Thoracic Pain Flashcards
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
1
2
3`
scapular region,
the paravertebral region 2–5 cm from midline and, anteriorly, over the costochondral region
Thoracic (also known as dorsal) pain is more
common in patients with abnormalities such as
______ and _______
kyphosis and Scheuermann disease
T or F
Intervertebral disc prolapse is very uncommon in
the thoracic spine
T
T or F
The older patient presenting with chest pain should
be regarded as having a cardiac cause until
proved otherwise
T
The______ is the commonest site in the
vertebral column for metastatic disease.
thoracic spine
________ which affects the lower
thoracic spine in adolescents, is often associated with
kyphosis and recurrent thoracic back pain
Scheuermann disease,
The commonest cause of thoracic back pain is
musculoskeletal, due usually to ______
musculoligamentous strains caused by poor posture
Problems of the thoracic spine usually occur at the?
lower cervical and thoracic spinal joints, especially those of the midthoracic (interscapular) area.
The various systemic infectious diseases such
as _______ and _________can
certainly cause diffuse backache
influenza and Epstein–Barr mononucleosis
Acute infections should be suspected in the following conditions
young patients_______
farm workers_______ and
migrants from South-East Asia and third world countries _______
(osteomyelitis),
(brucellosis)
(tuberculosis).
The three common primary malignancies that
metastasise to the spine are those originating in the
1
2
3
lung, breast and the prostate (all paired structures
Less common primaries that mets to the spine
thyroid,
the kidney and adrenals and malignant melanoma
Primary malignancies that develop in the
vertebrae include ___ and_____
multiple myeloma and sarcoma.
An _____ and _____ of the thoracic spine
should be the initial screening test in the presence of
these red flags
ESR and a plain X-ray
A common trap for the thoracic spine is lung cancer,
such as _______ which can invade parietal pleura
or structures adjacent to the vertebral column
mesothelioma,
Two commonly misdiagnosed problems
are a________ presenting with
lower thoracic pain and ______, which
can cause thoracic back pain
penetrating duodenal ulcer
oesophageal spasm
Inflammatory rheumatological problems are not
common in the thoracic spine but occasionally a
spondyloarthropathy such as_______
manifests here
ankylosing spondylitis
the strongest evidence indicates that pain from the
thoracic spine originates mainly from the ____ and _____
apophyseal
joints and rib articulations
The costovertebral joints are synovial joints unique
to the thoracic spine and have two articulations—
_____ and ______
costotransverse and costocentral
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.
T4 syndrome
most of the pain, stiffness and
discomfort arise from dysfunction of the upper and
middle thoracic segments with patients presenting
with the complaint of ______
pain between ‘my shoulder
blades’.
The unique feature of the thoracic spine is the
_____
costovertebral joint
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
3–4 cm
Characteristics of pain which is thoracic in origin
1
2
3
Aggravation and relief of pain on trunk rotation
Aggravation of pain by coughing, sneezing or deep
inspiration.
Relief of pain by firm pressure
The younger person in particular should be
screened for _____ which becomes
more prominent on forward flexion
scoliosis
A useful sign of scoliosis is _____
unequal
shoulder levels and apparent ‘winging’ of scapula
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)
spinous processes
apophyseal joints (2–3 cm from midline)
on side of spinous processes
costotransverse junctions (4–5 cm from midline)
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.
rotation,
Main investigation in thoracic pain?
The main investigation is an X-ray, which may
exclude the basic abnormalities and diseases, such as
osteoporosis and malignanc
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
‘postural backache’,
Inflammatory disorders to consider are_______ and _______ which may affect adolescent
males in the lower thoracic spine (around T9) and
thoracolumbar spine.
juvenile
ankylosing spondylitis and spinal osteochondritis
(Scheuermann disease),
can be associated with back
pain, especially as the patient grows older. It is the
commonest cause of kyphosis
(Scheuermann disease
______ is the normal curve of the thoracic spine
when viewed from the side. The normal range is
20–45 °
Kyphosis
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
Scheuermann
ankylosing spondylitis—and osteoporosis i
This is a structural saggital plane deformity of
unknown cause affecting the T7, 8, 9 or T11, 12 areas.
Scheuermann disease
Xray findings of Scheuermann disease
Diagnosis confirmed by X-ray (lateral
standing)—shows Schmorl node and anterior
vertebral body wedging
Exercises for Scheuermann disease
extension
A degree of scoliosis is detectable in____ of the
adolescent population
5%
_____ of significant
curves in adolescent scoliosis occur in girls.
Eighty-five per cent
T or F
The routine physical screening check
of an adolescent should include dx of scoliosis
T
Aims of Mx in Scoliosis
1
2
3
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
Rarely used brace for scolio
Milwaukee brace (rarely used)
How is the brace used
high-density polyethylene underarm orthosis
— to be worn for 20–22 hours each day until
skeletal maturity is reached
Guidelines for scoliosis surgery in patients who are still growing
• Still growing: <20 º observe (repeat examination + X-ray) 20–30 º observe, brace if progressive 30–45 º brace ≥ 45–50 º operate
Guidelines for scoliosis surgery in patients whos growth are complete
Growth complete:
<45 º leave alone
>45 º operate
Referral to consultant: >20
Dysfunction of the thoracic spine is also known as
thoracic
hypomobility syndrome
Mx of thoracic hypomobility syndrome
______ is helpful but the more forceful
______ produces better and quicker
results
Spinal mobilisation
manipulative therapy
Spinal mobilisation and manipulation
The ______ technique is widely used for upper thoracic segments and the ________ (patient prone) or posteroanterior indirect thrust
sternal thrust (Nelson hold)
crossed pisiform technique
There is _______ evidence that spinal
manipulation is effective compared with placebo
level II
Most disc
protrusions occur below_____, with the commonest site,
as expected, being ______
T9
T11–12.
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
Thoracic disc protrusion
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 _______
transthoracic lateral approach
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
Syrinx
A syrinx
usually begins at the ____ level and extends down
cervical
Muscle injury is due to_____, ______, _____
can cause pain.
injury of intercostal muscles, the serratus anterior and the
musculotendinous origins of the abdominal muscles
Several muscles including the _____, ______, ____
help stabilise scapular movement and may be a source
of pain in the scapular region.
rhomboids, serratus anterior and levator scapulae
The patient complains of a loud cracking or snapping
sound upon abduction of the scapula. There is often
associated crepitus. What condition?
Snapping scapula
CAuse of snapping scapula
bony spur on the superior
border of the scapula or an osteoma
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
Scapulocostal syndrome
Causes of Scapulocostal syndrome
friction between the scapula and
the thoracic wall, scoliosis, trauma and myofascial
strain due to poor posture
Common cause of winging of the scapula
The
common cause is neurogenic paralysis of the serratus
anterior muscle
_________ 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.
Fibromyalgia
Cause of fibrositis
It
is probably almost always secondary to upper thoracic
or lower cervical spinal dysfunction
Other features/association of fibromyalgia 1 2 3 4
• Poor sleep pattern
• Dermatographia
• Fatigue (similar to chronic fatigue syndrome)
• Psychological disorders (e.g. anxiety, depression,
tension headache, irritable digestive system
Thoracic back pain is frequently associated with
_______lesions
cervical
Upper thoracic pain and stiffness is common after
_____
‘whiplash
Symptoms due to a fractured vertebra usually last
_______
3 months and to a fractured rib 6 weeks
Consider multiple myeloma as a cause of an
________
osteoporotic collapsed vertebra
