Practice tips

• Feelings of anaesthesia or paraesthesia associated with thoracic spinal dysfunction are rare.

• Thoracic back pain is frequently associated with cervical lesions.

• Upper thoracic pain and stiffness is common after 'whiplash'.

• The T4 syndrome of upper to mid-thoracic pain with radiation (and associated paraesthesia) to the arms is well documented.

• Symptoms due to a fractured vertebra usually last 3 months and to a fractured rib 6 weeks.

• The pain of myocardial ischaemia, from either angina or myocardial infarction, can cause referred pain to the interscapular region of the thoracic spine.

• Beware of the old trap of herpes zoster in the thoracic spine, especially in the older person.

• Consider multiple myeloma as a cause of an osteoporotic collapsed vertebra.

• Examine movements with the patient sitting on the couch and hands clasped behind the neck.

• Spinal disease of special significance in the thoracic spine includes osteoporosis and neoplasia, while disc lesions, inflammatory diseases and degenerative diseases (spondylosis) are encountered less frequently than with the cervical and lumbar spines.

• It is imperative to differentiate between spinal and cardiac causes of chest pain: either cause is likely to mimic the other. A working rule is to consider the cause as cardiac until the examination and investigations establish the true cause.

• Always X-ray the thoracic spine following trauma, especially after motor vehicle accidents, as wedge compression fractures (typically between T4 and T8) are often overlooked.

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