The most common symptoms and signs that occur in the upper region of the back and spine are pain, tenderness, weakness, stiffness and/or deformity in the back. Pain is much more frequent in the lower (lumbar) back and in the neck than in the upper trunk (thoracic back). Besides local symptoms, the thoracic disorders may cause pain that radiates to the lumbar region and the lower limbs, to the neck and shoulders, to the rib cage and to the abdomen.
Painful Soft-Tissue Disorders
The causes of thoracic back pain are multifactorial and often obscure. The symptoms in many cases arise from an overuse, an overstretching and/or usually mild ruptures of the soft tissues. There are, however, also many specific disorders that can lead to back pain, such as severe scoliosis (hunchback) or kyphosis of different aetiology, Morbus Sheuermann (osteochondritis of the thoracic spine, sometimes painful in adolescents but seldom in adults), and other deformities which may follow trauma or some neurologic and muscular diseases. Infection in the spine (spondylitis) is often localized to the thoracic region. Many kinds of microbes may cause spondylitis, such as tuberculosis. Thoracic back pain may occur in rheumatic diseases, especially in ankylosing spondylitis and in severe osteoporosis. Many other intraspinal, intrathoracal and intra-abdominal diseases, such as tumours, may also result in back symptoms. Generally, it is common that the pain may be felt in the thoracic spine (referred pain). Skeletal metastases of cancer from other sites are frequently localized to the thoracic spine; this is especially true of metastatic breast, kidney, lung and thyroid cancers. It is extremely rare for a thoracic disc to rupture, the incidence being 0.25 to 0.5% of all intervertebral disc ruptures.
Examination: At examination many intra- and extraspinal disorders causing symptoms in the thoracic back should always be kept in mind. The older the patient, the more frequent the back symptoms arising from primary tumours or metastases. A comprehensive interview and a careful examination are therefore very important. The purpose of the examination is to clarify the aetio-logy of the disease. The clinical examination should include ordinary procedures, such as inspection, palpation, testing of the muscle strength, the joint mobility, the neurological state and so on. In cases with prolonged and severe symptoms and signs, and when a specific disease is suspected by plain x ray, other radiography tests, such as MRI, CT, isotope imaging and ENMG can contribute to clarifying the aetiological diagnosis and to localizing the disorder process. Nowadays, MRI is usually the radiological method of choice in thoracic back pain.
Degenerative Thoracic Spine Disorders
All adults suffer spinal degenerative changes which progress with age. Most people do not have any symptoms from these changes, which are often found while investigating other diseases, and are usually without any clinical importance. Infrequently, the degenerative changes in the thoracic region lead to local and radiating symptoms—pain, tenderness, stiffness and neurological signs.
Narrowing of the spinal canal, spinal stenosis, may lead to compression of vascular and neurologic tissues resulting in local and/or radiating pain and neurologic deficiency. A thoracic disc prolapse seldom provokes symptoms. In many cases a radiologically detected disc prolapse is a side finding and does not provoke any symptoms.
The main signs of degenerative disorders of the thoracic spine are local tenderness, muscle spasm or weakness and locally decreased mobility of the spine. In some cases there may be neurological disturbances—muscle paresis, reflex and sensation deficiencies locally and/or distally of the affected tissues.
The prognosis in thoracic disc prolapse is usually good. The symptoms subside as in the lumbar and neck region within a few weeks.
Examination. A proper examination is essential especially in old persons in prolonged and severe pain and in paresis. Besides a detailed interview, there should be an adequate clinical examination, including inspection, palpation, testing of mobility, muscle strength and neurological state. Of the radiological examinations, plain radiography, CT and especially MRI are advantageous in evaluating the aetiological diagnosis and the localization of the pathological changes in the spine. ENMG and isotope imaging may contribute to the diagnosis. In the differential diagnosis laboratory tests may be valuable. In pure spinal disc prolapse and degenerative changes there are no specific abnormalities in the laboratory tests.