Chapter 37

### Introduction

The maladies that afflict the clerks aforesaid arise from three causes; first constant sitting, secondly the incessant movement of the hand and always in the same direction, and thirdly the strain on the midline from the effort not to disfigure the books by error or cause loss to their employers.

The physician Ramazzini 1713

Thoracic (dorsal) back pain is common in people of all ages, including children and adolescents. It accounts for 10–15% of all spinal pain. Dysfunction of the joints of the thoracic spine, with its unique costovertebral joints (which are an important source of back pain), is very commonly encountered in medical practice, especially in people whose lifestyle creates stresses and strains through poor posture and heavy lifting. Muscular and ligamentous strains may be common, but they rarely come to light in practice because they are self-limiting and not severe.

This dysfunction can cause referred pain to various parts of the chest wall and can mimic the symptoms of various visceral diseases, such as angina, biliary colic and oesophageal spasm. In similar fashion, heart and gall bladder pain can mimic spinal pain.

Key facts and checkpoints

• The commonest site of pain in the spine is the costovertebral articulations especially the costotransverse articulation (see FIG. 37.1).

• 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 cm from midline and, anteriorly, over the costochondral region.

• Thoracic (also known as dorsal) pain is more common in patients with abnormalities such as kyphosis and Scheuermann disease.

• Trauma to the chest wall (including falls on the chest such as those experienced in body contact sport) commonly lead to disorders of the 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 disease, which affects the lower thoracic spine in adolescents, is often associated with kyphosis and recurrent thoracic back pain. Always inspect the thoracic spine of the younger patient for kyphosis and scoliosis, ideally at 9 years of age.

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

###### FIGURE 37.1

The functional unit of the thoracic spine

### A diagnostic approach

A summary of the diagnostic strategy model is presented in Table 37.1.

Table 37.1

Thoracic back pain: diagnostic strategy model

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