THORACIC SPINE Non-musculoskeletal causes of thoracic back pain are: Heart - myocardial infarction, angina, pericarditis Great vessels - dissecting aneurysm, pulmonary embolism, pulmonary infarction, pneumothorax, pneumonia, pleurisy Esophagus - esophageal rupture, esophageal spasm, esophagitis Subdiaphragmatic disorders - gall bladder, stomach, duodenum, pancreas, subphrenic collection Infections - herpes zoster, Bornholm's disease, infective endocarditis Those that should be carefully considered are myocardial infarction and dissecting aneurysm. Investigations for acute infections should be considered for those patients presenting with poor general health and fever. ) Symptoms and signs that should alert the clinician to malignant disease are: Back pain in an older person Unrelenting back pain, unrelieved by rest Night pain Rapidly increasing back pain Constitutional symptoms such as weight loss, fever, malaise History of cancer Two commonly misdiagnosed problems are penetrating duodenal ulcer presenting with lower thoracic pain, and esophageal spasm, which can cause thoracic back pain. Pain from the thoracic spine originates mainly from the zygapophyseal joints and rib articulations. Any one thoracic vertebra has ten separate articulations, so the potential for dysfunction is understandable. Pain of musculoskeletal origin in the upper costochondral region can arise from four sources: 1. it may be referred 2. be due to polyarthritis 3. post traumatic Section 16 Page 1
4. Tietze's syndrome The most common cause is referred pain from thoracic or cervical joint dysfunctions. Inflammatory arthritis, such as rheumatoid arthritis or spondyloarthritis, may produce pain in the synovial sternocostal joint. Pain, associated with some degree of prominence of one or two costochondral joints, may occur after a fit of coughing or local trauma. referral ta upper thorax from lower cervical spine same segmental - J------1>referral anterior abdominal referral three segments distal referral / The upper seven ribs articulate anteriorly with the sternum through their costal cartilages. The costochondral junction forms a fibrocartilaginous joint in which the ribs and cartilages are slotted together. With the exception of the first rib, these costal cartilages also articulate with the sternum through a synovial sternocostal joint. The 8th,_9th and 10th ribs articulate through their costal cartilage with the rib above it, but the last two ribs are unattached. Section 16 Page 2
Pain in the lower costochondral region of the 8th, 9th or 10th ribs may be referred pain from thoracic joint dysfunction. Pain may also arise from either direct or indirect trauma and produce a painful clicking of the costochondral junction. This condition is known as slipping or clicking rib. It produces a sharp stabbing or dull aching pain, localized in the epigastrium or hypochondrium, which is worse with movement. Dysfunction of the joints of the thoracic spine, with its unique costovertebral joints, can cause referred pain to various parts of the chest wall and can mimic symptoms of visceral disease such as angina, biliary colic and esophageal spasm. The most common sites of chest wall referral are the scapular region, the paravertebral region, and anteriorly over the costochondral junctions. Patients recovering from open heart surgery, where a longitudinal incision is made and the chest wall stretched out, commonly experience thoracic back pain. costotransverse articulation facet joint / The gliding plane between the scapula and thorax, lined by thin muscles, is necessary for normal scapular movement. With snapping scapula, the patient, who is usually young, presents with pain along the medial scapular border that is associated with a loud cracking or snapping sound as the scapula is abducted. The T4 syndrome can cause vague pain in the upper limbs and diffuse, vague head and posterior neck pain. One or more levels between T2 and T7 maybe affected, but the T4 level is nearly always involved. Disc protrusion in the thoracic spine is uncommon. The common presentation is back pain and radicular pain, which follows the appropriate dermatome. Thoracic disc lesions can produce spinal cord compression manifesting as sensory loss (e.g., paresthesia of the feet), loss of bladder control, and signs of upper motor neuron lesion (e.g., spastic gait, hyper-reflexia). Section 16 Page 3
An1erior longitudinal ligament ----+-.- m>.,,-- lntertransverse ligament Radiate ligament _,_"'"""t"- 'ffr-...,_ Superior costotransverse ligament -':jot-- Costotransverse articular capsule Without thoracic spine extensibility the more mobile spinal areas above and below the dysfunctional area, and the attached limbs are unable to achieve full mobility. The corner-wall stretch incorporates pectoral stretching, postural alignment axially and thoracic spine stretching. The sternum is moved towards the corner while forward head posture and increased lumbar lordosis are avoided. ) Joint Dysfunction Synovial joint dysfunction is indicated by stiffness or tightness of the joints. The patient will pull or tug on the upper thoracic spinous processes. Connective tissue joint dysfunction is indicated by a deep ache in the spine, in the mid-upper back and near the vertebral border of the scapula, or tightness in the upper ribs. If the patient reaches over his shoulder and tugs up on the midposterior ribs with his fingers this also suggests a connective tissue joint dysfunction. Section 16 Page 4
Palpation of the thoracic spine for joint dysfunction entails testing for joint play and tenderness by pressure against the side of the spinous process, springing the spinous process, pressure over the facet joints and costovertebral joints, and springing of the ribs. In palpating the first rib, the bulk of the trapezius should be raised posteriorly to enable access to the anterior and posterior upper borders as well as the angle. Enthesopathy Enthesis disruptions are indicated by spots of pain over the thoracic spinous processes, ribs or scapula. Enthesopathies along the upper part of the medial border of the scapula is called scapulocostal tendinitis. Superficial fascia! disruption Indicated by diffuse pain or spasm in the thoracic region. There may be a diffuse numbness as well. The patient will squeeze the area of involvement. Myofascial bands The patient will complain of a pulling or burning pain along the band. The most common is the interscapular band starting at T6 and traveling to the ipsilateral mastoid. The patient will indicate the location of the band by a sweeping motion of the fingers. / Herniated trigger points Numerous muscles affect the back. pain include: Scalenes Levator scapulae Trapezius Multifidus Those muscles causing upper thoracic back Muscles causing midthoracic back pain include: Scalenes lliocostalis thoracis Multifidus Rhomboids Serratus posterior superior lnfraspinatus Trapezius Serratus anterior Levator scapulae Muscles capable of causing low thoracic back pain include: lliocostalis thoracis Multifidus Serratus posterior inferior Rectus abdominis Section 16 Page 5
:: j. ::.& /1 ) Rhomboids Trapezius To examine the trigger point of the serratus posterior superior muscle, the scapula must be abducted. The patient sits and leans forward with the arm on the side to be examined placed in the opposite axilla. The muscle is palpated through the trapezius and rhomboid muscles. References / Travell JG, Simons DG. Myofascial Pain and Dysfunction. The Trigger Point Manual. Williams & Wilkins, Baltimore; 1982: 618, 650. Corrigan B, Maitland GD. Practical Orthopaedic Medicine. Butterworth Heinemann, Oxford; 1993: 384-385. Grieve GP. Ed. Modern Manual Therapy of the Vertebral Column. Churchill Livingstone, New York; 1986: 370, 543, 714. Murtagh JE, Kenna CT. Back Pain & Spinal Manipulation. 2nd ed. Butterworth Heinemann, Oxford; 1997: 212, 271. Murtagh J. General Practice. McGraw-Hill Book Co, Sydney; 1994: 279-282, 289. Section 16 Page6