Spinal dysfunction

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 dysfunction 1

The cervical spine is the origin of many confusing clinical problems such as headache, migraine-like headache, arm pain, facial pain, periauricular pain, anterior chest pain and even visual dysfunction and dizziness. 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 lecturers, 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 ( click here for further reference).

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.

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.

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. 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. People of all ages can experience thoracic problems and it is surprisingly common in young people, including children. 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.

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