The spine is an ordered series of bones running down your back. You sit on one end of it, sometimes too hard with ill effect, and your head sits on the other. Poor spine—what a load.
ANON, 19TH CENTURY
Spinal or vertebral dysfunction can be regarded as a masquerade mainly because the importance of the spine as a source of various pain syndromes has not been emphasised in medical training. Practitioners whose training and treatment are focused almost totally on the spine may swing to the other extreme and some may attribute almost every clinical syndrome to dysfunction of spinal segments. The true picture lies somewhere in between.
The diagnosis is straightforward when the patient is able to give a history of a precipitating event such as lifting, twisting the neck or having a motor vehicle accident, and can then localise the pain to the midline of the neck or back. The diagnostic problem arises when the pain is located distally to its source, whether it is radicular (due to pressure on a nerve root) or referred pain. The problem applies particularly to pain in anterior structures of the body.
If a patient has pain anywhere it is possible that it could be spondylogenic and practitioners should always keep this in mind.
The various syndromes caused by spinal dysfunction will be presented in more detail under neck pain, thoracic back pain and lumbar back pain.
Cervical spinal dysfunction1
The cervical spine is the origin of many confusing clinical problems and syndromes.
Clinical problems of cervical spinal origin
Pain originating from disorders of the cervical spine is usually, although not always, experienced in the neck. The patient may experience headache, or pain around the ear, face, arm, shoulder, upper anterior or posterior chest.2
arm pain (referred or radicular)
myelopathy (sensory and motor changes in arms and legs)
ipsilateral sensory changes of scalp
ear pain (peri-auricular)
anterior chest pain
FIGURE 24.1 indicates typical directions of referred pain from the cervical spine. Pain in the arm (brachialgia) is common and tends to cover the shoulder and upper arm as indicated.
Possible directions of referred pain from the cervical spine
If the cervical spine is overlooked as a source of pain (such as in the head, shoulder, arm, upper chest—anterior and posterior—and around the ear or face) the cause of the symptoms will remain masked and mismanagement will follow.
Dysfunction of the cervical spine can cause many unusual symptoms such as headache and vertigo, a fact that is often not recognised. Despite teaching to the contrary from some, the cervical spine is a common cause of headache, especially dysfunction of the facet joints at the C1–2 and C2–3 levels. The afferent pathways from these levels share a common pathway in the brain stem as the trigeminal nerve, hence the tendency for pain to be referred to the head and the face (see CHAPTER 52).
Manipulation of the cervical spine can be a dramatically effective technique, but it should be used with care and never used in the presence of organic disease and vertebrobasilar insufficiency. It should, therefore, be given only by skilled therapists. Two groups at special risk from quadriplegia are those with rheumatoid arthritis of the neck and Down syndrome, because of the instability of the odontoid process.
However, good results can be achieved by gentler techniques, such as mobilisation and muscle energy therapy (refer CHAPTER 62).
Thoracic spinal dysfunction
The most common and difficult masquerades related to spinal dysfunction occur with disorders of the thoracic spine (and also the low cervical spine), which can cause vague aches and pains in the chest, including the anterior chest. This applies particularly to unilateral pain.
Pain in the thoracic spine with referral to various parts of the chest wall and upper abdomen is common in all ages and can closely mimic the symptoms of visceral disease, such as angina pectoris and biliary colic (TABLE 24.1). If a non-cardiac cause of chest pain is excluded, then the possibility of referral from the thoracic spine should be considered in the differential diagnosis.3 People of all ages can experience thoracic problems and it is surprisingly common in young people, including children.
Table 24.1Conditions mimicked by thoracic spinal dysfunction (usually unilateral pain) ||Download (.pdf) Table 24.1 Conditions mimicked by thoracic spinal dysfunction (usually unilateral pain)
|Acute coronary syndromes |
|Dissecting aneurysm |
|Carcinoma lung, esp. mesothelioma |
|Pulmonary infarction |
|Fractured rib, esp. cough fracture |
|Renal colic |
|Urinary infection/pyelonephritis |
|Biliary colic |
|Herpes zoster |
|Epidemic pleurodynia (Bornholm disease) |
|Precordial catch (stitch in side) |
|Hernia (symptomatic) |
|Muscular tears |
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 (see FIG. 24.2).
Examples of referral patterns for the thoracic spine
Thoracic pain of lower cervical origin4
The clinical association between injury to the lower cervical region and upper thoracic pain is well known, especially with ‘whiplash’ injuries. It should be noted that the C4 dermatome is in close proximity to the T2 dermatome.
The T2 dermatome appears to represent the cutaneous areas of the lower cervical segments, as the posterior primary rami of C5, C6, C7, C8 and T1 innervate musculature and have no significant cutaneous innervation.
The pain from the lower cervical spine can also refer pain to the anterior chest, and mimic coronary ischaemic pain. The associated autonomic nervous system disturbance can cause considerable confusion in making the diagnosis.
The medical profession tends to have a blind spot about various pain syndromes in the chest, especially the anterior chest and upper abdomen, caused by the common problem of dysfunction of the thoracic spine. Doctors who gain this insight are amazed at how often they diagnose the cause that previously did not enter their ‘programmed’ medical minds.
Physical therapy to the spine can be very effective when used appropriately. An example of this therapy is shown in FIGURE 37.8 in CHAPTER 37, and for the lumbar spine refer to FIGURES 38.15 and 38.16 in CHAPTER 38. Unfortunately, many of us associate it with quackery. It is devastating for patients to create doubts in their minds about having a ‘heart problem’ or an ‘anxiety neurosis’ when the problem is spinal and it can be remedied simply (see CHAPTER 38).
Spinal manipulation of mid-thoracic spine in patient with no ‘red flags’ or serious disease
Lumbar-sacral spinal dysfunction
The association between lumbar dysfunction and pain syndromes is generally easier to correlate. The pain is usually located in the low back and referred to the buttocks or the backs of the lower limbs. Pain manifestations of radiculopathy (sciatica) may follow dermatome patterns (see FIG. 66.1 in CHAPTER 66). Problems arise with referred pain to the pelvic area, groin and anterior aspects of the leg. Such patients may be diagnosed as suffering from inguinal or obturator hernial and nerve entrapment syndromes.
Typical examples of referral and radicular pain patterns from various segments of the spine are presented in FIGURE 24.3.
Examples of referred and radicular pain patterns from the spine (one side shown for each segment)
Management of lumbar spinal dysfunction5
This is best managed conservatively under medical supervision with collaboration between the general practitioner and skilled physiotherapist. The patient should continue their normal activities even if uncomfortable, avoid painful aggravating activities, and take basic analgesics such as paracetamol and ibuprofen. Evidence supports the value of prescribed exercises and physical interventions such as traction and spinal mobilisation or manipulation for persistent pain (refer CHAPTERS 37 and 38).