Thoracic Spine Red Flags

Question 1

Visceral Referral Patterns

Pain in chest that is sudden onset, unrelenting, not relieved by position changes

that radiates to the back

Answer 1

Dissecting thoracic aneurysm

Dissecting Thoracici aneurysm w/ descending aorta invovlement

Question 2

Visceral Referral Patterns

Anterior chest pain or heaviness, nausea, pain radiating to the back

Answer 2

Myocardial ischemia

Question 3

Visceral Referral Patterns

Pain r/t exertion and relieved w/ rest

Answer 3

Stable angina

Question 4

Visceral Referral Patterns

Pain that occurs in random or unpredictable fashion and not r/t activity

Answer 4

Unstable angina

Question 5

Visceral Referral Patterns

• Boring pain from epigastric area to mid-thoracic spine
• thoracic pain triggered or relieved by eating
• h/o extensive NSAID use

Answer 5

Peptic Ulcer

Question 6

Visceral Referral Patterns

• Pain in RUQ and R infrascapular region, usually accompanied by fever, nausea, vomiting
• symptoms often occur 1-2 hours after heavy meal
• (+) Murphy sign: palpate R subcostal region and ask pt to take deep breath. Positive test is pain on inhalation

Answer 6

Cholecystitis (inflamed gallbladder)

Question 7

Visceral Referral Patterns

Pain around thoracolumbar region

Answer 7

Pancreatitis

Question 8

Visceral Referral Patterns

• pain around costobertebral angle or flank area
• usually accompanied by fever, nausea, vomiting, and renal colic
• renal colic is flank pain accompanied by lower abdominal pain that spreads into the labia in women and into the testicles in men
• Screen for recent or current UTI

Answer 8

Pyelonephritis (kidney infection) or kidney stones

Question 9

Serious Causes of Thoracic Pain

1. I….
2. F…..
3. N…..
4. ….. disorder

Answer 9

1. Infection
2. Fractures
3. Neoplasms
4. Inflammatory disorders

Question 10

Serious Causes of Thoracic Pain

Spinal metastases, usually secondary to primary __________, ____________, or ____________ CA are more common than primary thoracic tumors

Chance of thoracic pain being r/t CA is 0.66%

Answer 10

Breast, lung, or colon CA

Question 11

Serious Causes of Thoracic Pain

What are 3 common findings in thoracic spine tumors?

Answer 11

1. Painful scoliosis
2. Long-tract neurlogical signs
3. Leg pain

Question 12

What is the prediction rule for CA (4 things)?

Answer 12

1. age > 50
2. H/o CA
3. unexplained weight loss
4. Failure of conservative therapy

Question 13

Prediction Rule for Ankylosing Spondylitis (4 things)

Answer 13

1. Stiffness > 30 minutes duration
2. improvement in back pain w/ exercise, but not rest
3. awakening because of back pain during the second half of the night only
4. alternating buttock pain

3 variables present = sn 33%, sp 94%
2 variables present = sn 70%, sp 81%

Question 14

Clinical Findings for Ankylosing Spondyltitis (6 things)

Answer 14

1. limited chest expansion (KEY)
2. Sacroiliitis
3. Morning pain and stiffness
4. Peripheral joint involvement
5. 3:1 male:female, age of onset 15 - 40 y.o.
6. HLA-B27 positive (high false positive rate)

Question 15

Infection

• pretest probability of infection begin cause of back pain in general is 0.01%
• causes of throacic spine infection can be ___, ___________, and ___________
• __________ is hallmark sign

Answer 15

• causes of throacic spine infection can be osteomyelitis, diskitis, and epidural infections
• fever is hallmark sign

Question 16

CPR for Coronary Artery Disease

1. age/sex?
2. Known clinical vascular disease (i.e _____________)
3. Pain worse during __________
4. Pain not reproducable by _________________
5. Pt assumes pain is of _________ origin

Answer 16

1. femalr > 65 y.o.; male > 55y.o.
2. i.e. coronary artery, occlusive vascular, cerebrovascular diseases
3. pain worse during exercises
4. Pain not reproducable by palpation
5. Pt assumes pain is of cardiac origin

3 variables present = +LR 4.52
2 variables present = sn 98%