Thoracic Pain

Question 1

The commonest site of pain in the spine is
the costovertebral articulations especially the
______

Answer 1

costotransverse articulation

Question 2

Pain of thoracic spinal origin may be referred
anywhere to the chest wall, but the commonest sites
are the

1
2
3`

Answer 2

scapular region,

the paravertebral region 2–5 cm from midline and, anteriorly, over the costochondral region

Question 3

Thoracic (also known as dorsal) pain is more
common in patients with abnormalities such as
______ and _______

Answer 3

kyphosis and Scheuermann disease

Question 4

T or F

Intervertebral disc prolapse is very uncommon in
the thoracic spine

Answer 4

T

Question 5

T or F

The older patient presenting with chest pain should
be regarded as having a cardiac cause until
proved otherwise

Answer 5

T

Question 6

The______ is the commonest site in the

vertebral column for metastatic disease.

Answer 6

thoracic spine

Question 7

________ which affects the lower
thoracic spine in adolescents, is often associated with
kyphosis and recurrent thoracic back pain

Answer 7

Scheuermann disease,

Question 8

The commonest cause of thoracic back pain is

musculoskeletal, due usually to ______

Answer 8

musculoligamentous strains caused by poor posture

Question 9

Problems of the thoracic spine usually occur at the?

Answer 9

lower cervical and thoracic spinal joints, especially those of the midthoracic (interscapular) area.

Question 10

The various systemic infectious diseases such
as _______ and _________can
certainly cause diffuse backache

Answer 10

influenza and Epstein–Barr mononucleosis

Question 11

Acute infections should be suspected in the following conditions

young patients_______
farm workers_______ and

migrants from South-East Asia and third world countries _______

Answer 11

(osteomyelitis),

(brucellosis)

(tuberculosis).

Question 12

The three common primary malignancies that
metastasise to the spine are those originating in the
1
2
3

Answer 12

lung, breast and the prostate (all paired structures

Question 13

Less common primaries that mets to the spine

Answer 13

thyroid,

the kidney and adrenals and malignant melanoma

Question 14

Primary malignancies that develop in the

vertebrae include ___ and_____

Answer 14

multiple myeloma and sarcoma.

Question 15

An _____ and _____ of the thoracic spine
should be the initial screening test in the presence of
these red flags

Answer 15

ESR and a plain X-ray

Question 16

A common trap for the thoracic spine is lung cancer,
such as _______ which can invade parietal pleura
or structures adjacent to the vertebral column

Answer 16

mesothelioma,

Question 17

Two commonly misdiagnosed problems
are a________ presenting with
lower thoracic pain and ______, which
can cause thoracic back pain

Answer 17

penetrating duodenal ulcer

oesophageal spasm

Question 18

Inflammatory rheumatological problems are not
common in the thoracic spine but occasionally a
spondyloarthropathy such as_______
manifests here

Answer 18

ankylosing spondylitis

Question 19

the strongest evidence indicates that pain from the

thoracic spine originates mainly from the ____ and _____

Answer 19

apophyseal

joints and rib articulations

Question 20

The costovertebral joints are synovial joints unique
to the thoracic spine and have two articulations—
_____ and ______

Answer 20

costotransverse and costocentral

Question 21

A specific syndrome called the_______ has
been shown to cause vague pain and paraesthesia in
the upper limbs and diffuse, vague head and posterior
neck pain.

Answer 21

T4 syndrome

Question 22

most of the pain, stiffness and
discomfort arise from dysfunction of the upper and
middle thoracic segments with patients presenting
with the complaint of ______

Answer 22

pain between ‘my shoulder

blades’.

Question 23

The unique feature of the thoracic spine is the

_____

Answer 23

costovertebral joint

Question 24

Dysfunction of the costo-vertebral joint
commonly causes localised pain approximately
______ from the midline where the rib articulates
with the transverse process and the vertebral

Answer 24

3–4 cm

Question 25

Characteristics of pain which is thoracic in origin 1 2 3

Answer 25

Aggravation and relief of pain on trunk rotation Aggravation of pain by coughing, sneezing or deep inspiration. Relief of pain by firm pressure

Question 26

The younger person in particular should be screened for _____ which becomes more prominent on forward flexion

Answer 26

scoliosis

Question 27

A useful sign of scoliosis is _____

Answer 27

unequal | shoulder levels and apparent ‘winging’ of scapula

Question 28

Sequence of Palpation to reporduce patients' pain: 1 central—over _______ 2 unilateral—over_____ 3 transverse—_______ 4 unilateral—_____ 5 unilateral—over ribs (spring over posterior rib curve with ulnar border of hand, along axis of rib)

Answer 28

spinous processes apophyseal joints (2–3 cm from midline) on side of spinous processes costotransverse junctions (4–5 cm from midline)

Question 29

There are four main movements of the thoracic spine to assess, the most important of which is __________as this is the movement that so frequently reproduces the patient’s pain where it is facet joint or costovertebral in origin.

Answer 29

rotation,

Question 30

Main investigation in thoracic pain?

Answer 30

The main investigation is an X-ray, which may exclude the basic abnormalities and diseases, such as osteoporosis and malignanc

Question 31

The most common cause of thoracic back pain in children is ______ also known as ‘TV backache’, which is usually found in adolescent schoolgirls and is a diagnosis of exclusion

Answer 31

‘postural backache’,

Question 32

Inflammatory disorders to consider are_______ and _______ which may affect adolescent males in the lower thoracic spine (around T9) and thoracolumbar spine.

Answer 32

juvenile ankylosing spondylitis and spinal osteochondritis (Scheuermann disease),

Question 33

can be associated with back pain, especially as the patient grows older. It is the commonest cause of kyphosis

Answer 33

(Scheuermann disease

Question 34

______ is the normal curve of the thoracic spine when viewed from the side. The normal range is 20–45 °

Answer 34

Kyphosis

Question 35

In children a congenital cause of Kyphosis is likely (present from infancy); in adolescents it is usually due to ______ disease or is postural; in adults consider ______ and ______n the elderly

Answer 35

Scheuermann ankylosing spondylitis—and osteoporosis i

Question 36

This is a structural saggital plane deformity of | unknown cause affecting the T7, 8, 9 or T11, 12 areas.

Answer 36

Scheuermann disease

Question 37

Xray findings of Scheuermann disease

Answer 37

Diagnosis confirmed by X-ray (lateral standing)—shows Schmorl node and anterior vertebral body wedging

Question 38

Exercises for Scheuermann disease

Answer 38

extension

Question 39

A degree of scoliosis is detectable in____ of the | adolescent population

Answer 39

5%

Question 40

_____ of significant | curves in adolescent scoliosis occur in girls.

Answer 40

Eighty-five per cent

Question 41

T or F The routine physical screening check of an adolescent should include dx of scoliosis

Answer 41

T

Question 42

Aims of Mx in Scoliosis 1 2 3

Answer 42

Aims • To preserve good appearance—level shoulders and no trunk shift • Prevent increasing curve in adult life: less than 45 º • Not to produce a straight spine on X-ray

Question 43

Rarely used brace for scolio

Answer 43

Milwaukee brace (rarely used)

Question 44

How is the brace used

Answer 44

high-density polyethylene underarm orthosis — to be worn for 20–22 hours each day until skeletal maturity is reached

Question 45

Guidelines for scoliosis surgery in patients who are still growing

Answer 45

``` • Still growing: <20 º observe (repeat examination + X-ray) 20–30 º observe, brace if progressive 30–45 º brace ≥ 45–50 º operate ```

Question 46

Guidelines for scoliosis surgery in patients whos growth are complete

Answer 46

Growth complete: <45 º leave alone >45 º operate Referral to consultant: >20

Question 47

Dysfunction of the thoracic spine is also known as

Answer 47

thoracic | hypomobility syndrome

Question 48

Mx of thoracic hypomobility syndrome ______ is helpful but the more forceful ______ produces better and quicker results

Answer 48

Spinal mobilisation manipulative therapy

Question 49

Spinal mobilisation and manipulation The ______ technique is widely used for upper thoracic segments and the ________ (patient prone) or posteroanterior indirect thrust

Answer 49

sternal thrust (Nelson hold) crossed pisiform technique

Question 50

There is _______ evidence that spinal | manipulation is effective compared with placebo

Answer 50

level II

Question 51

Most disc protrusions occur below_____, with the commonest site, as expected, being ______

Answer 51

T9 T11–12.

Question 52

What condition? The common presentation is back pain and radicular pain that follows the appropriate dermatome so disc protrusion should be considered in patients with neurological signs at thoracic levels. This may include a flaccid area of the lower abdominal musculature

Answer 52

Thoracic disc protrusion

Question 53

The disc is relatively inaccessible to surgical intervention, but over the past decade there has been a significant improvement in the surgical treatment of thoracic disc protrusions, due to the _______

Answer 53

transthoracic lateral approach

Question 54

It is a rare, fluid-filled neurological cavity within the spinal cord. It is usually a congenital anomaly, but a neoplasm needs to be excluded

Answer 54

Syrinx

Question 55

A syrinx | usually begins at the ____ level and extends down

Answer 55

cervical

Question 56

Muscle injury is due to_____, ______, _____ | can cause pain.

Answer 56

injury of intercostal muscles, the serratus anterior and the | musculotendinous origins of the abdominal muscles

Question 57

Several muscles including the _____, ______, ____ help stabilise scapular movement and may be a source of pain in the scapular region.

Answer 57

rhomboids, serratus anterior and levator scapulae

Question 58

The patient complains of a loud cracking or snapping sound upon abduction of the scapula. There is often associated crepitus. What condition?

Answer 58

Snapping scapula

Question 59

CAuse of snapping scapula

Answer 59

bony spur on the superior | border of the scapula or an osteoma

Question 60

This condition causes localised pain and tenderness, often severe, along the upper part of the medial scapular border, with radiation around the chest wall and shoulder girdle to the neck

Answer 60

Scapulocostal syndrome

Question 61

Causes of Scapulocostal syndrome

Answer 61

friction between the scapula and the thoracic wall, scoliosis, trauma and myofascial strain due to poor posture

Question 62

Common cause of winging of the scapula

Answer 62

The common cause is neurogenic paralysis of the serratus anterior muscle

Question 63

_________ is relatively uncommon but when encountered presents an enormous management problem. It is not to be confused with so-called fibrositis or tender trigger points.

Answer 63

Fibromyalgia

Question 64

Cause of fibrositis

Answer 64

It is probably almost always secondary to upper thoracic or lower cervical spinal dysfunction

Question 65

``` Other features/association of fibromyalgia 1 2 3 4 ```

Answer 65

• Poor sleep pattern • Dermatographia • Fatigue (similar to chronic fatigue syndrome) • Psychological disorders (e.g. anxiety, depression, tension headache, irritable digestive system

Question 66

Thoracic back pain is frequently associated with | _______lesions

Answer 66

cervical

Question 67

Upper thoracic pain and stiffness is common after | _____

Answer 67

‘whiplash

Question 68

Symptoms due to a fractured vertebra usually last | _______

Answer 68

3 months and to a fractured rib 6 weeks

Question 69

Consider multiple myeloma as a cause of an | ________

Answer 69

osteoporotic collapsed vertebra