Not to be missed

A special problem with the thoracic spine is its relationship with the many thoracic and upper abdominal structures that can refer pain to the back. These structures are listed in Table 34.2 but, in particular, myocardial infarction and dissecting aneurysm must be considered.

Table 34.2 Non-musculoskeletal causes of thoracic back pain

Heart

Great vessels

Oesophagus

Subdiaphragmatic disorders of

Miscellaneous infections

Psychogenic

• myocardial infarction

• pericarditis

• dissecting aneurysm

• pulmonary embolism (rare)

• pulmonary infarction

• pneumothorax

• pneumonia/pleurisy

• oesophageal rupture

• oesophageal spasm

• oesophagitis

• stomach (including ulcers)

• duodenum (including ulcers)

• subphrenic collection

herpes zoster

• Boorholm disease

• infective endocarditis

Cardiopulmonary problems

The acute onset of pain can have sinister implications in the thoracic spine where various life-threatening cardiopulmonary and vascular events have to be kept in mind. The pulmonary causes of acute pain include spontaneous pneumothorax, pleurisy and pulmonary infarction. Thoracic back pain may be associated with infective endocarditis due to embolic phenomena. The ubiquitous myocardial infarction or acute coronary occlusion may, uncommonly, cause interscapular back pain, while the very painful dissecting or ruptured aortic aneurysm may cause back pain with hypotension.

Osteoporosis

Osteoporosis, especially in elderly women, must always be considered in such people presenting with acute pain, which can be caused by a pathological fracture. The association with pain following inappropriate physical therapy such as spinal manipulation should also be considered.

Acute infections

Infective conditions that can involve the spine include osteomyelitis, tuberculosis, brucellosis, syphilis and salmonella infections. Such conditions should be suspected in young patients (osteomyelitis), farm workers (brucellosis) and migrants from South-East Asia and Third World countries (tuberculosis). The presence of poor general health and fever necessitates investigations for these infections.

Neoplasia

Fortunately, tumours of the spine are uncommon. Nevertheless, they occur frequently enough for the full-time practitioner in back disorders to encounter some each year, especially metastatic disease. The three common primary malignancies that metastasise to the spine are those originating in the lung, breast and the prostate (all paired structures). The less common primaries to consider are the thyroid, the kidney and adrenals and malignant melanoma.

Reticuloses such as Hodgkin's disease can involve the spine. Primary malignancies that arise in the vertebrae include multiple myeloma and sarcoma.

Benign tumours to consider are often neurological in origin. An interesting tumour is the osteoid osteoma, which is aggravated by consuming alcohol and relieved by aspirin.

The tumours of the spine are summarised in Table 34.3 .

The symptoms and signs that should alert the clinician to malignant disease are:

• back pain occurring in an older person

• unrelenting back pain, unrelieved by rest (this includes night pain)

• rapidly increasing back pain

• constitutional symptoms, e.g. weight loss, fever, malaise

• a history of treatment for cancer, e.g. excision of skin melanoma

A common trap for the thoracic spine is carcinoma of the lung such as mesothelioma which can invade parietal pleura or structures adjacent to the vertebral column.

Table 34.3 Significant tumours affecting the thoracic and lumbar spine

Benign

Malignant

• osteoid osteoma

• haemangioma

Primary

• multiple myeloma

Of bone • osteoblastoma

• aneurysmal bone cyst

• eosinophilic granuloma

Extradural

Secondary

• adrenals/kidney

Spinal Intradural

• ependymoma

• meningioma

Direct spread

• uterus/cervix/ovary

Source: After Kenna and Murtagh 1

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