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The three essential questions of diagnosis

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1. Do the presenting symptoms reflect a visceral disorder, or a serious or potentially life-threatinging illness? 2. Where is the pain coming from? 3. What is happening with this person as a whole that would cause the pain experience to develop and persist?

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Thoracic spine pain: Non-musculoskeletal disorders Emergent conditions

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Dissecting aortic aneurysm Myocardial infarction Pulmonary embolism Ectopic pregnancy

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Thoracic spine pain: Non-musculoskeletal disorders Urgent conditions

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Pericarditis Pneumonia Esophageal pathology Acute pancreatitis Pancreatic tumor GI ulcers Pyelonephritis Visceral trauma Bone or soft tissue tumor

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Thoracic spine pain: Non-musculoskeletal disorders Potentially serious conditions

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Angina pectoris Cholecystolithiasis Hepatobiliary disease Pleuritis Endometriosis Kidney disease Urinary tract infection

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Herpes Zoster or shingles

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A painful, blistering skin rash that follows a dermatome, or linear nerve distribution. This infection is caused by the varicella-zoster virus, which also causes chickenpox.

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Common causes of thoracic spine pain

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Spinal cord and nerve root pathology Vertebral column disease Diffuse idiopathic skeletal hyperostosis Degenerative arthropathies Autoimmune arthopathies Discogenic pain Thoracic myofascial pain Thoracic muscle strain Thoracic facet syndrome Thoracic joint dysfunction

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Spinal cord and nerve root pathologies

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Spinal stenosis or hematoma

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Vertebral column disease

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Osteomyelitis, compression fracture, tumor, scoliosis, or kyphosis

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Diffuse idiopathic skeletal hyperostosis (DISH)

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A syndrome of calcification or hardening of the ligaments and tendons spine AKA: Forestier's disease

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DISH

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Advanced disease may have a "melted candle wax" appearance along the spine on radiographic studies

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Degenerative arthopathies

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Thoracic spondylosis (abnormal wear and tear) causes gradual narrowing of the disc space and deformed bone growth (bone spurs)

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Discogenic pain

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Caused by degenerative changes, herniations, or infections of the thoracic intervertebral discs. Pain is the presenting symptom in 60% of cases Herniated discs are rare in thoracic spine

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Thoracic myofascial pain

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Causes tender areas of muscle that may be referred to as "knots"that are sensitive to touch

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Thoracic muscle strain

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May be caused by an injury or irritating daily activities, such as improper posture or poor sleeping positions that leads to muscle spasms. The pain is mom only associated with stiffness and tightness in the upper back or shoulders

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Thoracic facet syndrome

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Consistent pain referral patterns that follow scleretomes (not dermatomes) depending on segment. The pain is usually aggravate by spinal extension and rotation.

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Thoracic joint dysfunction (subluxation)

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Characteristics of facet syndrome and muscular pain conditions Localized stiffness and painful ROM

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Red flag: History of CA, no positional relief, fever, constitutional symptoms, unexplained weight loss, blood in stool, night sweats

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Cancer

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Red Flag: History of fever, chills, localized tenderness, redness and swelling

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Infection

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Red Flag: History of trauma or osteoporosis, new pain in patient. Patient age >50

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Fracture

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History History of Present illness (HPI) Chief complaint (CC)

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Location Mechanism Onset Provocation/ Palliative Quality Radiation/ Region Severity Timing

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The art of taking the history Step 1

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Ask the patient, "How can I help you today?"

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The art of taking the history Step 2:

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SHUT UP Put your pen down and listen for 2 MINUTES. No notes. No questions.

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The are of taking the history Step 3

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Connect with the patient and show that you understand their problem. "How does this pain make you feel? What cant you do because of it? Ideally, what is your goal from treatment?" Use open-ended questions

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History Location

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Where does it hurt? Be specific Have the patient point to where it hurts DOCUMENT THIS

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History Mechanism

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How did it happen? Do your best to get the patient to describe exactly how the pain started or injury occurred Often there is no known cause (Unknown etiology, insidious onset) Try to at least nail down the timeline

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History Onset Acute onset

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Accident or trauma? (Fracture or dislocation?) no trauma but sudden onset for NAR? (Possible pathological fracture?) Onset after some unusual movement (bending, cough, sneeze) or activity?

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History Acute onset RED FLAGS

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Sudden onset severe pain in the thoracic spine and chest may suggest: Pulmonary embolism Thoracic aortic dissection Myocardial infarction (MI) These are MEDICAL EMERGENCIES) that require immediate attention

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History Onset Chronic onset

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Clear incident - associated with onset No clear onset- consider organic referral or chronic postural or occupational strain Possible organic/ visceral pathology referral

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History Provocation/ Palliative

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What activities or postures provoke the pain? What activities or postures are palliative? Does rest or activity help the pain? Is it getting better or worse overall? Is it worse with: neck movements? Arm movements, trunk movements? Coughing and deep breathing?

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History Provocation/ Palliative Non-mechanical

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Typically is not provoked or palliated by activities or postures (tends to be constant, often worse at rest) Musculoskeletal pain can usually be affected by specific movements or positions, and can often be reproduced by palpation or mechanical stress

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History Provocation/ Palliative Muscular pain

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Usually worse in morning and improves with use of the muscle

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DJD

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tends to be worse in the morning, improves with moderate activity, worsens later in the day or with extended activity

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Ligament pain

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Improves with rest, worsens with use

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Sharp, well-localized pain

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Typically ligament

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Dull, aching pain

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Typically muscular or tendon

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Deep, boring pain

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Suggests bone or organ tumor or osteoporosis (possible compression fracture)

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Achy, poorly localized pain

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Suggests vascular

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Sharp, stabbing, or burning pain

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Suggests nerve pain

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History Radiation

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Is the pain localized or does the pain of the CC radiate or "shoot" into another part of the body?

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Pain radiates around a rib

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Dermatome Suggests intercostal neuralgia or herpes zoster

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Upper extremity pain

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Radiation, numbness or weakness suggests cervical radiculopathy (nerve root damage in the C-spine)

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Lower extremity pain

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Radiation, numbness or weakness suggests lumbar radiculopathy (nerve root damage in the L-spine) - it might also be suggestive of myelopathy (spinal cord compression)

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Often a posterior rib joint restriction (costalvertebral joint)

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Will have a joint restriction in the same segment costo-sterna joint, causing PA radiation pain

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History Caution

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Cardiac pain can be in the chest, but may also have significant radiation to the back

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History Severity

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How bad is the pain: Quantify Visual analog Scale (VAS) Triple VAS Other pain measures

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History Timing

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(Temporal factors) Is the pain worse at any time of day? Have you experienced difficulty or pain... After everyday stresses During household activities After physical leisure-time activities After prolonged sitting After walking, standing, lifting, carrying

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History Vast Past

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Past and family history Previous history of similarly pain Was it treated? How? What helped/ didn't? Previous history of serious diseases? Traumas? Hospitalizations? Surgeries? Cancer? Heart disease?

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History Vast past Family history

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Family history of serious diseases? Congenital diseases? Status of parents, grandparents, siblings... Age and cause of death if known

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History Work/ social history

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Search for perpetuating factors What is happening with the person as a whole that would cause this pain to persist.

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History Work/ social history What is your typical day like?

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Screen for occupational risk factors (Heavy physical work, Sitting/ Inactivity, Job dissatisfaction) Domestic activity (leisure activities, hobbies, sports) Social situations (family, social support structure, social stressors) Habits: (smoking, alcohol use, illicit drug use, DIET, exercise/ activity level)

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History Work/ social history Risk factors for spinal pain

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Ago of 40 years or greater History of injury Deformities of the spine Poor posture/ excessive sitting Heavy physical work Job dissatisfaction Smoking. Drug abuse Poor physical conditions and lack of exercise

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History Questions for students and adolescents

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Exercise and sports Complaints while sitting at school Dislike of certain exercises and sports Problems during performance sports Have you discontinued any athletic performance training?

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Evaluation and assessment basics

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History Inspection Palpation Percussion Instrumentation Range of motion Orthopedic tests Neurological tests Ex ray (Imaging) Labratory

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Inspecition

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Discoloration Abrasions Scars Edema Deformities

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Inspection: Deformities

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Thoracic hyper-kyphosis Gibbous deformity Scoliosis Note any sternal deformities

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Thoracic hyper-kyphosis

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Abnormal forward curvature of the spine Can be postural or pathological

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Gibbous deformity

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May suggest compression fracture

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Scoliosis

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Abnormal lateral curvature of the spine Really a 3-dimensional curve with distortion in both the sagittal and coronal planes

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Note any sternal deformities

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May suggest the presence of a connective tissue disease (Marfan's)

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Inspection Shape and postural impairments

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Thoracic specific postural overview: A-p curves Rib asymmetry Prominence of trapezius, TL, erector spinae Carriage of scapulae Posterolateral rib prominence

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Palpation

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General palpation (MALT) Motion palpation scan (Joint play) POMP and joint endfeel

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General palpation

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Sweep flat hand paravertebrally Thumbs across erector spinae Fingers longitudinally in paraspinal gully Flat-handed vertical pressure Segmental palpation: feeling

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Palpation goals

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Seek abnormalities Moving the joint Apply pressure

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Palpation Anterior perspective

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While patient is supine" Palpation muscular tissue Palpation costocondrial junctions and diploid process Patient prone with arms to side Note any abnormalities and decide whether abnormality is significant

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Spinous percussion

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(With reflex hammer or finger) - if painful, suggests bony pathology (fracture, tumor, infection)

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Murphy's punch test

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Over costovertebral angle, if positive suggests kidney disease (infection or stone)

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Instrumentation Fair-to-good reliability and validity

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Duel inclinometer for accurate C/T and T/L ROM measurement Direct pressure algometry: measures pain threshold

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Instrumentation Poor to questionable reliability and validity

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Surface thermography Surface EMG

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Instrumentation Scoliometer

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Various designs to measure differences in shoulder or hip height and/or degree of lateral curvature "Gold standard" is still X-ray imaging

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Range of motion

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Watch for overall limitation and stiffness, especially in extension Give mild over pressure to verify apparently painless and full range Watch for asymmetrical movement, especially in lateral flexion and rotation Assess thoracic excursion and chest expansion with deep breath and cough

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Adam's test for scoliosis

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Considered the best non-invasive clinical test to evaluate scoliosis (Cannot be used as an effective tool for the early detection of scoliosis due to the high number of false positives)

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Sternal compression test

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Pronounces rib fractures Produces pain with costochondritis

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Neurological tests

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Check sensation over thoracic dermatomes.

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Abdominal reflex and cremasteric reflex

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Check for symmetry and presence Can help identify myelopathy and cord compression

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Perform neurological tests

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Of upper limbs if there is associated radiation Of lower limbs to rule out spinal cord pathology

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Imaging

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Avoid :routine imagine due to low diagnostic yield and significant risk of exposure

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Specific indications for radiography

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Suspect osteopenia Suspect bony pathology Suspect fracture Suspect significant structural abnormalities Presence of any other red flags

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Lab tests

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Routine lab blood tests like complete blood count and metabolic screens and routine urinalysis are safe, simple and fairly inexpensive You still may be called to justify their use based on sound clinical reasoning

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T4

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Innervates the nipple

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T7

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Innervates the xiphoid

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T10

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Innervates the umbilicus

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T12

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Innervates the inguinal region

Technique 5 Evaluation and Assessment of Thoracic Spine symptoms – Flashcards

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