Orthopaedic Surgery - Thoracolumbar Spine Fracture and Dislocation

⸻

Basics

Thoracolumbar fractures are among the most common:

Spinal fractures.

The region most frequently injured is the:

Thoracolumbar junction

particularly:

T11–L1.

This area is vulnerable because it represents a transition between the relatively rigid:

Thoracic spine

and the more mobile:

Lumbar spine.

⸻

Associated Spinal Injuries

Additional spinal injuries may occur in up to approximately:

15% of patients.

These may be:

Contiguous

or

Noncontiguous.

For this reason, the:

Entire spinal column

should be considered during trauma assessment.

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Associated Abdominal Injuries

Abdominal injuries occur in approximately:

20% of patients

with significant thoracolumbar trauma.

Potential associated injuries include:

Splenic rupture

Liver laceration

Renal injury

and

Bowel injury.

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Denis Three-Column Classification

The classic:

Denis three-column system

divides the thoracolumbar spine into:

Anterior

Middle

and

Posterior columns.

Although modern treatment also relies on newer concepts such as mechanical stability and posterior ligamentous complex integrity, this classification remains useful for understanding:

Fracture morphology.

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Anterior Column

The anterior column consists of approximately the:

Anterior two-thirds of the vertebral body and intervertebral disc

together with the associated anterior supporting structures.

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Middle Column

The middle column includes the:

Posterior one-third of the vertebral body and disc

and the:

Posterior longitudinal ligament.

Disruption of the middle column historically has been considered an important marker of:

Potential instability.

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Posterior Column

The posterior column includes the:

Pedicles

Facet joints

Laminae

Transverse processes

and

Spinous processes

together with the posterior ligamentous structures.

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Minor Injuries

Minor thoracolumbar injuries include isolated fractures involving structures such as:

Spinous processes

Transverse processes

Pars interarticularis

and

Facets.

These injuries may still be clinically important depending on their:

Mechanism

and associated injuries.

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Major Injuries

Major thoracolumbar injuries include:

Compression fractures

Burst fractures

Flexion-distraction injuries

Fracture-dislocations

and

Distraction-extension injuries.

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Epidemiology

High-energy thoracolumbar trauma occurs most frequently in:

Young adults

particularly:

Males between approximately 15 and 30 years of age.

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Older Adults

Elderly patients with:

Osteopenia

or

Osteoporosis

may sustain vertebral fractures after relatively:

Low-energy trauma.

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Risk Factors

Important risk factors include:

Motor vehicle collisions

Falls from height

High-energy trauma

and

Osteoporotic bone.

⸻

Associated Conditions

Thoracolumbar fractures may be accompanied by:

Neurologic injury

Spinal shock

Other spinal fractures

and significant:

Abdominal trauma.

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Spinal Shock

Following major spinal cord injury, patients may temporarily develop:

Flaccid paralysis

Loss of reflexes

and reduced:

Autonomic function

below the level of injury.

This transient state is known as:

Spinal shock.

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Diagnosis

Diagnosis requires careful assessment of:

Mechanism of injury

Spinal tenderness

Neurologic status

and

Imaging.

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History

For high-energy trauma, information should be obtained from:

The patient

and

Prehospital personnel

when available.

⸻

Mechanism of Injury

Important mechanisms include:

Motor vehicle collision

Fall from height

Crush injury

and

Direct high-energy trauma.

⸻

Relevant Medical History

Ask about conditions that may alter spinal biomechanics or bone quality, including:

Ankylosing spondylitis

Osteoporosis

Previous spinal surgery

Diabetes mellitus

and known:

Malignancy.

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Physical Examination

Repeated neurologic examination is essential.

Any deterioration may provide the earliest sign of:

Progressive neural compromise

or instability requiring:

Urgent intervention.

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Documentation

The initial examination should be documented carefully and compared with:

Prehospital findings

and subsequent:

Serial examinations.

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Inspection

Inspect the back and trunk for:

Ecchymosis

Seat-belt marks

Visible deformity

Step-off

or evidence of:

Open injury.

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Palpation

Palpate the:

Entire spinal column

for:

Tenderness

Gap

Step-off

or deformity.

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Motor Examination

Motor power should be graded using the:

Medical Research Council 0–5 scale.

⸻

Grade 0

No visible or palpable muscle contraction.

⸻

Grade 1

Flicker or trace contraction without joint movement.

⸻

Grade 2

Full joint motion with gravity eliminated.

⸻

Grade 3

Full joint motion against gravity.

⸻

Grade 4

Movement against gravity and some external resistance.

⸻

Grade 5

Normal strength against full resistance.

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Sensory Examination

A sensory level should be documented using reproducible:

Dermatomal landmarks.

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Thoracic Landmarks

Important landmarks include:

T4 – nipple line

T7 – xiphoid region

T10 – umbilicus

and

T12 – inguinal region.

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Lumbar and Sacral Landmarks

Additional landmarks include:

L1 – proximal anterior thigh

L2 – middle anterior thigh

L3 – region above the patella

L4 – medial malleolus

L5 – dorsum of the foot, classically near the third toe

and

S1 – lateral foot or small-toe region.

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Reflexes

Important lower-extremity reflexes include:

L4 – patellar reflex

and

S1 – Achilles reflex.

There is no routinely useful isolated:

L5 deep-tendon reflex.

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Sacral Examination

When neurologic injury is suspected, evaluate sacral function, including:

Perianal sensation

Voluntary anal contraction

and relevant:

Sacral reflexes.

⸻

Rectal Examination

Assessment may include:

Anal tone

Voluntary contraction

and

Perianal light touch or pinprick sensation

in approximately the:

S2–S5 distribution.

⸻

Bulbocavernosus Reflex

The:

Bulbocavernosus reflex

may help assess sacral reflex activity and can be useful during evaluation of:

Spinal shock.

⸻

Anal Wink

The:

Anal wink reflex

may also provide information about:

Sacral neurologic integrity.

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Imaging

⸻

Initial Trauma Imaging

In modern trauma care, imaging selection depends on:

Mechanism

Clinical examination

and trauma-system protocols.

CT is frequently used as the primary imaging modality in significant:

Thoracolumbar trauma.

⸻

Plain Radiographs

AP and lateral spinal radiographs may demonstrate:

Compression

Loss of vertebral height

Kyphosis

Translation

or

Fracture-dislocation.

They may still be useful in selected:

Lower-energy injuries.

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CT

CT provides excellent visualization of:

Fracture morphology

Canal compromise

Posterior element injury

and

Bony retropulsion.

It is also extremely valuable for:

Preoperative planning.

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Entire-Spine Assessment

Because noncontiguous fractures can occur, imaging of the entire spine should be considered in patients with:

Major trauma

or one confirmed:

Spinal fracture.

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MRI

MRI is particularly useful when there is concern for:

Spinal cord injury

Disc herniation

Epidural hematoma

or

Posterior ligamentous complex injury.

These soft-tissue abnormalities may not be adequately demonstrated by:

CT.

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Differential Diagnosis

Not every vertebral deformity represents an:

Acute fracture.

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Developmental Wedging

Conditions such as:

Scheuermann kyphosis

or congenital:

Vertebral wedging

may mimic:

Compression fracture.

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Osteoporotic and Pathologic Fracture

Patients older than approximately:

50 years

who sustain fractures after relatively minor trauma should be evaluated for:

Osteoporosis.

A:

Pathologic fracture

from malignancy or other bone disease should also be considered when clinically appropriate.

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Treatment

Treatment depends on:

Fracture morphology

Mechanical stability

Neurologic status

Posterior ligamentous complex integrity

and overall:

Patient condition.

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Initial Stabilization

Patients with suspected unstable spinal injury should be handled with:

Spinal precautions

until the injury has been adequately:

Evaluated and stabilized.

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Stable Fractures

Stable injuries may be treated with:

Early mobilization

with or without a:

Thoracolumbosacral orthosis, or TLSO.

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Brace Selection

A TLSO may be modified depending on the:

Fracture level

and specific:

Biomechanical needs.

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Unstable Fractures

Patients awaiting operative stabilization may require:

Restricted mobilization

until definitive fixation is performed.

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Compression Fractures

Simple compression fractures generally involve primarily the:

Anterior column.

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Mild Compression Fractures

Neurologically intact patients with mild stable fractures may be treated with:

Analgesia

Early mobilization

and often:

No brace.

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TLSO for Compression Fracture

A TLSO may be used when it improves:

Comfort

or provides additional:

External support.

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Osteoporotic Compression Fractures

Management should include evaluation and treatment of the underlying:

Osteoporosis

to reduce the risk of:

Future fractures.

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Vertebral Augmentation

Procedures such as:

Kyphoplasty

or

Vertebroplasty

may be considered in carefully selected patients with painful:

Osteoporotic

or

Osteolytic vertebral compression fractures.

They are not required for most uncomplicated:

Compression fractures.

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Burst Fractures

Burst fractures result from:

Axial compression

and commonly involve the:

Anterior and middle columns.

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Retropulsion

Fragments of the posterior vertebral body may be driven into the:

Spinal canal.

The presence of canal compromise alone does not automatically mandate:

Surgery.

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Nonoperative Burst-Fracture Treatment

Neurologically intact patients with stable alignment may be treated with:

Early mobilization

with or without a:

TLSO.

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Surgical Considerations for Burst Fractures

Surgery is more strongly considered when there is:

Neurologic injury

Progressive deformity

Mechanical instability

or major disruption of the:

Posterior ligamentous complex.

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Historical Radiographic Thresholds

Historical factors associated with operative treatment include:

Kyphosis greater than approximately 20°

Facet subluxation

Increased interspinous distance

More than 50% loss of vertebral body height

and

More than 50% canal compromise.

These thresholds should not be interpreted in isolation.

The overall:

Clinical and mechanical context

is more important than any single measurement.

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Flexion-Distraction Injury

Flexion-distraction injuries are often called:

Chance fractures

or

Seat-belt injuries.

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Mechanism

These injuries involve distraction of the:

Posterior spinal structures

with compression or fracture of the:

Anterior column.

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Ligamentous Injury

When the injury is primarily ligamentous, healing may be less reliable and the injury is generally:

Unstable.

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Abdominal Injury Association

Flexion-distraction injuries have a strong association with:

Intra-abdominal trauma

particularly:

Bowel injury.

A careful abdominal assessment is therefore essential.

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Nonoperative Management

Selected purely bony Chance fractures in neurologically intact patients may occasionally be treated:

Nonoperatively.

However, injuries with substantial:

Ligamentous disruption

more commonly require:

Surgical stabilization.

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Fracture-Dislocation

Fracture-dislocations may demonstrate:

Facet fracture-dislocation

Rotation

and

Translation.

These injuries are generally:

Highly unstable.

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Neurologic Risk

Because of major displacement, fracture-dislocations carry a high risk of:

Spinal cord

or

Cauda equina injury.

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Treatment of Fracture-Dislocation

Nonoperative treatment is rarely appropriate.

Surgery usually begins with:

Reduction

and

Posterior stabilization.

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Distraction-Extension Injury

Distraction-extension injuries are:

Uncommon

and often occur in patients with an unusually rigid spine, such as those with:

Ankylosing spondylitis

Diffuse idiopathic skeletal hyperostosis

or other disorders affecting:

Spinal biomechanics.

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Stability

These injuries are typically:

Highly unstable

and usually require:

Operative fixation.

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Surgical Strategy

Treatment commonly involves:

Posterior instrumentation and fusion

with additional anterior reconstruction when required by:

Fracture morphology.

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Activity

Patients treated with stable fixation or a suitable brace may advance toward:

Progressive mobilization and weight bearing

as allowed by:

Fracture stability

and

Neurologic status.

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Neurologic Injury

Patients with neurologic deficits require individualized:

Rehabilitation

based on the level and completeness of:

Spinal cord or cauda equina injury.

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Nursing Care

Serial assessment should include:

Vital signs

and repeated:

Neurologic examinations.

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Change in Neurologic Status

Any deterioration in:

Strength

Sensation

or

Sacral function

requires prompt:

Reassessment.

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Counseling

Patients with spinal cord injury may require:

Psychological support

and counseling regarding:

Mobility

Employment

Independence

and long-term:

Lifestyle adaptation.

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Physical Therapy

Physical therapy plays an essential role in:

Mobilization

and

Functional recovery.

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Benefits of Early Rehabilitation

Appropriate rehabilitation may reduce complications such as:

Pressure injury

Pneumonia

Venous thromboembolism

Contractures

and

Disuse osteoporosis.

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Occupational Therapy

Occupational therapy is particularly important for patients with neurologic injury who require adaptation for:

Transfers

Self-care

Mobility

and

Activities of daily living.

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Medication

Pain control should be individualized.

There is generally no role for routine:

Long-term maintenance opioid therapy.

⸻

First-Line Analgesia

Options may include:

Acetaminophen

and

NSAIDs

when medically appropriate.

⸻

NSAIDs

Anti-inflammatory medications should be used cautiously in patients with:

Renal disease

Gastrointestinal risk

or other relevant:

Contraindications.

⸻

Opioids

Short-term opioid therapy may be appropriate for:

Severe acute fracture pain

particularly during the early:

Post-traumatic period.

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Radiotherapy

Radiotherapy may have a role in selected patients with:

Radiosensitive tumors

causing pathological thoracolumbar:

Fractures.

Its purpose is primarily to reduce:

Tumor burden

and improve:

Local disease control.

⸻

Surgery

The goals of surgery are to:

Restore alignment

Stabilize the spinal column

and, when necessary,

Decompress neural structures.

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Surgical Approach

The optimal approach depends on:

Fracture morphology

Neurologic compression

Bone quality

and surgeon:

Experience.

⸻

Posterior Instrumentation

Posterior instrumentation is commonly favored because it provides effective:

Reduction

Fixation

and

Correction of alignment

without the additional morbidity of a major:

Anterior approach.

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Neural Decompression

Decompression is indicated when there is clinically significant compression of the:

Spinal cord

Conus medullaris

or

Cauda equina

and when decompression is expected to improve:

Neurologic outcome or mechanical stability.

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Anterior Approach

An anterior approach may be useful when substantial:

Vertebral body destruction

or

Anterior canal compression

requires direct:

Decompression and reconstruction.

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Retropulsed Fragments

Anterior surgery may be particularly useful for selected cases involving significant:

Retropulsed vertebral-body fragments

compressing the:

Anterior spinal canal.

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Fusion

Fusion may accompany fixation when:

Instability

Major ligamentous disruption

or extensive bony injury prevents reliable healing without:

Arthrodesis.

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Follow-Up

Patients with major injuries often benefit from coordinated follow-up involving:

Spine surgery

Rehabilitation medicine

Physical therapy

and

Occupational therapy.

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Rehabilitation Facility

Patients with severe neurologic injury may recover best initially in a specialized:

Inpatient rehabilitation facility.

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Pain Specialist Referral

Persistent chronic pain may warrant referral to:

Pain medicine.

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Rehabilitation Medicine

Patients with spinal cord or cauda equina injury should be followed by:

Physical medicine and rehabilitation specialists.

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Neurology Consultation

Neurologic consultation may be useful when the pattern of deficit does not correlate with the identified:

Spinal injury.

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Prognosis

Outcome depends strongly on:

Fracture severity

and particularly on:

Neurologic status.

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Neurologically Intact Patients

Patients with stable low-energy injuries and preserved neurologic function usually have an:

Excellent prognosis.

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Neurologic Injury

Patients with significant neurologic deficits may experience long-term effects on:

Mobility

Bladder and bowel function

Employment

and

Independence.

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Complications

Potential complications include:

Infection

Neurologic deterioration

Pseudarthrosis

Spinal deformity

Junctional degeneration

Spinal stenosis

Chronic pain

and

Disability.

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Brace-Related Complications

TLSO braces can cause:

Skin irritation

Pressure injury

and discomfort over:

Bony prominences.

Regular skin checks are important.

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Pseudarthrosis

Failure of an intended fusion to heal may cause:

Persistent pain

Implant failure

or progressive:

Deformity.

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Junctional Degeneration

Long spinal fusion constructs may increase mechanical stress at adjacent levels, contributing to:

Junctional degeneration

or

Stenosis.

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Chronic Pain

Persistent pain may arise from:

Residual deformity

Neurologic injury

Degenerative change

or

Postoperative complications.

⸻

Patient Monitoring

Patients should be monitored for:

Pain resolution

Neurologic recovery

Maintenance of alignment

and

Fracture healing.

⸻

Fusion Monitoring

If arthrodesis has been performed, follow-up should also evaluate for:

Solid fusion

and

Implant stability.

⸻

Red-Flag Findings

Urgent reassessment is required for:

New or progressive weakness

New sensory loss

Loss of bowel or bladder control

Increasing saddle anesthesia

or

Worsening spinal deformity.

⸻

Key Principle

Thoracolumbar spine fractures most commonly involve the:

T11–L1 junction, where the rigid thoracic spine transitions to the more mobile lumbar spine.

Evaluation must include careful assessment for:

Noncontiguous spinal injury, neurologic compromise, and associated abdominal trauma.

CT is the principal imaging study for defining:

Fracture morphology, while MRI is especially useful for evaluating:

Spinal cord, disc, epidural, and posterior ligamentous complex injury.

Stable fractures may often be treated with:

Early mobilization with or without a TLSO, whereas unstable injuries such as:

Fracture-dislocations, major ligamentous flexion-distraction injuries, and distraction-extension injuries

usually require:

Operative stabilization.

The major goals of treatment are to preserve or restore:

Neurologic function, spinal alignment, mechanical stability, and early safe mobilization.

Orthopaedic Surgery - Thoracic Outlet Syndrome

Basics

Thoracic outlet syndrome, or:

TOS

is a clinical disorder caused by compression of:

Neural

or

Vascular structures

supplying the upper extremity as they pass through the:

Thoracic outlet

and adjacent:

Supraclavicular region.

Structures Involved

The principal structures at risk are the:

Brachial plexus

Subclavian artery

and

Subclavian vein.

Synonyms

Historical terms include:

Scalenus anticus syndrome

Costoclavicular syndrome

and

Cervical rib syndrome.

Major Clinical Types

Thoracic outlet syndrome is generally divided into:

Neurogenic TOS

Venous TOS

and

Arterial TOS.

Neurogenic disease is by far the most common form.

Neurogenic Thoracic Outlet Syndrome

Neurogenic TOS results from compression or irritation of the:

Brachial plexus.

Symptoms commonly include:

Pain

Paresthesia

Numbness

and occasionally:

Weakness.

Venous Thoracic Outlet Syndrome

Venous TOS results from compression or thrombosis involving the:

Subclavian or axillary vein.

It may produce:

Arm swelling

Cyanosis

and

Venous congestion.

Arterial Thoracic Outlet Syndrome

Arterial TOS results from compression or injury of the:

Subclavian artery.

It may produce:

Coolness

Fatigue

Ischemic pain

or distal:

Embolic symptoms.

Epidemiology

Thoracic outlet syndrome is relatively:

Uncommon.

Incidence

Historical estimates vary widely, approximately between:

0.03% and 0.8%.

The fully developed syndrome is considerably less common than nonspecific:

Upper-extremity pain or paresthesia.

Age

Thoracic outlet syndrome occurs most commonly in:

Young to middle-aged adults.

Sex

It is reported more frequently in:

Women

than in men.

Risk Factors

Potential predisposing factors include:

Cervical ribs

Congenital fibrous bands

Abnormal first-rib anatomy

and disorders that increase susceptibility to:

Peripheral nerve dysfunction.

Systemic Conditions

Associated systemic conditions include:

Diabetes mellitus

Thyroid disease

and

Alcohol-related neuropathy.

These disorders may make peripheral nerves more vulnerable to:

Compression.

Aggravating Factors

Symptoms may be worsened by:

Obesity

Postural abnormalities

Repetitive overhead activity

and prolonged positions that narrow the:

Thoracic outlet.

Shoulder-Girdle Position

A chronically depressed or forward-positioned shoulder girdle may decrease available space for the:

Brachial plexus

and

Subclavian vessels.

Etiology

Thoracic outlet syndrome is often:

Multifactorial.

Potential contributors include:

Trauma

Repetitive occupational activity

Congenital anatomy

Postural abnormalities

and systemic:

Neuropathic disease.

Overhead Activity

Occupations requiring prolonged:

Overhead arm use

such as ceiling painting may provoke symptoms over a relatively:

Short period.

Repetitive Lower-Elevation Activity

Occupations involving repetitive upper-extremity motion without extreme elevation may also contribute over:

Many years.

Examples include prolonged:

Keyboard use

or

Driving.

Double-Crush Phenomenon

Thoracic outlet syndrome may coexist with more distal nerve-compression disorders such as:

Carpal tunnel syndrome

or

Cubital tunnel syndrome.

Concept of Double Crush

The double-crush concept proposes that a nerve compromised proximally may become more susceptible to compression at another point along its:

Course.

This theory remains clinically relevant but does not explain every patient with multiple:

Entrapment neuropathies.

Associated Conditions

Patients with:

Diabetes mellitus

Thyroid disease

Alcohol-related neuropathy

and systemic arthritis may have increased susceptibility to:

Multiple nerve-compression syndromes.

Diagnosis

The diagnosis is primarily:

Clinical.

No single provocative maneuver or diagnostic test can reliably confirm or exclude:

Thoracic outlet syndrome.

Signs and Symptoms

Symptoms depend on whether the primary compression is:

Neural

Arterial

or

Venous.

Neurogenic Symptoms

Patients may report:

Neck pain

Shoulder pain

Arm pain

Paresthesia

or

Numbness.

Distribution

Symptoms may involve the entire:

Upper extremity

but commonly predominate along the:

Ulnar side of the forearm

and the:

Ring and small fingers.

The middle finger may occasionally also be involved.

Sensory Findings

Objective sensory abnormalities are often:

Subtle.

They may involve the:

Ulnar aspect of the hand

and sometimes the:

Medial forearm.

Nocturnal Symptoms

Night pain and paresthesia may occur.

These symptoms should be distinguished from:

Carpal tunnel syndrome

which more often affects the:

Thumb

Index finger

Middle finger

and radial half of the:

Ring finger.

Overhead Intolerance

A common complaint is difficulty using the arm in an:

Elevated or overhead position.

Symptoms may increase during:

Hair washing

Overhead work

or carrying the arm in prolonged:

Abduction.

Weakness and Dexterity

Some patients report reduced:

Grip strength

or

Hand dexterity

even when obvious muscle atrophy is:

Absent.

Additional Pain

Associated discomfort may occur in the:

Head

Neck

Chest

Shoulder

and

Arm.

Arterial Symptoms

Arterial compression is less common and may produce:

Coolness

Arm fatigue

Diffuse aching

and occasionally:

Raynaud-like symptoms.

Venous Symptoms

Venous compression may be:

Intermittent

or

Persistent.

Typical findings include:

Arm swelling

Heaviness

and varying degrees of:

Cyanosis.

Physical Examination

A complete examination should assess:

Neck

Supraclavicular region

Shoulder girdle

and both:

Upper extremities.

Posture

The affected scapula may sit:

Lower

and

More anteriorly

than the opposite side.

Clavicular Position

The clavicle may appear relatively:

Horizontal

or depressed.

Supraclavicular Examination

Palpate the:

Brachial plexus region

for:

Tenderness

or a palpable:

Mass.

Tinel Sign

Percussion over the brachial plexus may reproduce:

Distal paresthesia

often along the:

Ulnar side of the hand.

Shoulder Examination

Evaluate for:

Glenohumeral instability

Rotator cuff disease

and

Scapular dyskinesis

because these can mimic or contribute to:

Thoracic outlet symptoms.

Neurologic Examination

Perform a bilateral examination of:

Motor strength

Sensation

and

Reflexes.

Intrinsic Hand Strength

Assess:

Finger abduction

Finger adduction

Grip strength

and other intrinsic:

Hand-muscle functions.

Vascular Examination

Document:

Radial pulses

Skin temperature

Color

and

Arm swelling.

Provocative Maneuvers

Several stress tests have historically been used to provoke symptoms.

These tests should be interpreted:

Cautiously.

Important Limitation

Loss of the radial pulse alone during arm positioning is:

Not diagnostic.

Pulse reduction can occur in many:

Asymptomatic individuals.

A maneuver is more meaningful when it reproduces the patient’s:

Typical symptoms.

Adson Maneuver

The Adson maneuver is performed with the arm near the:

Side

while the neck is:

Extended

and the head turned toward the:

Affected side.

Wright Maneuver

The Wright maneuver places the shoulder in:

Abduction

and

External rotation.

The patient may also be asked to take a:

Deep breath.

Elbow Position

Keeping the elbow extended during provocative testing may reduce confounding from:

Ulnar nerve compression at the elbow.

Additional Provocative Testing

Other commonly used maneuvers may include:

Elevated arm stress testing

and

Costoclavicular positioning.

No single test has sufficiently high sensitivity and specificity to establish the diagnosis by itself.

Imaging

Cervical Spine Radiographs

AP and lateral radiographs of the cervical spine may identify:

Cervical ribs

Elongated transverse processes

and

Degenerative cervical disease.

Chest Radiograph

A chest radiograph may help identify:

Cervical rib anatomy

and important alternative diagnoses such as:

Apical lung tumor.

This is particularly relevant in patients with:

Smoking history

or unexplained:

Constitutional symptoms.

MRI

MRI is useful when there is concern for:

Cervical disc disease

or another structural lesion causing:

Neural compression.

Electrodiagnostic Studies

Electrodiagnostic testing may help evaluate for:

Carpal tunnel syndrome

Cubital tunnel syndrome

Cervical radiculopathy

or other:

Peripheral neuropathies.

Role in Neurogenic TOS

Electrodiagnostic studies may be normal in many patients with:

Nonspecific neurogenic symptoms.

They are most useful when an objective neuropathy or alternative diagnosis is:

Suspected.

Vascular Studies

When arterial or venous TOS is suspected, evaluation may include:

Duplex ultrasonography

CT angiography

MR angiography

or other:

Vascular imaging.

Pathological Findings

Thoracic outlet syndrome involves compression of:

Neural

or

Vascular structures

as they pass through the:

Scalene triangle

Costoclavicular space

or

Subcoracoid/pectoralis minor region.

Common Sites of Compression

Important anatomical compression zones include the:

Interscalene triangle

Costoclavicular space

and

Pectoralis minor space.

Differential Diagnosis

The differential diagnosis is broad.

Cervical Spine Disorders

Important cervical causes include:

Cervical spondylosis

Disc herniation

and

Cervical radiculopathy.

Brachial Plexus Lesions

Tumors or other masses involving the:

Brachial plexus

or

Apex of the lung

may produce similar symptoms.

Trauma

Previous trauma involving the:

Neck

Clavicle

First rib

or

Shoulder girdle

may cause chronic pain or neurologic symptoms that resemble:

TOS.

Peripheral Nerve Entrapment

Important alternatives include:

Carpal tunnel syndrome

Cubital tunnel syndrome

Radial nerve compression

and

Suprascapular nerve compression.

Systemic Neuropathy

Neuropathies related to:

Diabetes

Alcohol use

Vitamin deficiency

or

Heavy-metal toxicity

may mimic thoracic outlet syndrome.

Complex Regional Pain Syndrome

Complex regional pain syndrome may cause:

Pain

Swelling

Color change

and

Autonomic abnormalities.

Arterial Differential Diagnosis

Potential arterial disorders include:

Atherosclerotic disease

Aneurysm

Arterial occlusion

Embolism

Raynaud disease

and

Vasculitis.

Venous Differential Diagnosis

Venous alternatives include:

Upper-extremity deep venous thrombosis

Effort thrombosis

and

Thrombophlebitis.

Treatment

Initial management is generally:

Nonoperative

for patients with uncomplicated neurogenic:

Thoracic outlet syndrome.

General Measures

Treatment focuses on:

Postural correction

Muscle strengthening

Activity modification

and elimination of:

Contributing mechanical factors.

Patient Education

Explaining the mechanical basis of symptoms can help patients understand why:

Posture

Work position

and

Repetitive overhead activity

may aggravate the condition.

Occupational Modification

Activities involving prolonged:

Arm elevation

or repetitive shoulder-girdle loading should be modified when possible.

Weight Management

When obesity contributes to postural or mechanical loading, appropriate:

Weight reduction

may improve symptoms.

Physical and Occupational Therapy

A structured rehabilitation program is the cornerstone of treatment for:

Neurogenic TOS.

Postural Reeducation

Therapy should emphasize:

Scapular positioning

Thoracic posture

and avoidance of chronic:

Shoulder depression or protraction.

Muscle Strengthening

Important muscles include:

Trapezius

Rhomboids

Levator scapulae

and other:

Scapular stabilizers.

Resistance Exercises

Strengthening may be performed using:

Elastic bands

or

Light free weights

with the shoulder generally maintained below approximately:

90° of elevation

during early rehabilitation.

Pectoral and Scalene Flexibility

Stretching may address tight:

Pectoralis minor

Scalene

and other anterior shoulder-girdle:

Soft tissues.

Time to Improvement

Symptomatic improvement may require approximately:

Several weeks to 2 months

or longer.

Long-Term Exercise

Exercises should be continued until:

Posture improves

Scapular control is restored

and weakness or deconditioning has been:

Corrected.

Medication

Medication plays a secondary role.

Treatment may include:

NSAIDs

Acetaminophen

or selected medications for:

Neuropathic pain.

Vascular Thoracic Outlet Syndrome

Patients with arterial or venous TOS require:

Specialist vascular evaluation.

Treatment may differ substantially from management of:

Neurogenic TOS.

Venous Thrombosis

Acute venous thrombosis may require:

Anticoagulation

Thrombolysis

and eventual:

Thoracic outlet decompression

depending on severity and timing.

Arterial Disease

Arterial TOS with aneurysm, thrombosis, or embolization may require:

Arterial reconstruction

in addition to:

Surgical decompression.

Surgery

Surgery is considered when:

A carefully supervised conservative program fails

and symptoms remain sufficiently severe to cause:

Major functional limitation.

Surgical Decision-Making

Patients should understand that outcomes are variable and that surgery is generally reserved for those with:

Persistent significant symptoms

or objective:

Neurovascular compromise.

Common Surgical Procedures

Typical operations include:

First-rib resection

Scalenectomy

or a combination of:

Both.

Fibrous Band Release

Congenital or acquired:

Fibrous bands

may also be divided when they contribute to:

Compression.

Vascular Reconstruction

Patients with arterial or venous injury may additionally require:

Vessel repair

Patch angioplasty

Thrombectomy

or

Grafting.

Follow-Up

Patients undergoing nonoperative treatment should be followed for:

Postural improvement

Strength

Symptom reduction

and tolerance of:

Work or activity.

Postoperative Follow-Up

After surgery, monitoring should assess:

Neurologic function

Vascular status

Wound healing

and recurrence of:

Symptoms.

Prognosis

Most patients with uncomplicated neurogenic TOS improve with:

Nonoperative management.

Surgical Prognosis

With appropriate patient selection, many patients undergoing surgery experience:

Symptomatic improvement.

Results are generally more predictable when there is a clearly defined:

Anatomic or vascular lesion.

Complications

Potential surgical complications include:

Pneumothorax

Infection

Vascular injury

Brachial plexus injury

and

Shoulder-girdle dysfunction.

Pneumothorax

Pleural injury during first-rib resection may produce:

Pneumothorax.

Vascular Injury

The proximity of the:

Subclavian vessels

creates a risk of significant:

Hemorrhage.

Brachial Plexus Injury

Manipulation or traction may result in:

Neurologic injury

with postoperative:

Pain

Weakness

or

Sensory loss.

Recurrence

Symptoms may recur after surgery because of:

Scar formation

Persistent muscle weakness

Scapular depression

or

Incomplete decompression.

Patient Monitoring

Long-term monitoring should focus on:

Pain

Paresthesia

Hand strength

Arm swelling

Vascular symptoms

and progression through:

Physical therapy.

Key Principle

Thoracic outlet syndrome is a clinical disorder caused by compression of the brachial plexus or subclavian vessels as they pass from the neck into the upper extremity.

The disorder may be:

Neurogenic, venous, or arterial, with neurogenic disease being the most common.

Diagnosis is primarily:

Clinical, and provocative maneuvers should be interpreted cautiously because pulse changes alone are not:

Diagnostic.

The differential diagnosis includes:

Cervical radiculopathy, carpal and cubital tunnel syndromes, systemic neuropathy, brachial plexus lesions, and vascular disease.

Initial management of uncomplicated neurogenic TOS centers on:

Postural correction, scapular strengthening, activity modification, and occupational rehabilitation.

Surgery, typically involving:

First-rib resection and/or scalenectomy, is reserved for selected patients with persistent disabling symptoms or significant vascular or neurologic compromise.

Orthopaedic Surgery - Thoracic Disc Herniation

Basics

Thoracic disc herniation is protrusion or extrusion of an intervertebral disc within the:

Thoracic spine

that may compress the:

Spinal cord

or

Thoracic nerve roots.

The condition can be difficult to diagnose because symptoms are often:

Nonspecific

and may resemble disorders involving the:

Chest

Abdomen

Spine

or

Peripheral nervous system.

Incidental Disc Abnormalities

A major diagnostic challenge is the high prevalence of:

Asymptomatic thoracic disc abnormalities.

Disc degeneration or herniation on imaging does not necessarily indicate that the abnormality is responsible for the patient’s:

Symptoms.

Clinical findings must therefore correlate carefully with the:

Anatomic level

and degree of:

Neural compression.

Epidemiology

Symptomatic thoracic disc disease most commonly presents during approximately the:

Fifth decade of life.

Sex

A slight predominance in:

Males

has been reported historically.

Trauma

Up to approximately:

50% of symptomatic patients

report some preceding:

Traumatic event

before symptoms begin.

Incidence

Symptomatic thoracic disc herniation is uncommon, with an estimated incidence of approximately:

1 per 100,000 persons per year.

Prevalence on MRI

Thoracic disc abnormalities are much more common than clinically symptomatic disease.

MRI studies have reported abnormalities in up to approximately:

73% of individuals.

Asymptomatic Herniation

Approximately:

37%

of individuals in some imaging series have demonstrated:

Asymptomatic thoracic disc herniation.

Genetics

There is no recognized specific:

Genetic association

with thoracic disc herniation.

Pathophysiology

Symptoms develop when the herniated disc compresses the:

Spinal cord

or

Thoracic nerve root.

Spinal Cord Compression

Because the thoracic spinal canal contains the:

Spinal cord

rather than the cauda equina, central disc herniation may produce:

Myelopathy.

Thoracic Myelopathy

Thoracic cord compression may cause:

Lower-extremity weakness

Spasticity

Hyperreflexia

Sensory disturbance

Gait dysfunction

and

Bowel or bladder abnormalities.

Unlike cervical myelopathy, upper-extremity findings are generally:

Absent.

Radiculopathy

A lateral or foraminal herniation may compress a:

Thoracic nerve root

and produce band-like pain along the:

Chest wall

or

Abdominal wall.

Associated Conditions

Thoracic disc herniation may occasionally occur in adolescents with:

Scheuermann disease.

Diagnosis

Diagnosis requires careful assessment because of the broad:

Differential diagnosis

and the high frequency of incidental:

Thoracic MRI abnormalities.

Signs and Symptoms

Patients may present with:

Axial thoracic pain

Radicular pain

or

Myelopathy.

Axial Pain

Pain may be localized to the:

Mid-thoracic

or

Lower thoracic spine.

It can be:

Aching

Deep

or

Mechanical.

Radicular Pain

Thoracic radiculopathy often produces:

Band-like pain

around the trunk.

The:

T10 dermatome

is a commonly reported symptomatic distribution.

Bowel and Bladder Dysfunction

Bowel or bladder dysfunction has historically been reported in up to approximately:

20% of symptomatic patients.

These findings suggest significant:

Spinal cord involvement.

Clinical Patterns

Two broad clinical presentations are often described.

Younger Patients

Patients younger than approximately:

40 years

more commonly have:

Soft disc herniations.

Acute Soft Disc Herniation

These cases may follow:

Trauma

and may produce relatively acute:

Cord compression

or

Radiculopathy.

They often respond favorably to appropriately selected:

Nonoperative or operative treatment.

Older Patients

Patients older than approximately:

40 years

more commonly have:

Degenerative

or

Calcified disc herniations.

Chronic Calcified Herniation

These patients may have:

Longstanding symptoms

without a clear history of trauma.

Compression of the cord or nerve root tends to be more:

Chronic.

Physical Examination

A complete neurologic examination should be performed with careful assessment for:

Myelopathy.

Gait

Observe for:

Spastic gait

Balance disturbance

Shortened stride

or difficulty with:

Tandem walking.

Motor Examination

Assess lower-extremity:

Strength

and look for signs of:

Upper motor neuron dysfunction.

Reflexes

Evaluate:

Patellar reflexes

Achilles reflexes

and look for:

Hyperreflexia

Clonus

or abnormal:

Plantar responses.

Sensory Level

A sensory level may help localize the lesion.

Useful landmarks include:

T4 – nipple line

T7 – xiphoid process

T10 – umbilicus

and

T12 – inguinal crease.

Abdominal Muscle Examination

Asymmetric contraction of the:

Rectus abdominis

during a sit-up may suggest segmental:

Thoracic neurologic dysfunction.

Superficial Reflexes

The examination may include:

Superficial abdominal reflexes

and, when appropriate,

Cremasteric reflexes.

Range of Motion

Thoracic and lumbar:

Range of motion

should be assessed, although abnormalities are usually:

Nonspecific.

Laboratory Tests

Routine laboratory tests are not required for straightforward:

Disc herniation.

Infection or Malignancy

If infection or tumor is part of the differential diagnosis, testing may include:

Complete blood count

ESR

and

C-reactive protein.

Imaging

Plain Radiographs

AP and lateral thoracic spine radiographs may demonstrate:

Degenerative changes

Disc-space narrowing

Calcification

Deformity

or

Spondylolisthesis.

Excluding Other Disorders

Radiographs may also identify:

Fracture

Tumor

Infection

or other structural abnormalities.

Level Localization

Precise localization of the involved vertebral level is essential.

Imaging should include adequate landmarks to permit reliable:

Vertebral counting.

Historically, radiographs were obtained to include the:

First rib

Twelfth rib

and

Sacrum

when possible.

MRI

MRI is the preferred imaging study for suspected:

Thoracic disc herniation.

MRI Sequences

Evaluation should include:

Sagittal

and

Axial

T1- and T2-weighted sequences.

MRI Findings

MRI can demonstrate:

Disc morphology

Spinal cord compression

Nerve-root compression

and possible:

Cord signal abnormality.

Correct-Level Confirmation

Because wrong-level surgery is a major concern in the thoracic spine, the abnormal disc level must be:

Confirmed carefully.

A sagittal localizer may be used to count:

Downward from C2

and

Upward from the sacrum.

Correlation with:

Plain radiographs

or

CT

is useful.

CT

CT is particularly useful for identifying:

Calcification

and defining:

Bony anatomy.

CT Myelography

CT myelography can demonstrate:

Neural compression

and may be used when MRI is:

Contraindicated

or limited by:

Artifact.

Limitations of CT Myelography

Because it requires:

Intrathecal contrast injection

CT myelography is invasive.

Potential complications include:

Post-dural puncture headache.

Discography

Discography has historically been used to investigate:

Axial thoracic pain

when multiple disc levels are abnormal or severe pain persists despite relatively limited:

Imaging findings.

Its diagnostic value remains:

Controversial.

Differential Diagnosis

The differential diagnosis is extensive.

Intrathoracic Causes

Potential causes include:

Pulmonary

Pleural

or other:

Thoracic abnormalities.

Intra-Abdominal Causes

Abdominal pathology can occasionally mimic:

Thoracic radicular pain.

Infectious Causes

Important possibilities include:

Discitis

Vertebral osteomyelitis

and

Epidural abscess.

Neoplastic Causes

Primary or metastatic tumors may cause:

Thoracic pain

Radiculopathy

or

Myelopathy.

Degenerative Causes

Other spinal causes include:

Facet arthropathy

Thoracic stenosis

and other forms of:

Degenerative spondylosis.

Metabolic and Deformity Causes

Consider:

Metabolic bone disease

Compression fracture

and spinal:

Deformity.

Neurogenic Causes

Neurologic alternatives include:

Peripheral neuropathy

Herpes zoster

Spinal cord tumor

and other causes of:

Thoracic neuralgia or myelopathy.

Treatment

Treatment depends primarily on the presence or absence of:

Neurologic compromise.

General Measures

Acute thoracic disc herniation without significant neurologic deficit can often be treated initially:

Nonoperatively.

Natural History

Soft acute thoracic disc herniations may behave similarly to:

Lumbar disc herniations

and may improve with:

Time

and

Conservative management.

Activity

Activity may continue:

As tolerated

provided there is no associated:

Fracture

Gross instability

or other structural contraindication.

Relative Rest

Short-term reduction of provoking activities may help control:

Acute pain.

Prolonged bed rest is generally avoided.

Physical Therapy

Physical therapy may be useful for:

Pain control

Mobility

Flexibility

and

Strengthening.

Acute Phase

Passive modalities may include:

Heat

Ice

and selected therapeutic:

Modalities.

Rehabilitation Phase

As symptoms improve, treatment may progress to:

Range-of-motion exercises

Flexibility exercises

and

Strengthening.

Extension Exercises

Some programs include:

Thoracic extension exercises.

These should be individualized and discontinued if they increase:

Radicular pain

or

Myelopathic symptoms.

Medication

First-Line Treatment

Medication may include:

Acetaminophen

or

NSAIDs

when medically appropriate.

NSAIDs

Anti-inflammatory medication may help reduce:

Pain

provided the patient does not have important:

Gastrointestinal

Renal

or other contraindications.

Aspirin

Enteric-coated aspirin has historically been used for:

Pain and inflammation

although other NSAIDs are now more commonly selected.

Chronic Opioids

There is no routine role for:

Long-term maintenance opioid therapy

in uncomplicated thoracic disc disease.

COX-2 Inhibitors

Selected patients may receive:

COX-2 selective anti-inflammatory medication

after considering:

Cardiovascular

Renal

and

Gastrointestinal risks.

Injections

Selected patients with persistent radicular pain may benefit from:

Thoracic epidural steroid injection

or

Intercostal injection.

These treatments may reduce pain but do not correct:

Mechanical spinal cord compression.

Surgery

Surgery is indicated when:

Neurologic compromise progresses

or nonoperative management fails to provide an acceptable:

Quality of life.

Major Surgical Indications

Common indications include:

Progressive myelopathy

Significant motor deficit

Severe spinal cord compression

or persistent disabling:

Pain.

Preoperative Assessment

Because thoracic surgical approaches may involve the chest and carry substantial physiologic stress, selected patients may require preoperative evaluation by:

Internal medicine

Cardiology

or

Anesthesiology.

Surgical Level Confirmation

Intraoperative imaging should be used to verify the:

Correct vertebral level

before disc removal.

Anterior Transthoracic Approach

The:

Anterior transthoracic approach

has traditionally been used for many central thoracic disc herniations because it permits direct access to the:

Anterior spinal canal.

Posterior Approaches

Direct posterior laminectomy alone is generally:

Not recommended

for central thoracic disc removal because manipulation of the spinal cord carries a high risk of:

Neurologic injury.

Pediculofacetectomy

A posterior:

Transpedicular or pediculofacetectomy approach

may be appropriate for selected:

Lateral lesions.

Lateral Approaches

Other options include:

Costotransversectomy

and

Lateral extracavitary approaches.

Thoracoscopic Surgery

Video-assisted thoracoscopic surgery provides a:

Minimally invasive anterior approach

for selected patients.

Fusion

Whether spinal fusion is required remains dependent on:

Extent of bone removal

Pre-existing deformity

and resultant:

Stability.

Rib-Cage Stability

The thoracic spine has inherent stability from the:

Rib cage.

However, substantial resection of:

Facets

Pedicles

or vertebral body structures may produce:

Iatrogenic instability.

Follow-Up

Follow-up should assess:

Pain

Neurologic status

and progression of:

Recovery.

Historical Follow-Up Schedule

A traditional postoperative schedule may include visits at approximately:

6 weeks

3 months

6 months

1 year

and

2 years

with subsequent long-term review as indicated.

Referral

Patients may require evaluation by other specialists when alternative diagnoses remain possible, including:

Thoracic surgeons

General surgeons

Rheumatologists

or other relevant:

Specialists.

Prognosis

Most appropriately selected patients undergoing thoracic disc excision achieve:

Good or excellent long-term outcomes.

Prognostic Factors

Recovery depends on:

Duration of symptoms

Severity of myelopathy

Extent of spinal cord compression

Disc calcification

and

Preoperative neurologic status.

Acute Soft Disc Prognosis

Younger patients with:

Soft acute herniations

and shorter symptom duration generally have greater potential for:

Neurologic recovery.

Chronic Calcified Disc Prognosis

Longstanding compression from:

Calcified disc material

may produce irreversible:

Spinal cord injury.

Complications

Surgical Complication Rate

Historical series have reported an overall complication rate of approximately:

14–15%

after thoracic disc excision.

Neurologic Injury

The most serious complication is:

Spinal cord injury

with:

Paraparesis

or

Paralysis.

Dural Injury

Possible complications include:

Dural tear

and

Cerebrospinal fluid leak.

Pulmonary Complications

Anterior thoracic approaches may be associated with:

Pneumothorax

Hemothorax

Pleural effusion

or other:

Pulmonary problems.

Infection

Potential infectious complications include:

Wound infection

and deeper:

Spinal infection.

Instability and Deformity

Extensive surgical resection may lead to:

Segmental instability

or

Postoperative kyphosis.

Nonoperative Neurologic Progression

Patients treated nonoperatively must be monitored for progression of:

Myelopathy

or other:

Neurologic compromise.

Patient Monitoring

Monitoring should include assessment of:

Pain

Gait

Motor function

Sensation

and

Bowel and bladder function.

After Fusion

If arthrodesis is performed, follow-up should also evaluate:

Fusion maturation

and

Spinal alignment.

Red-Flag Findings

Urgent reassessment is warranted for:

Progressive leg weakness

Increasing gait difficulty

New sensory level

Worsening spasticity

or

New bowel or bladder dysfunction.

Key Principle

Thoracic disc herniation is an uncommon symptomatic disorder despite the frequent finding of incidental thoracic disc abnormalities on MRI.

Clinical presentation may consist of:

Axial thoracic pain, radiculopathy, or spinal cord compression with myelopathy.

MRI is the preferred imaging study for assessing:

Neural compression, while CT is particularly valuable for evaluating:

Calcified disc material and bony anatomy.

Patients without significant neurologic compromise may initially be treated with:

Activity modification, analgesia, and physical therapy.

Surgery is reserved for:

Progressive myelopathy, substantial neurologic deficit, severe cord compression, or persistent disabling symptoms despite appropriate nonoperative care.

Simple posterior laminectomy for central disc excision is generally avoided because of the risk of:

Spinal cord injury.

Orthopaedic Surgery - Thoracic Disc Herniation

Basics

Thoracic disc herniation is protrusion or extrusion of an intervertebral disc within the:

Thoracic spine

that may compress the:

Spinal cord

or

Thoracic nerve roots.

The condition can be difficult to diagnose because symptoms are often:

Nonspecific

and may resemble disorders involving the:

Chest

Abdomen

Spine

or

Peripheral nervous system.

Incidental Disc Abnormalities

A major diagnostic challenge is the high prevalence of:

Asymptomatic thoracic disc abnormalities.

Disc degeneration or herniation on imaging does not necessarily indicate that the abnormality is responsible for the patient’s:

Symptoms.

Clinical findings must therefore correlate carefully with the:

Anatomic level

and degree of:

Neural compression.

Epidemiology

Symptomatic thoracic disc disease most commonly presents during approximately the:

Fifth decade of life.

Sex

A slight predominance in:

Males

has been reported historically.

Trauma

Up to approximately:

50% of symptomatic patients

report some preceding:

Traumatic event

before symptoms begin.

Incidence

Symptomatic thoracic disc herniation is uncommon, with an estimated incidence of approximately:

1 per 100,000 persons per year.

Prevalence on MRI

Thoracic disc abnormalities are much more common than clinically symptomatic disease.

MRI studies have reported abnormalities in up to approximately:

73% of individuals.

Asymptomatic Herniation

Approximately:

37%

of individuals in some imaging series have demonstrated:

Asymptomatic thoracic disc herniation.

Genetics

There is no recognized specific:

Genetic association

with thoracic disc herniation.

Pathophysiology

Symptoms develop when the herniated disc compresses the:

Spinal cord

or

Thoracic nerve root.

Spinal Cord Compression

Because the thoracic spinal canal contains the:

Spinal cord

rather than the cauda equina, central disc herniation may produce:

Myelopathy.

Thoracic Myelopathy

Thoracic cord compression may cause:

Lower-extremity weakness

Spasticity

Hyperreflexia

Sensory disturbance

Gait dysfunction

and

Bowel or bladder abnormalities.

Unlike cervical myelopathy, upper-extremity findings are generally:

Absent.

Radiculopathy

A lateral or foraminal herniation may compress a:

Thoracic nerve root

and produce band-like pain along the:

Chest wall

or

Abdominal wall.

Associated Conditions

Thoracic disc herniation may occasionally occur in adolescents with:

Scheuermann disease.

Diagnosis

Diagnosis requires careful assessment because of the broad:

Differential diagnosis

and the high frequency of incidental:

Thoracic MRI abnormalities.

Signs and Symptoms

Patients may present with:

Axial thoracic pain

Radicular pain

or

Myelopathy.

Axial Pain

Pain may be localized to the:

Mid-thoracic

or

Lower thoracic spine.

It can be:

Aching

Deep

or

Mechanical.

Radicular Pain

Thoracic radiculopathy often produces:

Band-like pain

around the trunk.

The:

T10 dermatome

is a commonly reported symptomatic distribution.

Bowel and Bladder Dysfunction

Bowel or bladder dysfunction has historically been reported in up to approximately:

20% of symptomatic patients.

These findings suggest significant:

Spinal cord involvement.

Clinical Patterns

Two broad clinical presentations are often described.

Younger Patients

Patients younger than approximately:

40 years

more commonly have:

Soft disc herniations.

Acute Soft Disc Herniation

These cases may follow:

Trauma

and may produce relatively acute:

Cord compression

or

Radiculopathy.

They often respond favorably to appropriately selected:

Nonoperative or operative treatment.

Older Patients

Patients older than approximately:

40 years

more commonly have:

Degenerative

or

Calcified disc herniations.

Chronic Calcified Herniation

These patients may have:

Longstanding symptoms

without a clear history of trauma.

Compression of the cord or nerve root tends to be more:

Chronic.

Physical Examination

A complete neurologic examination should be performed with careful assessment for:

Myelopathy.

Gait

Observe for:

Spastic gait

Balance disturbance

Shortened stride

or difficulty with:

Tandem walking.

Motor Examination

Assess lower-extremity:

Strength

and look for signs of:

Upper motor neuron dysfunction.

Reflexes

Evaluate:

Patellar reflexes

Achilles reflexes

and look for:

Hyperreflexia

Clonus

or abnormal:

Plantar responses.

Sensory Level

A sensory level may help localize the lesion.

Useful landmarks include:

T4 – nipple line

T7 – xiphoid process

T10 – umbilicus

and

T12 – inguinal crease.

Abdominal Muscle Examination

Asymmetric contraction of the:

Rectus abdominis

during a sit-up may suggest segmental:

Thoracic neurologic dysfunction.

Superficial Reflexes

The examination may include:

Superficial abdominal reflexes

and, when appropriate,

Cremasteric reflexes.

Range of Motion

Thoracic and lumbar:

Range of motion

should be assessed, although abnormalities are usually:

Nonspecific.

Laboratory Tests

Routine laboratory tests are not required for straightforward:

Disc herniation.

Infection or Malignancy

If infection or tumor is part of the differential diagnosis, testing may include:

Complete blood count

ESR

and

C-reactive protein.

Imaging

Plain Radiographs

AP and lateral thoracic spine radiographs may demonstrate:

Degenerative changes

Disc-space narrowing

Calcification

Deformity

or

Spondylolisthesis.

Excluding Other Disorders

Radiographs may also identify:

Fracture

Tumor

Infection

or other structural abnormalities.

Level Localization

Precise localization of the involved vertebral level is essential.

Imaging should include adequate landmarks to permit reliable:

Vertebral counting.

Historically, radiographs were obtained to include the:

First rib

Twelfth rib

and

Sacrum

when possible.

MRI

MRI is the preferred imaging study for suspected:

Thoracic disc herniation.

MRI Sequences

Evaluation should include:

Sagittal

and

Axial

T1- and T2-weighted sequences.

MRI Findings

MRI can demonstrate:

Disc morphology

Spinal cord compression

Nerve-root compression

and possible:

Cord signal abnormality.

Correct-Level Confirmation

Because wrong-level surgery is a major concern in the thoracic spine, the abnormal disc level must be:

Confirmed carefully.

A sagittal localizer may be used to count:

Downward from C2

and

Upward from the sacrum.

Correlation with:

Plain radiographs

or

CT

is useful.

CT

CT is particularly useful for identifying:

Calcification

and defining:

Bony anatomy.

CT Myelography

CT myelography can demonstrate:

Neural compression

and may be used when MRI is:

Contraindicated

or limited by:

Artifact.

Limitations of CT Myelography

Because it requires:

Intrathecal contrast injection

CT myelography is invasive.

Potential complications include:

Post-dural puncture headache.

Discography

Discography has historically been used to investigate:

Axial thoracic pain

when multiple disc levels are abnormal or severe pain persists despite relatively limited:

Imaging findings.

Its diagnostic value remains:

Controversial.

Differential Diagnosis

The differential diagnosis is extensive.

Intrathoracic Causes

Potential causes include:

Pulmonary

Pleural

or other:

Thoracic abnormalities.

Intra-Abdominal Causes

Abdominal pathology can occasionally mimic:

Thoracic radicular pain.

Infectious Causes

Important possibilities include:

Discitis

Vertebral osteomyelitis

and

Epidural abscess.

Neoplastic Causes

Primary or metastatic tumors may cause:

Thoracic pain

Radiculopathy

or

Myelopathy.

Degenerative Causes

Other spinal causes include:

Facet arthropathy

Thoracic stenosis

and other forms of:

Degenerative spondylosis.

Metabolic and Deformity Causes

Consider:

Metabolic bone disease

Compression fracture

and spinal:

Deformity.

Neurogenic Causes

Neurologic alternatives include:

Peripheral neuropathy

Herpes zoster

Spinal cord tumor

and other causes of:

Thoracic neuralgia or myelopathy.

Treatment

Treatment depends primarily on the presence or absence of:

Neurologic compromise.

General Measures

Acute thoracic disc herniation without significant neurologic deficit can often be treated initially:

Nonoperatively.

Natural History

Soft acute thoracic disc herniations may behave similarly to:

Lumbar disc herniations

and may improve with:

Time

and

Conservative management.

Activity

Activity may continue:

As tolerated

provided there is no associated:

Fracture

Gross instability

or other structural contraindication.

Relative Rest

Short-term reduction of provoking activities may help control:

Acute pain.

Prolonged bed rest is generally avoided.

Physical Therapy

Physical therapy may be useful for:

Pain control

Mobility

Flexibility

and

Strengthening.

Acute Phase

Passive modalities may include:

Heat

Ice

and selected therapeutic:

Modalities.

Rehabilitation Phase

As symptoms improve, treatment may progress to:

Range-of-motion exercises

Flexibility exercises

and

Strengthening.

Extension Exercises

Some programs include:

Thoracic extension exercises.

These should be individualized and discontinued if they increase:

Radicular pain

or

Myelopathic symptoms.

Medication

First-Line Treatment

Medication may include:

Acetaminophen

or

NSAIDs

when medically appropriate.

NSAIDs

Anti-inflammatory medication may help reduce:

Pain

provided the patient does not have important:

Gastrointestinal

Renal

or other contraindications.

Aspirin

Enteric-coated aspirin has historically been used for:

Pain and inflammation

although other NSAIDs are now more commonly selected.

Chronic Opioids

There is no routine role for:

Long-term maintenance opioid therapy

in uncomplicated thoracic disc disease.

COX-2 Inhibitors

Selected patients may receive:

COX-2 selective anti-inflammatory medication

after considering:

Cardiovascular

Renal

and

Gastrointestinal risks.

Injections

Selected patients with persistent radicular pain may benefit from:

Thoracic epidural steroid injection

or

Intercostal injection.

These treatments may reduce pain but do not correct:

Mechanical spinal cord compression.

Surgery

Surgery is indicated when:

Neurologic compromise progresses

or nonoperative management fails to provide an acceptable:

Quality of life.

Major Surgical Indications

Common indications include:

Progressive myelopathy

Significant motor deficit

Severe spinal cord compression

or persistent disabling:

Pain.

Preoperative Assessment

Because thoracic surgical approaches may involve the chest and carry substantial physiologic stress, selected patients may require preoperative evaluation by:

Internal medicine

Cardiology

or

Anesthesiology.

Surgical Level Confirmation

Intraoperative imaging should be used to verify the:

Correct vertebral level

before disc removal.

Anterior Transthoracic Approach

The:

Anterior transthoracic approach

has traditionally been used for many central thoracic disc herniations because it permits direct access to the:

Anterior spinal canal.

Posterior Approaches

Direct posterior laminectomy alone is generally:

Not recommended

for central thoracic disc removal because manipulation of the spinal cord carries a high risk of:

Neurologic injury.

Pediculofacetectomy

A posterior:

Transpedicular or pediculofacetectomy approach

may be appropriate for selected:

Lateral lesions.

Lateral Approaches

Other options include:

Costotransversectomy

and

Lateral extracavitary approaches.

Thoracoscopic Surgery

Video-assisted thoracoscopic surgery provides a:

Minimally invasive anterior approach

for selected patients.

Fusion

Whether spinal fusion is required remains dependent on:

Extent of bone removal

Pre-existing deformity

and resultant:

Stability.

Rib-Cage Stability

The thoracic spine has inherent stability from the:

Rib cage.

However, substantial resection of:

Facets

Pedicles

or vertebral body structures may produce:

Iatrogenic instability.

Follow-Up

Follow-up should assess:

Pain

Neurologic status

and progression of:

Recovery.

Historical Follow-Up Schedule

A traditional postoperative schedule may include visits at approximately:

6 weeks

3 months

6 months

1 year

and

2 years

with subsequent long-term review as indicated.

Referral

Patients may require evaluation by other specialists when alternative diagnoses remain possible, including:

Thoracic surgeons

General surgeons

Rheumatologists

or other relevant:

Specialists.

Prognosis

Most appropriately selected patients undergoing thoracic disc excision achieve:

Good or excellent long-term outcomes.

Prognostic Factors

Recovery depends on:

Duration of symptoms

Severity of myelopathy

Extent of spinal cord compression

Disc calcification

and

Preoperative neurologic status.

Acute Soft Disc Prognosis

Younger patients with:

Soft acute herniations

and shorter symptom duration generally have greater potential for:

Neurologic recovery.

Chronic Calcified Disc Prognosis

Longstanding compression from:

Calcified disc material

may produce irreversible:

Spinal cord injury.

Complications

Surgical Complication Rate

Historical series have reported an overall complication rate of approximately:

14–15%

after thoracic disc excision.

Neurologic Injury

The most serious complication is:

Spinal cord injury

with:

Paraparesis

or

Paralysis.

Dural Injury

Possible complications include:

Dural tear

and

Cerebrospinal fluid leak.

Pulmonary Complications

Anterior thoracic approaches may be associated with:

Pneumothorax

Hemothorax

Pleural effusion

or other:

Pulmonary problems.

Infection

Potential infectious complications include:

Wound infection

and deeper:

Spinal infection.

Instability and Deformity

Extensive surgical resection may lead to:

Segmental instability

or

Postoperative kyphosis.

Nonoperative Neurologic Progression

Patients treated nonoperatively must be monitored for progression of:

Myelopathy

or other:

Neurologic compromise.

Patient Monitoring

Monitoring should include assessment of:

Pain

Gait

Motor function

Sensation

and

Bowel and bladder function.

After Fusion

If arthrodesis is performed, follow-up should also evaluate:

Fusion maturation

and

Spinal alignment.

Red-Flag Findings

Urgent reassessment is warranted for:

Progressive leg weakness

Increasing gait difficulty

New sensory level

Worsening spasticity

or

New bowel or bladder dysfunction.

Key Principle

Thoracic disc herniation is an uncommon symptomatic disorder despite the frequent finding of incidental thoracic disc abnormalities on MRI.

Clinical presentation may consist of:

Axial thoracic pain, radiculopathy, or spinal cord compression with myelopathy.

MRI is the preferred imaging study for assessing:

Neural compression, while CT is particularly valuable for evaluating:

Calcified disc material and bony anatomy.

Patients without significant neurologic compromise may initially be treated with:

Activity modification, analgesia, and physical therapy.

Surgery is reserved for:

Progressive myelopathy, substantial neurologic deficit, severe cord compression, or persistent disabling symptoms despite appropriate nonoperative care.

Simple posterior laminectomy for central disc excision is generally avoided because of the risk of:

Spinal cord injury.

Orthopaedic Surgery - Tenosynovitis

Basics

Tenosynovitis is a painful disorder involving:

Inflammation or irritation of a tendon and its surrounding synovial sheath.

It most often affects long tendons in the:

Fingers

Wrist

or

Ankle.

Causes

Tenosynovitis may result from:

Acute injury

Repetitive mechanical loading

Systemic inflammatory disease

Infection

or, in some patients,

No identifiable cause.

Age

The condition is uncommon in:

Children

and is seen most frequently during:

Early to middle adulthood.

Classification by Duration

Tenosynovitis may be described as:

Acute

or

Chronic.

Acute Tenosynovitis

Acute tenosynovitis generally produces symptoms lasting only:

Several days.

Noninfectious acute cases may improve relatively quickly with:

Activity modification

Rest

and

Anti-inflammatory treatment.

Chronic Tenosynovitis

Symptoms persisting longer than approximately:

2–3 weeks

may be considered chronic.

Chronic disease may be accompanied by greater:

Sheath thickening

Fibrosis

and

Tendon degeneration.

These cases may be more difficult to:

Resolve completely.

Common Locations

Frequent clinical forms include:

Posterior tibial tenosynovitis

Flexor tendon tenosynovitis of the hand

Biceps tenosynovitis

and

de Quervain tenosynovitis.

de Quervain Tenosynovitis

de Quervain disease affects the first dorsal extensor compartment, principally the:

Abductor pollicis longus

and

Extensor pollicis brevis tendons.

Synonym

The term:

Tendinitis

is sometimes used interchangeably, although tendinitis refers primarily to the:

Tendon itself

whereas tenosynovitis specifically involves the:

Synovial tendon sheath.

Prevention

Because many cases arise unpredictably, there is no reliable method for preventing all forms of:

Tenosynovitis.

Activity Modification

In patients whose symptoms are related to repetitive loading, prevention of recurrence may involve:

Ergonomic adjustment

Technique modification

and avoidance of abrupt increases in:

Repetitive activity.

Epidemiology

Tenosynovial disorders are among the more common:

Musculoskeletal complaints.

Many individuals experience at least one episode of tendon or tendon-sheath irritation during:

Their lifetime.

Sex

Women appear to be affected slightly more frequently than:

Men.

Risk Factors

Potential risk factors include:

Rheumatoid arthritis

Other inflammatory arthropathies

Previous tenosynovitis

Pregnancy

and selected repetitive:

Occupational or recreational activities.

Repetitive Motion

The relationship between repetitive motion and every form of tenosynovitis is not absolute.

However, repetitive loading may contribute in susceptible patients, especially when activity is:

New

Unusually intense

or associated with poor:

Biomechanics.

Etiology

Repeated use or mechanical constriction may irritate the:

Tendon sheath

causing thickening and impaired:

Tendon gliding.

Noninfectious Tenosynovitis

Many noninfectious cases occur in adults between approximately:

30 and 50 years of age

who perform repetitive:

Hand

Wrist

or

Lower-extremity activities.

Systemic Inflammatory Disease

Tenosynovitis may be a manifestation of:

Rheumatoid arthritis

Systemic lupus erythematosus

or other:

Inflammatory arthritides.

Infectious Tenosynovitis

Infection usually develops when bacteria gain access to the:

Tendon sheath

through:

Penetrating trauma

Laceration

Puncture wound

or, less commonly,

Hematogenous spread.

Flexor Tendon Sheath Infection

Infectious flexor tenosynovitis of the hand is particularly important because infection can spread rapidly within the:

Closed tendon sheath.

It represents an:

Urgent surgical condition.

Pregnancy Considerations

Pregnancy may precipitate or worsen:

Tenosynovitis

particularly:

de Quervain tenosynovitis.

Fluid retention and hormonal changes may contribute to:

Tendon-sheath swelling.

Associated Conditions

Important associated disorders include:

Rheumatoid arthritis

Lupus

and other:

Inflammatory arthropathies.

Diagnosis

Diagnosis is usually based on:

History

Physical examination

and, when necessary,

Laboratory or imaging studies.

Signs and Symptoms

The most common symptom is:

Pain along the course of the affected tendon.

Onset

Pain may develop:

Suddenly

or

Gradually.

It frequently follows a period of:

New or unusually strenuous activity.

Activity-Related Pain

Symptoms generally worsen with:

Use of the involved tendon

and improve with:

Rest.

Swelling

There may be localized:

Swelling

or fullness along the:

Tendon sheath.

Crepitus

Some patients develop palpable or audible:

Crepitus

as the tendon moves within an inflamed or thickened:

Sheath.

de Quervain Symptoms

de Quervain tenosynovitis typically causes:

Radial-sided wrist pain

near the:

Radial styloid.

Symptoms worsen with:

Thumb motion

Gripping

and

Ulnar deviation of the wrist.

Trigger Finger

Tenosynovial thickening around the flexor tendons may produce:

Trigger finger.

Triggering Mechanism

The tendon catches as it passes through a constricted:

Flexor pulley system.

This may produce:

Clicking

Snapping

or

Locking

during finger flexion or extension.

Physical Examination

The examination should identify the specific:

Tendon or tendon sheath

responsible for symptoms.

Tenderness

Tenderness is typically distributed:

Longitudinally

along the course of the:

Affected tendon.

Severity

Tenderness may be:

Mild

Moderate

or

Severe

depending on the underlying:

Cause and duration.

Swelling

Visible or palpable swelling may follow the:

Tendon sheath.

Crepitus With Motion

Moving the affected tendon may reproduce:

Pain

and occasionally:

Crepitus.

Range of Motion

Assess:

Active

and

Passive range of motion.

Restriction may result from:

Pain

Swelling

or mechanical:

Tendon constriction.

Infectious Flexor Tenosynovitis

When infection is suspected in a finger, look for the classic:

Kanavel signs.

These include:

Fusiform swelling of the digit

Tenderness along the flexor tendon sheath

Finger held in slight flexion

and

Pain with passive extension.

The presence of these findings should prompt:

Urgent surgical evaluation.

Laboratory Tests

Laboratory studies are not always required for uncomplicated noninfectious:

Tenosynovitis.

Suspected Infection

When infection is possible, useful studies may include:

Complete blood count

Erythrocyte sedimentation rate

and

C-reactive protein.

Systemic Disease Evaluation

Additional testing may be appropriate when symptoms suggest:

Rheumatoid arthritis

Lupus

Gout

or another systemic:

Inflammatory disorder.

Imaging

Plain Radiographs

Radiographs may be useful when there is:

Penetrating trauma

Suspected fracture

Adjacent arthritis

or another potential:

Bony cause of symptoms.

Radiographic Role

Plain films generally do not demonstrate the tendon-sheath inflammation directly.

They are primarily used to identify:

Alternative diagnoses

and associated:

Skeletal abnormalities.

Ultrasound

Ultrasound can demonstrate:

Tendon-sheath fluid

Synovial thickening

Tendon abnormalities

and dynamic:

Tendon motion.

MRI

MRI may show:

Fluid surrounding the tendon

Synovial thickening

Tendon degeneration

or associated:

Soft-tissue pathology.

Role of Advanced Imaging

Ultrasound or MRI is most helpful when:

The diagnosis is uncertain

Symptoms persist despite treatment

or a mass, tear, or other structural lesion is:

Suspected.

Pathological Findings

The pathological appearance varies according to the:

Cause.

Acute Inflammatory Disease

Acute inflammatory tenosynovitis may show:

Synovial edema

Hyperemia

and infiltration by:

Inflammatory cells.

Chronic Disease

Chronic cases may demonstrate:

Synovial thickening

Fibrosis

and degenerative changes affecting the:

Tendon.

Infectious Disease

Septic tenosynovitis may contain:

Purulent fluid

with marked:

Synovial inflammation

and potentially:

Tendon damage.

Differential Diagnosis

Important alternatives include:

Tendon strain

Partial tendon tear

Complete tendon rupture

Tendon-sheath infection

Arthritis

and other causes of regional:

Soft-tissue pain.

Treatment

Treatment depends on whether the process is:

Mechanical

Inflammatory

or

Infectious.

General Measures

Most uncomplicated noninfectious cases are initially treated with:

Relative rest

Activity modification

and gentle:

Range-of-motion exercises.

Relative Rest

The provoking activity should be reduced sufficiently to allow symptoms to:

Settle.

Complete inactivity is generally avoided when painless movement is:

Possible.

Immobilization

Short-term use of a:

Splint

or

Brace

may be helpful when symptoms are severe.

Prolonged immobilization should generally be avoided because it may lead to:

Stiffness

and

Weakness.

Physical and Occupational Therapy

Physical and occupational therapists may assist with:

Splinting

Stretching

Strengthening

and

Work or activity modification.

Ergonomic Modification

When occupational activity contributes to symptoms, therapy may focus on:

Tool modification

Workstation adjustment

and changes in:

Repetitive movement patterns.

Stretching

Gentle stretching can help maintain:

Tendon excursion

and surrounding:

Joint mobility.

Strengthening

Once acute pain improves, progressive strengthening may restore:

Tendon capacity

and reduce recurrence.

Medication

NSAIDs

NSAIDs may provide short-term relief of:

Pain

and

Inflammatory symptoms.

They are commonly used in:

Noninfectious tenosynovitis.

Corticosteroid Injection

Corticosteroid injection may be effective for selected disorders, particularly:

de Quervain tenosynovitis

and

Trigger finger.

Injection Precautions

Injection should be performed carefully to avoid:

Direct intratendinous injection

which can increase the risk of:

Tendon weakening or rupture.

Systemic Inflammatory Disease

Tenosynovitis caused by rheumatoid arthritis or another inflammatory disease may improve with:

Disease-modifying antirheumatic therapy

and appropriate systemic:

Anti-inflammatory treatment.

Infectious Tenosynovitis

Septic tenosynovitis requires:

Urgent treatment.

Antibiotics

Treatment includes prompt:

Intravenous or appropriately targeted antibiotics

based on the suspected organism and:

Culture results.

Surgery

Surgery may be required when:

Nonoperative treatment fails

or when mechanical compression prevents normal:

Tendon gliding.

Surgical Release

Operative treatment may involve:

Opening or releasing the tendon sheath

to relieve:

Constriction.

Synovectomy

Diseased or hypertrophic synovium may be:

Excised

to improve tendon:

Gliding.

Tendon Débridement

Degenerated tendon tissue may require:

Débridement

in selected chronic cases.

de Quervain Surgery

Persistent de Quervain disease may require complete release of the:

First dorsal extensor compartment.

Both the:

Abductor pollicis longus

and any separate compartment containing the:

Extensor pollicis brevis

must be adequately decompressed.

Postoperative Splinting

Temporary splinting may be used after surgery depending on:

Procedure

and

Tendon condition.

Septic Tenosynovitis Surgery

Infectious tenosynovitis may require urgent:

Tendon-sheath irrigation and decompression

with removal of:

Purulent material

and

Infected synovium.

Timing in Infection

Delay in treatment can lead to:

Tendon necrosis

Adhesions

Loss of motion

or spread of:

Infection.

Referral

Patients with suspected systemic inflammatory disease should be referred for appropriate:

Rheumatologic evaluation.

Rheumatology

Patients with:

Rheumatoid arthritis

Lupus

or another inflammatory arthropathy may require:

Disease-modifying therapy

rather than isolated treatment of the:

Tendon sheath.

Follow-Up

Patients should be reassessed according to:

Severity

Location

and

Treatment response.

Typical Monitoring

Nonoperative cases may be reviewed at approximately:

4–6 week intervals.

Examination During Follow-Up

Follow-up should evaluate:

Pain

Swelling

Range of motion

Tendon function

and return to:

Normal activity.

Prognosis

Most uncomplicated cases respond successfully to:

Nonoperative treatment.

Recurrent Disease

Some tendon regions have a greater tendency toward recurrence, particularly the:

Posterior tibial tendon

and

Achilles tendon.

Chronic Tenosynovitis

Longstanding disease may be more difficult to resolve because of:

Fibrosis

Tendon degeneration

and persistent:

Mechanical irritation.

Infectious Prognosis

Outcome in septic tenosynovitis depends heavily on:

Early recognition

and

Prompt treatment.

Delayed care increases the risk of permanent:

Tendon and joint dysfunction.

Complications

The principal complication of noninfectious disease is:

Persistence or recurrence of symptoms.

Tendon Degeneration

Chronic tenosynovitis may contribute to:

Tendon weakening

and occasionally:

Tendon rupture.

Adhesions

Inflammation or surgery can lead to:

Tendon adhesions

and impaired:

Tendon gliding.

Stiffness

Pain and prolonged immobilization can result in:

Joint stiffness

and reduced:

Range of motion.

Infection Complications

Untreated septic tenosynovitis may cause:

Abscess formation

Tendon necrosis

Joint infection

Osteomyelitis

or permanent:

Functional loss.

Patient Monitoring

Patients should be monitored for:

Resolution of pain

Improved tendon excursion

Restoration of range of motion

and recurrence of:

Swelling or triggering.

Key Principle

Tenosynovitis is a disorder of the synovial tendon sheath that may result from mechanical overuse, systemic inflammatory disease, infection, or an idiopathic process.

Typical findings include:

Pain and tenderness along the tendon, swelling, crepitus, and pain with use.

Most noninfectious cases improve with:

Relative rest, temporary splinting, NSAIDs, activity modification, and therapy.

Selected conditions such as:

de Quervain tenosynovitis and trigger finger

may respond to:

Corticosteroid injection.

Persistent mechanical disease may require:

Surgical sheath release or synovectomy, whereas:

Septic flexor tenosynovitis is an urgent condition requiring antibiotics and often operative irrigation and decompression.

Orthopaedic Surgery - Tennis Elbow

Basics

Tennis elbow, also called:

Lateral epicondylitis

is a degenerative tendinopathy involving the origin of the:

Extensor carpi radialis brevis

at the:

Lateral epicondyle of the humerus.

Despite the traditional term “epicondylitis,” the disorder is predominantly:

Degenerative rather than inflammatory.

Synonyms

Other terms include:

Lateral epicondylosis

Lateral epicondylalgia

Wrist extensor tendinosis

and

Tennis elbow.

Anatomy

The lateral epicondyle provides attachment for the:

Common extensor tendon.

Important contributing muscles include:

Extensor carpi radialis longus

Extensor carpi radialis brevis

Extensor digitorum communis

and

Extensor carpi ulnaris.

Extensor Carpi Radialis Brevis

The:

Extensor carpi radialis brevis, or ECRB

is the tendon most commonly involved.

It lies deep to the:

Extensor carpi radialis longus.

Function

The wrist extensors stabilize the wrist during:

Gripping

Lifting

and repetitive:

Forearm and hand activity.

They are also highly active during the:

Backhand stroke in tennis.

Clinical Setting

Although strongly associated with racket sports by name, lateral epicondylosis is actually more commonly encountered in patients performing repetitive:

Occupational

or

Daily-living activities.

It affects both:

Athletes

and

Nonathletes.

Typical Patient

The classic presentation is an adult in the:

Fourth or fifth decade

with overuse of the:

Dominant upper extremity.

Natural History

Lateral epicondylosis is generally:

Self-limited.

Symptoms may nevertheless persist for:

Many months

and occasionally longer before resolving.

Prevention

Prevention focuses on reducing excessive repetitive loading of the:

Wrist extensor origin.

Ergonomics

Patients performing repetitive occupational activity may benefit from:

Ergonomic assessment

and modification of their:

Workstation or tools.

This is particularly relevant for patients with prolonged:

Computer

Manual

or

Repetitive hand use.

Athletic Technique

Tennis players should be assessed for:

Racket grip size

Backhand technique

Racket weight

String tension

and training:

Volume.

Epidemiology

Lateral epicondylosis affects:

Men and women approximately equally.

Incidence

Peak incidence occurs during approximately the:

Fifth decade of life.

Lifetime Occurrence

Approximately:

1–3% of the population

develop lateral epicondylosis at some point.

Risk Factors

The condition is associated with activities involving repetitive:

Forearm pronation

Supination

Wrist extension

and

Gripping.

Elbow Position

Repetitive forearm rotation performed with the elbow near:

Full extension

may increase loading at the:

Common extensor origin.

Sports

Associated athletic activities include:

Tennis

Other racket sports

and

Fencing.

Occupational Activities

Occupations and activities associated with repetitive upper-extremity use include:

Plumbing

Painting

Knitting

Dentistry

and prolonged:

Computer work.

Tennis-Specific Factors

Potential contributing factors include:

Poor stroke mechanics

Incorrect racket grip size

Excessive racket weight

and inappropriate:

String tension.

Playing Surface

Harder court surfaces may increase force transmission through the:

Racket

and upper extremity, potentially increasing stress at the:

Lateral epicondyle.

Etiology

The disorder usually begins as repetitive microscopic injury to the:

ECRB origin.

Microtrauma

Repeated loading may produce:

Microscopic tendon tearing

that exceeds the tendon’s ability to:

Repair itself.

Other Involved Tendons

The:

Extensor carpi radialis longus

and

Extensor digitorum communis

may occasionally also demonstrate:

Degenerative involvement.

Failed Tendon Healing

An inadequate healing response leaves the tendon susceptible to repeated:

Microtrauma

and progressive:

Tendinosis.

Pathophysiology

The process is characterized more by:

Collagen degeneration

than by acute:

Inflammation.

This explains why the term:

Lateral epicondylosis

is often considered more pathologically accurate than “epicondylitis.”

Diagnosis

Diagnosis is usually:

Clinical.

The combination of characteristic:

Lateral elbow tenderness

and pain with resisted:

Wrist extension

is strongly suggestive.

Signs and Symptoms

Patients typically report a history of:

Repetitive upper-extremity activity.

Pain Location

Pain is centered around the:

Lateral epicondyle

and may radiate a short distance distally along the:

Proximal extensor muscle mass.

Activity-Related Pain

Symptoms generally worsen with:

Activity

and improve with:

Rest.

Gripping Pain

Patients commonly report pain while:

Gripping objects

Lifting a cup

Shaking hands

or

Carrying objects.

Resisted Wrist Extension

Pain is reproduced when the patient extends the wrist against:

Resistance.

Symptoms are often more pronounced when the elbow is:

Extended.

Range of Motion

Elbow range of motion is generally:

Preserved.

Loss of motion should raise concern for:

Alternative or additional pathology.

Physical Examination

The most characteristic finding is localized tenderness over the:

Common extensor origin

at or just distal to the:

Lateral epicondyle.

Distal Tenderness

Tenderness may extend several centimeters distally over the:

ECRB region.

Resisted Wrist Extension Test

The examiner stabilizes the forearm while the patient attempts:

Wrist extension against resistance.

Reproduction of lateral elbow pain supports the diagnosis.

Passive Wrist Flexion

Passive flexion of the wrist with the elbow:

Extended

stretches the common extensor origin and may reproduce:

Pain.

Grip Testing

Painful or reduced:

Grip strength

may be present because gripping requires stabilization by the:

Wrist extensors.

Radial Tunnel Examination

The clinician should evaluate for:

Radial tunnel syndrome.

Resisted Middle-Finger Extension

Pain reproduced with resisted:

Middle-finger extension

may suggest involvement of the:

Radial tunnel or posterior interosseous nerve region.

This finding should be interpreted with the remainder of the:

Clinical examination.

Cervical Spine Examination

A cervical spine examination is appropriate, especially when symptoms are:

Bilateral

Atypical

or accompanied by:

Neck pain or neurologic findings.

Imaging

Plain Radiographs

AP and lateral radiographs of the elbow may be obtained to exclude:

Fracture

Arthritis