Thoracic spine

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The presenting symptoms of pathology in the thoracic spine are usually localised spinal pain (see Disorders box) or pain radiating round the chest wall or, less frequently, symptoms of paraparesis including sensory loss, leg weakness, and loss of bladder or bowel control. Disc lesions are rare and may be accompanied by girdle pain radiating around the chest, mimicking cardiac or pleural disease. Pain arising from joints at the thoracolumbar junction can occur in ankylosing spondylitis and again may be confused with pulmonary, renal or cardiac problems. The patient with osteoporosis may complain of becoming progressively stooped (Dowager hump) with loss of height but without neurological features. Acute osteoporotic and malignant vertebral collapse are common causes of acute thoracic pain, and the latter is not infrequently associated with spinal cord compression.

With acute pain, infection should also he considered, especially when pain is associated with systemic upset or fever. When thoracic pain is poorly localised and no satisfactory explanation can be found, intrathoracic causes such as aortic aneurysm should also be considered.


Causes of pain in the thoracic spire

Adofescenfs and young adults m Scheuermann's disease

• Ankylosing spondylitis

Middle age and elderly

• Degenerative change

• Osteoporotic fracture

Any age m Tumour

Lumbar spine

Back pain is an almost ubiquitous cxpcriencc and most adults will have experienced it by the time they are middle-aged. An important objective of the history is to distinguish those patients who have significant spinal pathology from those who do not. The important spinal conditions to be identified include acute disc protrusion, spinal stenosis, ankylosing spondylitis, osteoporotic fracture, infection, and tumours. Infection and tumours arc likely to be associated with symptoms of ill health such as weight loss or fever. Abdominal and retroperitoneal pathology should also be considered. In the majority of patients, however, backache is either a manifestation of poor posture, or age-related degenerative changes in discs and facet joints (spondylosis), or a presenting symplom of psychosocial distress.

A common complaint is of low back pain after standing for too long, or sitting in a poor position. The symptoms tend to be worse as the day progresses and better after resting or on rising in the morning. This pattern is usually due to poor posture and related ligament stresses. Sometimes contributory factors such as inequality of leg length or psychosocial problems can be identified. In the latter case, there is often no clear pattern to the reported pain, and the possibility of mood disturbance should be considered.

In contrast, the insidious onset of backache and stiffness in a young adult suggests inflammatory disease such as ankylosing spondylitis. The symptoms are usually worse in the morning or after inactivity and ease with movement. Morning stiffness is more marked than in osteoarthritis, lasting 30-60 minutes. Often there are Other clues to the diagnosis, such as involvement of peripheral joints, non articular features such as iritis, or a family history of spondylarthritis.

Acute onset of tow back pain, in a young adult, usually associated with bending or lifting, is the typical presentation of acute disc protrusion. Sudden movement, such as coughing, will exacerbate the pain. In addition, there may or may not be symptoms of compression of lumbar or sacral nerve roots (cauda equina syndrome). If sacral nerve roots arc involved, there may be loss of sphincter control and perianal sensation. The acute episode may be superimposed on a background of preceding mild episodic-backache due to disc degeneration. Acute back pain in the middle-aged, elderly or those with predisposing factors such as steroid therapy, may be due to osteoporotic fracture. The pain of this type of fracture is cased by lying, exacerbated by spinal flexion and is not associated with neurological symptoms.

An acute onset of severe progressive pain, especially if associated with systemic features such as malaise, weight loss or night sweats usually indicates pyogenic or tuberculous infection of the lumbar spine. The patient will report great difficulty in moving the spine. The infection may involve both the intervertebral discs and adjacent vertebrae, and at times may track into the sheath of the psoas muscle presenting as a painful flexed hip or as a swelling in the groin. In patients reporting unremitting spinal pain of recent onset, often with sleep disturbance, malignant disease involving a vertebral body should be considered. There may be other clues such as previous history of carcinoma, systemic symptoms or weight loss. Tumours rarely affect intervertebral discs.

Intermittent discomfort or pain in the lumbar spine occurring over a long period of time are the typical symptoms of degenerative disc disease. There is stiffness in the morning or after immobility. The pain and stiffness are relieved by gentle activity but recur with or after excessive activity. Over years or decades there is gradual loss of mobility of the lumbar spine, sometimes with spontaneous improvement in the pain as the facet joints become increasingly stiff,

Diffuse pain in the buttocks or thighs brought on by standing loo long or walking is the presenting symptom of lumbosacral spinal stenosis, which can be difficult to distinguish from intermittent claudication (p. 108), Sometimes the pain is accompanied by tingling and numbness and can be difficult for the patient to describe. Typically the pain is relieved by rest or flexion of the spine. Stooping, or holding onto a supermarket trolley, may increase exercise tolerance. Narrowing of the spinal canal or neural exit foraminae, is usually caused by degenerative changes in the intervertebral discs and facet joints, and there is often a long preceding history of discomfort typical of degenerative joint disease.

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