Chapter 37: Thoracic back pain

Thoracic (dorsal) or upper back pain, which is defined as pain localised between the neck and above the costal margin, is common in people of all ages. It accounts for 10–15% of all spinal pain and has a 1-year prevalence in 20% of adults. 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. It is also referred to as non-specific thoracic spinal pain. 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.

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

Probability diagnosis

The commonest cause of thoracic back pain is musculoskeletal, due usually to musculoligamentous strains caused by poor posture. However, these pains are usually transitory and present rarely to the practitioner. The problems that commonly present are those caused by dysfunction of the lower cervical and thoracic spinal joints, especially those of the mid-thoracic (interscapular) area.

Arthritic conditions of the thoracic spine are not relatively common although degenerative osteoarthritis is encountered at times; the inflammatory spondyloarthropathies are uncommon.

The various systemic infectious diseases such as influenza and Epstein–Barr mononucleosis can certainly cause diffuse backache but should be assessed in context.

Not to be missed

A special problem with the thoracic spine is its relationship with the many thoracic and upper abdominal structures that can refer pain to the back. These structures are listed in TABLE 37.2 but, in particular, myocardial infarction and dissecting aneurysm must be considered. A complex problem described by neurosurgeons is the patient presenting with severe sudden thoracic back pain caused by an epidural haematoma related to aspirin or warfarin therapy.

Cardiopulmonary problems

The acute onset of pain can have sinister implications in the thoracic spine where various life-threatening cardiopulmonary and vascular events have to be kept in mind. The pulmonary causes of acute pain include spontaneous pneumothorax, pleurisy and pulmonary infarction. Thoracic back pain may be associated with infective endocarditis due to embolic phenomena. The ubiquitous myocardial infarction or acute coronary occlusion may, uncommonly, cause interscapular back pain, while the very painful dissecting or ruptured aortic aneurysm may cause back pain with hypotension.

Osteoporosis

Osteoporosis, especially in people over 60 years, including both men and women, must always be considered in such people presenting with acute pain, which can be caused by a pathological fracture. The association with pain following inappropriate physical therapy such as spinal manipulation should also be considered.

Acute infections

Infective conditions that can involve the spine include osteomyelitis, tuberculosis, brucellosis, syphilis and Salmonella infections. Such conditions should be suspected in young patients (osteomyelitis), farm workers (brucellosis) and migrants from South-East Asia and third world countries (tuberculosis). The presence of poor general health and fever necessitates investigations for these infections.

Neoplasia

Fortunately, tumours of the spine are uncommon. Nevertheless, they occur frequently enough for the full-time practitioner in back disorders to encounter some each year, especially metastatic disease.

The three common primary malignancies that metastasise to the spine are those originating in the lung, breast and the prostate (all paired structures). The less common primaries to consider are the thyroid, the kidney and adrenals and malignant melanoma.

Reticuloses such as Hodgkin lymphoma can involve the spine. Primary malignancies that develop in the vertebrae include multiple myeloma and sarcoma.

Benign tumours to consider are often neurological in origin. An interesting tumour is the osteoid osteoma, which is aggravated by consuming alcohol and relieved by aspirin.

The tumours of the spine are summarised in TABLE 37.3.

The symptoms and signs that should alert the clinician to malignant disease are:

• back pain occurring in an older person

• unrelenting back pain, unrelieved by rest (this includes night pain)

• rapidly increasing back pain

• constitutional symptoms (e.g. unexplained weight loss, fever, malaise)

• a history of treatment for cancer (e.g. excision of skin melanoma)

FBE, ESR, CRP and a plain X-ray of the thoracic spine should be the initial screening test in the presence of these pointers.

A common trap for the thoracic spine is lung cancer, such as mesothelioma, which can invade parietal pleura or structures adjacent to the vertebral column.

Pitfalls

Pitfalls include ischaemic heart disease presenting with interscapular pain, herpes zoster at the pre-eruption stage and the various gastrointestinal disorders. Two commonly misdiagnosed problems are a penetrating duodenal ulcer presenting with lower thoracic pain and oesophageal spasm, which can cause thoracic back pain.

Inflammatory rheumatological problems are not common in the thoracic spine but occasionally a spondyloarthropathy such as ankylosing spondylitis manifests here, although it follows some time after the onset of sacroiliitis.

Seven masquerades checklist

Spinal dysfunction is the outstanding cause in this checklist, but urinary tract infection may occasionally cause lower thoracic pain. Depression always warrants consideration in any pain syndrome, especially back pain. It can certainly cause exaggeration of pre-existing pain from vertebral dysfunction or some other chronic problem.

Psychogenic considerations

Psychogenic or non-organic causes of back pain can present a complex dilemma in diagnosis and management. The causes may be apparent from the incongruous behaviour and personality of the patient, but often the diagnosis is reached by a process of exclusion. There is obviously some functional overlay in everyone with acute or chronic pain, hence the importance of appropriate reassurance to these patients that their problem invariably subsides with time and that they do not have cancer.

The functional unit of the thoracic spine is illustrated in FIGURE 37.1. Although there is scant literature and evidence about the origins of pain in the thoracic spine,³ the strongest evidence indicates that pain from the thoracic spine originates mainly from the apophyseal joints and rib articulations. Any one thoracic vertebra has 10 separate articulations, so the potential for dysfunction and the difficulty in clinically pinpointing the precise joint at a particular level are apparent.

The costovertebral joints are synovial joints unique to the thoracic spine and have two articulations— costotransverse and costocentral. Together with the apophyseal joints, they are capable of presenting with well-localised pain close to the midline or as referred pain, often quite distal to the spine, with the major symptoms not appearing to have any relationship to the thoracic spine.

Generalised referral patterns are presented in FIGURE 24.2 (see CHAPTER 24), while the dermatome pattern is outlined in FIGURE 37.2.

The pain pattern acts as a guide only because there is considerable dermatomal overlap within the individual and variation from one person to another. It has been demonstrated that up to five nerve roots may contribute to the innervation of any one point in the anterior segments of the trunk dermatomes, a fact emphasised by the clinical distribution of herpes zoster.

Upper thoracic pain¹

Dysfunction of the joints of the upper thoracic spine usually gives rise to localised pain and stiffness posteriorly but also can cause distal symptoms, probably via the autonomic nervous system.

A specific syndrome called the T4 syndrome⁴ has been shown to cause vague pain and paraesthesia in the upper limbs and diffuse, vague head and posterior neck pain. Examination may reveal hypomobility of the upper thoracic segments. It has been proven to respond to spinal manipulation, which restores full mobility.

However, 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’.

Costovertebral joint dysfunction¹

The unique feature of the thoracic spine is the costovertebral joint. Dysfunction of this joint commonly causes localised pain approximately 3–4 cm from the midline where the rib articulates with the transverse process and the vertebral body. In addition, it is frequently responsible for referred pain ranging from the midline, posterior to the lateral chest wall, and even anterior chest pain.

When the symptoms radiate laterally, the diagnosis is confirmed only when movement of the rib provokes pain at the costovertebral joint. This examination will simultaneously reproduce the referred pain.

FIGURE 37.3 presents the pattern of referred pain from these joints and highlights the capacity of the thoracic spine to refer pain centrally to the anterior chest and upper abdomen. Confusion arises for the clinician when the patient’s history focuses on the anterior chest pain and fails to mention the presence of posterior pain, should it be present. The shaded areas on FIGURE 37.3 represent those areas where the patient experiences pain following the injection of hypertonic saline into the posterior elements of the spine.

History

The history of a patient presenting with thoracic back pain should include a routine pain analysis, which usually provides important clues for the diagnosis. The age, sex and occupation of the patient are relevant. Pain in the thoracic area is very common in people who sit bent over for long periods, especially working at desks. Students, secretaries and stenographers are therefore at risk, as are nursing mothers, who have to lift their babies.

People who are kyphotic or scoliotic or who have ‘hunchbacks’ secondary to disease such as tuberculosis and poliomyelitis also suffer from recurrent pain in this area.

Older people are more likely to present with a neoplastic problem in the thoracic spine and with osteoporosis. Senile osteoporosis is usually a trap because it is symptomless until the intervention of a compression fracture. Symptoms following such a fracture can persist for 3 months.

Pain that is present day and night indicates a sinister cause.

Features of the history that give an indication that the pain is arising from dysfunction of the thoracic spine include:

• Aggravation and relief of pain on trunk rotation. The patient’s pain may be increased by rotating (twisting) towards the side of the pain but eased by rotating in the opposite direction.

• Aggravation of pain by coughing, sneezing or deep inspiration. This can produce a sharp catching pain which, if severe, tends to implicate the costovertebral joint. Care must be taken to rule out pneumonia and pleurisy.

• Relief of pain by firm pressure. Patients may state that their back pain is eased by firm pressure such as leaning against the corner of a wall.

It is very important to be able to differentiate between chest pain due to vertebral dysfunction and that caused by myocardial ischaemia.

Key questions

• Can you recall injuring your back, such as by lifting something heavy?

• Did you have a fall onto your chest or back?

• Is the pain present during the night?

• Do you have low back pain or neck pain?

• Does the pain come on after walking or any strenuous effort?

• Does the pain come on after eating or soon after going to bed at night?

• Have you noticed a fever or sweating at any time, especially at night?

• Have you noticed a rash near where you have the pain?

• What drugs are you taking? Do you take drugs for arthritis or pain? Cortisone?

• What happens when you take a deep breath, cough or sneeze?

Examination

The examination of the thoracic spine is straightforward with the emphasis on palpation of the spine—central and laterally. This achieves the basic objective of reproducing the patient’s symptoms and finding the level of pain. The ‘LOOK, FEEL, MOVE, X-RAY’ clinical approach is most appropriate for the thoracic spine.

Inspection

Careful inspection, especially of posture, is important since it may be possible to observe at a glance why the patient has thoracic pain. Note the symmetry, any scars, skin creases and deformities, ‘flat spots’ in the spine, the nature of the scapulae or evidence of muscle spasm. Look for kyphosis and scoliosis.

Kyphosis may be generalised, with the back having a smooth uniform contour, or localised where it is due to a collapsed vertebra, such as occurs in an older person with osteoporosis. Generalised kyphosis is common in the elderly, especially those with degenerative spinal disease. In the young it may reflect the important Scheuermann disease.

The younger person in particular should be screened for scoliosis (see FIG. 37.4), which becomes more prominent on forward flexion (see FIG. 37.6). Look for any asymmetry of the chest wall, inequality of the scapulae and differences in the levels of the shoulders. A useful sign of scoliosis is unequal shoulder levels and apparent ‘winging’ of scapula. When viewed anteriorly a difference in the levels of the nipples indicates the presence of scoliosis, or other problems causing one shoulder to drop. Inspection should therefore take place with posterior, lateral (side) and anterior views. For acute pain, check the skin for evidence of herpes zoster (rash or scars).

Palpation²

The best position is to have the patient prone on the examination table with the thoracic spine preferably in slight flexion. This is achieved by lowering the top of the table.

Test passive extension of each joint with firm pressure from the pad of the thumbs or the bony hand (either the pisiform prominence or the lateral border of the fifth metacarpal). Spring up and down with a few firm oscillations, keeping the elbows straight, but being well above the patient. Ask the patient if the pressure reproduces the pain.

Apart from asking the patient ‘Is that the pain?’ note:

• the distribution of pain and its change with movement

• the range of movement

• the type of resistance in the joint

• any muscle spasm

Palpation must follow a set plan in order to reproduce the patient’s pain. The sequence is as follows:

1. central—over spinous processes

2. unilateral—over apophyseal joints (2–3 cm from midline)

3. transverse—on side of spinous processes

4. unilateral—costotransverse junctions (4–5 cm from midline)

5. unilateral—over ribs (spring over posterior rib curve with ulnar border of hand, along axis of rib)

Movements

There are four main movements of the thoracic spine to assess, the most important of which is rotation, as this is the movement that so frequently reproduces the patient’s pain where it is facet joint or costovertebral in origin.

The movements of the thoracic spine and their normal ranges are:

Ask the patient to sit on the table with hands placed behind the neck and then perform the movements. Check these four active movements, noting any hypomobility, the range of movement, reproduction of symptoms and function and muscle spasm.

Neurological examination

This includes sensory testing for altered sensation in a dermatomal distribution.

Investigations

The plain X-ray and MRI scan is of no utility in patients with non-specific back pain but has a place in the presence of red flags, where the MRI is most appropriate to investigate suspected serious pathology. A plain X-ray may exclude basic bony abnormalities and diseases, such as osteoporosis and malignancy. CT scanning has a minimal role in the evaluation of thoracic spinal pain.

Other investigations to consider are:

• FBE and ESR/CRP

• serum alkaline phosphatase

• serum electrophoresis for multiple myeloma

• Bence–Jones protein analysis

• Brucella agglutination test

• blood culture for pyogenic infection and bacterial endocarditis

• tuberculosis studies

• HLA-B₂₇ antigen for spondyloarthropathies

• ECG or ECG stress tests (suspected angina)

• gastroscopy or barium studies (peptic ulcer)

• MRI scanning if myelopathy is suspected

• radionuclide bone scan if neoplastic or metabolic disease is suspected

The most common cause of thoracic back pain in children is ‘postural backache’, also known as ‘TV backache’, which is usually found in adolescent schoolgirls and is a diagnosis of exclusion.

Important, although rare, problems in children include infections (tuberculosis, discitis and osteomyelitis) and tumours such as osteoid osteoma and malignant osteogenic sarcoma.

Dysfunction of the joints of the thoracic spine in children and particularly in adolescents is very common and often related to trauma such as a heavy fall in sporting activities or falling from a height (e.g. off a horse). Fractures, of course, have to be excluded.

Inflammatory disorders to consider are juvenile ankylosing spondylitis and spinal osteochondrosis (Scheuermann disease), which may affect adolescent males in the lower thoracic spine (around T9) and thoracolumbar spine. The latter condition may be asymptomatic, but can be associated with back pain, especially as the patient grows older. It is the commonest cause of kyphosis.

It is important to screen adolescent children for idiopathic scoliosis, which may be without associated backache.

Kyphosis⁵

Kyphosis is the normal curve of the thoracic spine when viewed from the side. The normal range is 20–45° (see FIG. 37.5). An excessive angle (>45–50°) occurs with a kyphotic deformity. In children a congenital cause is likely (present from infancy); in adolescents it is usually due to Scheuermann disease or is postural; in adults consider ankylosing spondylitis—and osteoporosis in the elderly. Tuberculosis of the spine can cause a gross deformity. Children with significant kyphosis should be referred for management which includes exercises, bracing or surgery.

Scheuermann disease

This is a structural saggital plane deformity of unknown cause affecting the T7, 8, 9 or T11, 12 areas.

Clinical features

• Age 11–17 years

• Males > females

• Lower thoracic spine

• Thoracic pain or asymptomatic

• Increasing thoracic kyphosis over 1–2 months

• Wedging of the vertebrae

• Pain in the wedge, especially on bending (only 20% present with pain)

• Short hamstrings

• Cannot touch toes

• Diagnosis confirmed by X-ray (lateral standing)— shows Schmorl node and anterior vertebral body wedging

Treatment

• Explanation and support

• Extension exercises, avoid forward flexion

• Postural correction

• Avoidance of sports involving lifting and bending

• Consider bracing or surgery if serious deformity

• If detected early hyperextension body casts followed by a Milwaukee brace can prevent deformity

Adolescent idiopathic scoliosis

A degree of scoliosis is detectable in 5% of the adolescent population.⁶ The vast majority of curves, occurring equally in boys and girls, are mild and of no consequence. Eighty-five per cent of significant curves in adolescent scoliosis occur in girls.⁶ Inheritance is a factor. The highest incidence is in first-degree female relatives (12%). The scoliotic deformity develops at 10 years of age. Such curves appear during the peripubertal period, usually coinciding with the growth spurt. The screening test (usually in 12–14 year olds but ideally as early as 9) is to note the contour of the back on forward flexion (see FIG. 37.6). The routine physical screening check of an adolescent should include this area.

The test

The subject stands with the feet parallel and together, and bends forward as far as possible with outstretched hands, palms facing each other, pointed between the great toes.

Investigation

A single erect PA spinal X-ray is sufficient;⁷ the Cobb angle (see FIG. 37.7) is the usual measurement yardstick.

Management

Aims

• To preserve good appearance—level shoulders and no trunk shift

• Prevent increasing curve in adult life: less than 45º

• Not to produce a straight spine on X-ray

Methods

• Braces:

  • – Milwaukee brace (rarely used)

  • – high-density polyethylene underarm orthosis

  • – to be worn for 20–22 hours each day until skeletal maturity is reached.

• Surgical correction: depends on curve and skeletal maturity

Guidelines for treatment

• Still growing:

  Table Graphic Jump Location

  Favorite Table | Download (.pdf) | Print

  <20º	observe (repeat examination + X-ray)
  20–30º	observe, brace if progressive
  30–45º	brace
  ≥45–50º	operate

• Growth complete:

  Table Graphic Jump Location

  Favorite Table | Download (.pdf) | Print

  <45º	leave alone
  >45º	operate

  Referral to consultant: >20º

Elderly patients: thoracic back pain due to mechanical causes is not such a feature in the elderly, although vertebral dysfunction still occurs quite regularly. However, when the elderly person presents with thoracic pain, a very careful search for organic disease is necessary. Special problems to consider are:

• malignant disease (e.g. multiple myeloma, lung, prostate)

• osteoporosis

• vertebral pathological fractures

• polymyalgia rheumatica

• Paget disease (may be asymptomatic)

• herpes zoster

• visceral disorders: ischaemic heart disease, penetrating peptic ulcer, oesophageal disorders, biliary disorders

Dysfunction of the thoracic spine

Also referred to as non-specific thoracic back pain, this is the outstanding cause of pain in adulthood presenting to the practitioner and is relatively easy to diagnose. It is often referred to as the thoracic hypomobility syndrome with the disorder arising in the facet joints, costovertebral joints and thoracic musculoligamentous structure, singularly or in combination. The most efficacious treatment for painful dysfunctional problems varies according to practitioners with a special interest in this area. There is a paucity of studies and evidence supporting the multiplicity of therapies, especially focal injections and physical therapy. Many claim and bear testimony that appropriate skilled mobilisation and manipulation therapy provides effective short-term, sometimes immediate, relief.⁸

Typical profile:²

Management

First-line management

• Explanation with printed information

• Reassurance, including spontaneous recovery likely

• Continued activity according to pain level

• Back education program

• Analgesics, if required (e.g. paracetamol 1 g (o) qid or 1.33g (o) 8-hourly), is first line

• Posture education and specific mobilising exercise program, esp. extension and rotation exercises to overcome stiffness

• Physical therapy: a short course of spinal mobilisation and manipulation (if appropriate) to help with pain and mobility

Spinal mobilisation and manipulation

Spinal mobilisation is helpful but the more forceful manipulative therapy (with extreme care) produces better and quicker results. There are many techniques that can be employed, the choice depending on which part of the back is affected.⁷ The sternal thrust (Nelson hold) technique is widely used for upper thoracic segments and the crossed pisiform technique (patient prone) or posteroanterior indirect thrust (patient supine—see FIG. 37.8) is claimed to be the most—effective for the mid-thoracic spine. There is level II evidence that spinal manipulation is effective compared with placebo.⁸

Thoracic disc protrusion

Fortunately, a disc protrusion in the thoracic spine is uncommon. This reduced incidence is related to the firm splintage action of the ribcage. Most disc protrusions occur below T9, with the commonest site, as expected, being T11–12.

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.

However, disc lesions in the thoracic spine are prone to produce spinal cord compression, manifesting as sensory loss, bladder incontinence and signs of upper motor neurone lesion. 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.

Syrinx

A syrinx usually comes to notice as a radiological finding in the presence of thoracic back pain when it may in fact be asymptomatic. 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. An MRI of the spinal cord defines the problem. Any symptoms usually appear between adolescence and age 50, due to a central cord syndrome (see CHAPTER 62). A syrinx usually begins at the cervical level and extends down. Treat conservatively, but refer to an expert, who may consider surgical intervention if it is symptomatic.

Muscular injuries such as tearing are uncommon in the chest wall. The strong paravertebral muscles do not appear to be a cause of chest pain, but strains of intercostal muscles, the serratus anterior and the musculotendinous origins of the abdominal muscles can cause pain. Injuries to these muscles can be provoked by attacks of violent sneezing or coughing or overstrain, e.g. lifting a heavy suitcase down from an overhead luggage rack.

The gliding plane between the scapula and thoracic wall permits a considerable range of scapular movement, which contributes significantly to movement of the shoulder. Several muscles, including the rhomboids, serratus anterior and levator scapulae, help stabilise scapular movement and may be a source of pain in the scapular region.

Snapping scapula

The patient complains of a loud cracking or snapping sound upon abduction of the scapula. There is often associated crepitus. Pain is felt along the medial scapular border. The patient may develop a habit (‘tic’) of neurotically clicking the shoulder back and forth.

On examination, there is usually generalised hypermobility of the scapula, abnormal movement and tenderness to palpation along the medial edge on full abduction.

The cause (uncommon) may be an underlying bony abnormality such as a bony spur on the superior border of the scapula or an osteoma. X-rays should include a lateral view of the scapula to search for this possibility.

Treatment

• Explanation and reassurance (if X-rays normal)— otherwise resect any bone abnormality.

• Avoid repeated scapular movement and ‘trick’ movements.

• Appropriate exercises under physiotherapy supervision.

• Infiltrate any very tender area in the muscle (with care) with local anaesthetic and steroid.

• Deep massage to the tender focus.

Scapulocostal syndrome

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. Pain is usually worse with prolonged shoulder use towards the end of the day. It is commonly seen in typists, gymnasts and other sportspeople. It is related to poor posture. The cause may include friction between the scapula and the thoracic wall, scoliosis, trauma and myofascial strain due to poor posture.

Treatment

• Avoid the movements producing the pain.

• Posture and re-education exercises and scapula stretching.

• Deep friction massage.

• Local injections of local anaesthetic and corticosteroid into the tender area.

Winging of the scapula

The asymmetry may not be apparent until the patient tries to contract the serratus anterior against resistance by pushing the outstretched arm against the wall. There may be parascapular discomfort. The common cause is neurogenic paralysis of the serratus anterior muscle. Paralysis may result from injury to the long thoracic nerve (from C5, 6, 7 nerve roots) such as a neck injury or a direct blow to the suprascapular area and from injury to the brachial plexus such as excessive carrying of heavy packs, severe traction on the arm or forceful cervical manipulation. Most cases settle spontaneously, although it may take 1–2 years.

Fibromyalgia is relatively uncommon, but when encountered it presents an enormous management problem. It is not to be confused with so-called fibrositis or tender trigger points. Referral to a specialist with expertise in this condition or to a multidisciplinary pain clinic for the definitive diagnosis is recommended.

Fibrositis is not a diagnosis but a symptom, indicating a localised area of tenderness or pain in the soft tissues, especially of the upper thoracic spine. It is probably almost always secondary to upper thoracic or lower cervical spinal dysfunction.

Myofascial trigger points

As described by Travell and Rinzler,¹⁰ a trigger point is characterised by:

• circumscribed local tenderness

• localised twitching with stimulation of juxtaposed muscle

• pain referred elsewhere when subjected to pressure

Trigger spots also tend to correspond to the acupuncture points for pain relief.

Treatment¹¹

Local injection is relatively easy and may give excellent results. Identify the maximal point of pain and inject 5–8 mL of local anaesthetic (LA; e.g. lignocaine/lidocaine 1%) into the painful point (see FIG. 37.9). Post-injection massage or exercises should be performed.

Don’t:

• use large volumes of LA

• use corticosteroids

• cause bleeding

Do:

• use a moderate amount of LA (only)

Fibromyalgia syndrome¹²

AKA chronic diffuse non-inflammatory pain. Its pathophysiology is poorly understood.

Clinical features

The main diagnostic features are:

1. a history of widespread pain (neck to low back)

2. pain in 11 of 18 tender points on digital palpation

These points must be painful, not tender. Smythe and Moldofsky have recommended 14 of these points on a map as a guide for management¹² (see FIG. 37.10). No consistent measurable investigations have been identified.

Other features

• Female to male ratio = 4:1

• Usual age onset 29–37 years: diagnosis 44–53 years

• Poor sleep pattern

• Dermatographia

• Fatigue (similar to chronic fatigue syndrome)

• Psychological disorders (e.g. anxiety, depression, tension headache, irritable digestive system)

This disorder is very difficult to treat and is usually unresponsive in the long term to passive physical therapy or injections.¹³ Patients require considerable explanation, support and reassurance, including screening with ESR/CRP. Best evidence to date supports the value of educational programs and regular aerobic exercise.¹⁴ Consider referral to a specialist or fibromyalgia clinic.

Treatment

• Explanation, patient education, reassurance and counselling

• Attention to sleep disorders, stress factors and physical factors¹⁴

• Relaxation program

• Rehabilitation: graduated exercise program (e.g. walking, water exercises, swimming or cycling)

• Use paracetamol for first-line analgesia

• Carefully assess any change in the nature or pattern of symptoms

Medication (often disappointing but worth a trial)

Antidepressants (of proven short-term value);^15,16 start low then monthly increments as tolerated:

• amitriptyline 10–50 mg (o) nocte

• or

• dothiepin 25–75 mg (o) nocte

• or

• duloxetine 30 mg (o) mane, increasing to 60 mg over 2 weeks¹⁷

• Note: NSAIDs are of no proven benefit.

Diffuse idiopathic skeletal hyperostosis (DISH)

DISH is ligamentous ossification of the spine leading to progressive stiffness and possible pain in some parts. Possible associated metabolic disorder e.g. diabetes. Ankylosing spondylitis is a differential diagnosis.

There is no specific treatment. Manage as for spinal dysfunction.

The following points regarding serious vertebral organic disease are worth repeating in more detail.

Metastatic disease¹⁸

Secondary deposits in the thoracolumbar spine may be the first presenting symptoms of malignant disease. Any patient of any age presenting with progressive severe night pain of the back should be regarded as having a tumour and investigated with a technetium bone scan as part of the primary investigations.

Secondary deposits in the spine can lead to rapid onset paralysis due to spinal cord infarction. Many such metastases can be controlled in the early stages with radiotherapy.

Multiple myeloma

Osteoporotic vertebral body collapse should be diagnosed only when multiple myeloma has been excluded. Investigations should include an ESR, Bence–Jones protein analysis, and immunoglobulin electrophoresis.

Early treatment of multiple myeloma can hold this disease in remission for many years and prevent crippling vertebral fractures (see CHAPTER 26).

Infective discitis, vertebral osteomyelitis and epidural/subdural abscess

Severe back pain in an unwell patient with fluctuating temperature (fever) should be considered as infective until proved otherwise. Investigations should include blood cultures, serial X-rays and nuclear bone scanning. Biphasic bone scans using technetium with either indium or gallium scanning for white cell collections usually clinch this diagnosis.

Strict bed rest with high-dose antibiotic therapy is usually curative. If left untreated, vertebral end plate and disc space collapse is common and extremely disabling. Consider tuberculosis osteomyelitis in people at risk. Suspect an epidural abscess in the presence of persistent and increased back pain. Percuss the spine for localised tenderness (see CHAPTER 30).

• Persistent pain or dysfunction—refer to a physical therapist.

• Evidence or suspicion of a sinister cause (e.g. neoplasia, infective discitis/osteomyelitis in a child).

• Suspicion of cardiac or gastrointestinal referred (persistent) pain.

• Significant idiopathic adolescent scoliosis or kyphosis (e.g. Scheuermann disease).

Hand-out sheets from Murtagh’s Patient Education 7th edition:

• Exercises for your thoracic spine

• Fibromyalgia

• Scoliosis