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.

• 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.

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