Anatomical and clinical features

The functional unit of the thoracic spine is illustrated in Figure 34.1 . It appears that pain from the thoracic spine originates mainly from the apophyseal joints and rib articulations. Any one thoracic vertebra has ten 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 34.2 , while the dermatome pattern is outlined in Figure 34.3 .

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.

Fig. 34.3 Dermatomes for the thoracic nerve roots, indicating possible referral areas REPRODUCED FROM C. KENNA AND J. MURTAGH, BACK PAIN AND SPINAL MANIPULATION

(2ND EDITION), BUTTERWORTH-HEINEMANN, OXFORD, 1997, WITH PERMISSION

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