'Ii THORA<tIC PAIN

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ible 34.1 Thoracic back pain: diagnostic strategy model

Probability diagnosis

Musculoligamentous strains (mainly postural) vertebral dysfunction

Serious disorders not to be missed Cardiovascular

" myocardial infarction " dissecting aneurysm

'I" pulmonary infarction ".Neoplasia

• myeloma

• lung (with infiltration)

• metastatic disease Severe infections

" pleurisy

• infectious endocarditis

• osteomyelitis Pneumothorax Osteoporosis

J Pitfalls (often missed) 1... Angina

Gastrointestinal disorders

• oesophageal dysfunction

• peptic ulcer (penetrating)

• hepatobiliary

• pancreatic Herpes zoster

~ Spondyloarthropathies Fibromyalgia syndrome Polyrnyalgia rheumatica Chronic infection

• tuberculOSis

• brucellosis

O. Seven masquerades checklist

A.. DepreSSion I

Diabetes \

Drugs

A.naemia

ThyrOid disease

Spinal dysfunction

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~ulte possible with many cases of back pam.

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Table 34.2 Non-musculoskeletal causes t thoracic back pain

Heart • myocardial infarction

angina

• pericarditis

Great vessels • dissecting aneurysm

• pulmonary embolism (rare)

• pulmonary infarction

• pneumothorax

• pneumonia/pleurisy

• oesophageal rupture

• oesophageal spasm

• oesophagitis

• gall bladder

• stomach } including

duodenum ulcers

• pancreas

• subphrenic collection

Oesophagus

Subdiaphragmatic disorders of

Miscellaneous infections

• herpes zoster

• Boorholm disease

• infective endocarditis

Psychogenic

Thoracic Pain

Key facts and checkpoints

• The commonest site of pain in the spine is the costovertebral articulations especially the costotransverse articulation.

• Pain of thoracic spinal origin may be referred anywhere to the chest wall, but the commonest sites are the scapular region, the paravertebral region 2 - 5 em from the midline and, anteriorly, over the costochondral region.

• Thoracic (also known as dorsal) pain is more common in patients with abnormalities such as excessive kyphosis and Scheurmann's disorder.

~ • Trauma to the chest wall (including falls on the chest such as those experienced in body contact

sport) commonly lead to disorders ofthe thoracic spine.

• Unlike the lumbar spine the joints are quite superficial and it is relatively easy to find the affected painful segment.

• Intervertebral disc prolapse is very uncommon in the thoracic spine

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

• If the chest pain is non-cardiac then the possibility of referral from the thoracic spine should be considered.

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

• Scheuermann's disorder, which affects the lower thoracic spine in adolescents is often associated with exaggerated kyphosis and recurrent thoracic back pain.

• Palpation is the most important component of the physical examination.

Features of the history that give an indication that the pain is arising from dysfunction of the thoracic spine include:

• Aggravation and relief of pain on trunk rotation

The patients pain may be increased by rotation (twisting) towards the side of the pain but eased by rotating in the opposite direction.

• Aggravation by coughing, sneezing or deep inspiration:

This can produce a sharp catching pain which, if severe, tends to implicate the costovertebraljoint.

• Relief of pain by firm pressure:

Patients may state that their pain is eased by firm pressure such as leaning against the comer of a wall.

Typical profile of dysfunction of the thoracic spine

Age Any age, especially between 20 and 40
History of injury Sometimes slow or sudden onset
Site and radiation Spinal and paraspinal
- e.g. interscapular, arms, lateral chest, anterior chest, substernal, iliac
crest
Type of pain Dull, aching, occasionally sharp;
severity related to activity, site and posture
Aggravation Deep inspiration
Postural movement of the thorax
Slumping or bending
Walking upstairs
Activities (e.g. lifting children, making beds)
Beds too hard or too soft
Sleeping or sitting for long periods
Association Chronic poor posture
Diagnosis confirmation Examination of the spine 322 PART 3 PROBLEM SOLVING IN GENERAL PRACTICE

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referral to upper thorax from lower cervical spine

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Fi g. 34.2 Examples of reterral patterns for {he thoracic spine

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~ Scheuermann's disorder

Scheuermann first described the radiographic changes of anterior wedging and vertebral end-plate irregularities in the thoracic spine associated with kyphosis. The disease is also known as vertebral osteochondritis, and osteochondritis deformans juvenile dorsi. Disc material herniated into the vertebral bodies (Schmorls nodes) is a common associated finding.

Cause - unknown

Pathology

Bones ossify from three centres: primary centre in the middle of the vertebra, and two secondary centres on the upper and lower surfaces of the vertebral body. The latter centres are known as the "ring epiphyses", which appear around puberty in the cartilaginous end-plates that separate the vertebral bodies from the disc.

Scheuennanns disease, is the disturbance of normal development of the cartilage plates and ring epiphyses resulting in disc content bursting through cartilage into the vertebral body.

Changes occur at the anterior margins of the vertebral body where the most weight is placed. The disc becomes narrowed and through deficient growth of the effected part of the ring epiphyses the vertebral body becomes wedge shaped - kyphosis. Osteoarthritis develops in later life.

Clinical features

• Age 11-17

• Males> females

• Lower thoracic spine

;) • Thoracic pain or asymptomatic

• Increasing thoracic kyphosis over 1 - 2 months

• Wedging of the vertebrae

• Pain in the wedge, especially on bending

• Short hamstrings

• Cannot touch toes

• Diagnosis confirmed by x-ray

Treatment

• Exercises to strengthen the posterior spinal muscles

• Brace to support spine in extension if necessary

Calves Vertebral Compression

Calves disease affects the central bony nucleus of a vertebral body and is generally confined to a single vertebra. It is uncommon.

Pathology

In a typical case, the bony nucleus of the vertebral bodies, usually in the thoracic region, becomes soft and is condensed into a thin wafer. Later, the bone may re-develop surprisingly well, but unlikely to regain it's full height. The intervertebral discs above and below are intact.

It is thought that in most cases, Calves vertebral compression is associated with eosinophilic granuloma (brownish granulation tissue containing abundant histiocytes and eosinophils with leucocytes and giant cells).

Clinical features

• Usually children 2 - 10 years of age

• Pain, usually in the thoracic region

• Slight localised kyphosis

• Deep local tenderness over affected area

• Little impairment of ROM

Natural History

This condition is non progressive

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Adolescent idiopathic scoliosis

• A degree of scoliosis is detectable in 5 % of the adolescent population' .

• The vast majority of curves, occurring equally in boys and girls, are mild and of no consequence.

• Eighty-five percent of significant curves in adolescent scoliosis occur in girls 2.

• Inheritance is a factor. The highest incidence is in first degree female relatives (12%). The scoliotic deformity develops at 10 years of age.

• Such curves appear during the peripubertal period, usually coinciding with the growth spurt.

• The screening test (usually in 12 - 14 year oIds) is to note the contour of the back on forward flexion.

Management

Aims

• To preserve good appearance -level shoulders and no trunk shift

• To prevent increasing curve in adult life: less than 45°.

• Not to produce a straight spine on x-ray

Method

• Braces: Milwaukee brace (rarely used)

High density Polyethylene underarm orthosis to be worn for 20 - 22 hours each day until skeletal maturity is reached

~ • Surgical correction: depends on the curve and skeletal maturity

References

1. Stephens, J. Idiopathic adolescent scoliosis. Aust Fam Physician, 1984, 13: 180 - 184

2. Kane, WJ and Moe, JH. A scoliosis prevalence survey in Minnesota. Clin Orthop, 1970,69: 216 -218

Guidelines for treatment

S till growing:

< 20 0 observe (repeat

examination and x-ray) 20 - 30 0 observe, brace if progressive

30 - 45 0 brace

>45-50 0 operate

Growth complete:

< 45 0 leave alone

> 45 0 operate

Referral to consultant:

top of vertebra at top end of

bottom of vertebra at lower end of curve

Fig. 34.7 Scoliosis: the Cobb method of curve measurement

> 200