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 34.4 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 34.4 represent those areas where the patient experiences pain following the injection of hypertonic saline into the posterior elements of the spine.
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