlying departments.

Rotation:

• i.p. The patient is standing, legs are shoulder-width apart;
• the patient should turn his shoulders and body to the right, then to the left; The pelvis must be fixed:
  • hands of the doctor;
  • i.p. Patient - sitting on a chair,
• the normal rotation is 40-45 °, and any asymmetry should be considered a pathology.

B. Investigation of passive movements

I.p. Patient - sitting on the edge of the couch, legs apart, hands laid behind the head, elbows stretched forward.

Extension: the doctor with one hand gently raises the elbows of the patient upwards and forwards, while the other hand palpates the interstitial spaces of the thoracic region with the other hand.

Flexion: the doctor with one hand gently slides the elbows of the patient down, exerting a certain pressure; the other hand palpates the interstitial spaces of the thoracic region.

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

Lateral slopes: the doctor is behind the patient whose head is tilted toward the tilt being examined. One hand of the doctor is on the patient's head, the thumb of the other hand is on the lateral side (paravertebral motor segment being checked), between the adjacent spinous processes.

After this, it is necessary to make an additional lateral push to feel the resistance and elasticity of the tissues in this motor segment with the thumb. For a more pronounced lateral incline in the lower thoracic spine, you can use the axillary area of the doctor as a lever. To do this, the doctor presses his axillary area on the patient's shoulder; carrying his brush in front of his chest to the opposite axillary area of the patient, controlling the thumb of the other hand, located between the spinous processes, paravertebrally, the amplitude of the movement of each motor segment being checked /

In the presence of immobilized PDS, the following violations are noted:

• violation of the smoothness of the arc of spinous processes;
• appearance of "the phenomenon of running away one half of the back";
• a change in the supine position of the respiratory wave as a phenomenon of "plateau-shaped hardening" /

Chest and rib examination

The thoracic spine is functionally integral with the thorax. Any restriction of mobility in the thoracic region causes a corresponding restriction of the mobility of the ribs, which also needs to be eliminated in order to normalize the function of its spine as an axial organ. When breathing, the chest moves as a unit.

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

1. Rocking movements of the "rocker" type, when during the inhalation the sternum with the ribs is raised as a whole, and the ventral segments of the ribs follow it, resulting in the diameter of the top of the chest growing. With such a sternocostal type of motion, the ribs remain relatively parallel with respect to each other.
2. Movement type "bucket handle", when the "trunk" (spine and sternum) stands still, and the ribs swing up and down between the front and rear fixation points.
3. Movement of the "lateral swing" type, in which the sternal end of the ribs laterally moves away from the midline, this movement stretches the costal cartilages and widens the angle of the ribs.

Most abnormalities of the ribs are caused by spasms of the intercostal musculature, resulting in a reduced normal excursion (rapprochement and retraction) between the 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 a constant tonic tension, it can lead to painful sensations, which increase with deep breathing, coughing, etc. With prolonged spasm of the intercostal muscle, the fusion of the ribs may occur. Since the stair muscles are attached to the I and II ribs, any tension of these muscles breaks 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 tensify. Dysfunctions and tenderness in the area of the XI-XII ribs can be the result of a spasm of attached fibers of the square muscle of the waist /

A.Stoddard (1978) distinguishes three types of violations of the function of the ribs.

1. Fixation of ribs in the lower parts of the sternum as a result of degenerative age changes. In this case, the normal anteroposterior movement of the swing in the hinge joint of the xiphoid process disappears.
2. Dislocation of the osteochondral part of the rib. Very often, a pathology occurs as a result of trauma or discoordination of the fixing muscles. The patient complains of severely delineated pain, corresponding to the projection of the osteochondral ligament of the corresponding rib.
3. Opening of cartilaginous ends of XI and XII ribs, where they approach each other to form a costal arch. In this case, the patient can have pain every time, when the XI and XII ribs touch each other.

Investigation of passive rib movements is carried out in order to determine the degree of remoteness and proximity of two adjacent ribs, as they move together when fully tilted back, forward, sideways, when the patient's position is sitting - sitting on the edge of the couch, the legs are placed at the width of the shoulders. When examining the passive movements of the ribs when flexing and unbending the patient's hands are laid behind the head, elbows are pushed forward. With one hand, manipulating the elbows of the patient, the doctor conducts the 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 intercostal spaces being examined. When examining the passive movements of the ribs during rotation, the patient's position is the same, only one hand of the doctor is on his shoulder, gradually producing the maximum rotation, and the index and middle fingers of the other hand are on the intercostal spaces being examined, controlling the amplitude of the ribs' movement. To check the passive movements of the ribs, when tilted to the side, the doctor presses the axillary area on the patient's shoulder, holding his brush in front of his chest in the opposite armpit of the patient, controlling the amplitude of movement of the ribs under the control of the index and middle fingers of the other hand.

The study of the active mobility of the ribs is carried out in the initial position of the patient lying on the abdomen: first, the visual excursion of the thorax and the functional activity of the intercostal muscles are determined, then the intercostal space (between 6 and 7 rib) is measured by the centimeter band during inspiration and exhalation. The difference in inspiration and exhalation of 7.5 cm is normal.

The diameter of the chest is measured by a large thick 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 brachial arc (the distance between the acromial points, measured along the posterior surface of the trunk) serves as a guide in determining such a defect in posture as a stoop and is called a shoulder index:

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

For example, if a person practicing exercise therapy or recreational physical education during the training process decreases this indicator, then one can judge that they develop stoop. Apparently, this is due to the fact that strong pectoral muscles "pull" the acromial processes forward, and the muscles located behind (interblade area) are weakly developed and do not resist the pull of the pectoral muscles.

When measuring the anterior-posterior (sagittal) diameter of the chest, one leg of the compass is placed on the middle of the sternum (place of attachment of the IV rib 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 one. The legs of the compass are placed along the middle axillary lines on the corresponding ribs.

The circumference of the chest is determined by inhalation, exhalation and during a pause. A centimeter tape is placed behind the right angle to the shoulder blades, and in front of men and children on the lower edge of the sucking-in circles, and in women - under the mammary glands at the attachment of the IV rib to the sternum (at the mid-thoracic point). It is recommended to first measure the circumference of the chest at the maximum possible inspiration, then on a deep exhalation and in a pause with normal calm breathing. The patient should not lift his shoulders when inhaling, but with exhalation, bring them forward, bend or change the position of the body. The measurement results are recorded in centimeters. Calculate and record the difference between the indications on inspiration and the indications on the exhalation, which characterizes the excursion of the chest - an important functional magnitude.

[5], [6], [7], [8]