1. Lindsey E. Eberman, MS, ATC, LAT Chapter 10 Thoracic and Lumbar Spine

2. Curves in the Spine Cervical Spine- Lordotic, greatest ROM 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

9. Ligament NameDescription Anterior Longitudinal Ligament (ALL) A primary spine stabilizer About one-inch wide, the ALL runs the entire length of the spine from the base of the skull to the sacrum. It connects the front (anterior) of the vertebral body to the front of the annulus fibrosis. Posterior Longitudinal Ligament (PLL) A primary spine stabilizer About one-inch wide, the PLL runs the entire length of the spine from the base of the skull to sacrum. It connects the back (posterior) of the vertebral body to the back of the annulus fibrosis. Supraspinous LigamentThis ligament attaches the tip of each spinous process to the other. Interspinous LigamentThis thin ligament attaches to another ligament, called the ligamentum flavum that runs deep into the spinal column. Ligamentum Flavum The strongest ligament This yellow ligament is the strongest one. It runs from the base of the skull to the pelvis, in front of and behind the lamina, and protects the spinal cord and nerves. The ligamentum flavum also surrounds the facet joint capsules.

10. Sacrum and Coccyx

12. Spinal Nerves

15. Extrinsic Muscles

17. MuscleAction Iliocostalis LumborumB: Extension U: Same side lateral bending Iliocostalis ThoracisB: Extension U: Same side lateral bending Longissimus ThoracisB: Extension U: lateral bending Spinalis ThoracisB: Extension U: Same side lateral bending Semispinalis ThoracisB: Extension of thoracic and cervical spine U: Opposite side rotation MultifidusB: Stabilization U: Opposite side rotation RotatoresB: Extension, Stabilization U: Rotation 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 1. Spinous processes 2. Supraspinous ligaments 3. Costovertebral junction 4. Trapezius 5. Paravertebral muscles 6. Scapular muscles

32. Palpations- Lumbar Spine 1. Spinous processes 2. Step-off deformity 3. Paravertebral muscles

33. Palpations- Sacrum and Pelvis 1. Median sacral crests 2. Iliac crests 3. Posterior superior iliac spine 4. Gluteal muscles 5. Ischial tuberosity 6. Greater trochanter 7. Sciatic nerve 8. Pubic symphysis

34. Palpations- Sacrum and Pelvis 1. Iliac crest 2. Tensor fascia latae 3. Gluteus medius 4. Iliotibial band 5. Greater trochanter 6. Trochanteric bursa

35. Palpations- Pelvis 1. Pubis 2. Anterior superior iliac sine 3. Anterior inferior iliac spine 4. Sartorius 5. 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