Back pain, thoracic

Question 1

Thoracic back pain, features

Answer 1

Common in people of all ages

mainly due to dysfunction of the joints of the thoracic spine, with its unique costovertebral joints.

Muscular and ligamentous strains may be common, but rarely come to light in practice because they are self-limiting and not severe.

This dysfunction can cause referred pain to various parts of the chest wall

can mimic the symptoms of various visceral diseases, such as angina, biliary colic and oesophageal spasm.

Intervertebral disc prolapse is very uncommon in the thoracic spine and then occurs below T9, usu. T11–12, but it is a target for bony metastases

Question 2

Probability diagnosis

Answer 2

Musculoligamentous strains (mainly postural)

Vertebral dysfunction

Question 3

Serious disorders not to be missed

Answer 3

Cardiovascular:

• myocardial infarction
• dissecting aneurysm
• pulmonary infarction
• epidural haematoma (blood-thinning agents)

Neoplasia/cancer:

• myeloma
• pancreas
• lung (with infiltration)
• metastatic disease (e.g. lung, breast)

Infection:

• epidural/subdural abscess
• infective discitis
• pleurisy
• infectious endocarditis
• osteomyelitis
• pyelonephritis

Other:

• pneumothorax
• osteoporosis

Question 4

Pitfalls (often missed)

Answer 4

Angina

Gastrointestinal disorders;

• oesophageal dysfunction
• peptic ulcer (penetrating)
• hepatobiliary
• pancreatic

Herpes zoster

Spondyloarthropathies

Costochondritis:

• Tietze syndrome

Fibromyalgia syndrome

Notalgia parasthetica

Polymyalgia rheumatica

Chronic infection:

• tuberculosis
• brucellosis

Question 5

Masquerades checklist

Answer 5

Depression

Spinal dysfunction

UTI

Question 6

Masquerades checklist

Answer 6

Depression

Spinal dysfunction

UTI

Question 7

Is the patient trying to tell me something?

Answer 7

Yes, quite possible with many cases of back pain.

Question 8

Key history

Answer 8

analysing pain characteristics to differentiate between chest pain due to vertebral dysfunction (musculoskeletal strain) and that caused by myocardial ischaemia.

Drug history, family history, and occupational hx

Questions about red flags that point to serious disease.

Question 9

Key examination

Answer 9

The LOOK, FEEL, MOVE, MEASURE clinical approach applies to the thoracic spine.

The emphasis is on palpation-central and laterally.

The movements and their normal ranges are:

• extension 30°
• lateral flexion (right and left) 30°
• flexion 90°
• rotation (right and left) 60°.

Question 10

Key investigations

Answer 10

FBE

ESR/CRP

alkaline phosphase

A plain X-ray is the main investigation, may exclude;

• the basic skeletal abnormalities
• diseases such as osteoporosis
• malignancy.

If normal and disease is suspected a radionucleide scan or MRI is advisable.

Question 11

Diagnostic tips

Answer 11

The commonest site of pain is the costovertebral articulations of the spine.

Pain may be referred anywhere to the chest wall.

The older pts should be regarded as having a cardiac cause until proved otherwise.

Pain is frequently associated with cervical lesions that refer to the upper back.

The thoracic spine is the commonest site in the vertebral column for metastatic disease.