Thoracic / Chest

Discogenic Thoracic Pain

Definition

Thoracic pain is described as pain at the front and/or back of the chest with the hips marking the lower limit. The aetiology can be very diverse: cardiac, vascular, infectious, spine related, costal, metastases, carcinoma, pulmonary, pleural, visceral and tissue scars.

Aetiology

Thoracic pain is relatively rare and is seen in an estimated 3-22% of patients referred to a pain clinic. The prevalence of thoracic pain in the general population is about 15%. Thoracic disc prolapse is found in 37% of asymptomatic persons..

Symptomatic thoracic disc prolapse is related to normal degeneration of the spine, Scheuermann disease and past trauma.

Aetiology

Thoracic pain is relatively rare and an estimated 3 to 22% of the referred patients to a pain clinic have these complaints. The prevalence of thoracic pain in the general population is about 15%. In chronic thoracic pain degenerative thoracic facet joints cause 34% to 48%.

Signs and symptoms

In all thoracic pain, extensive anamnesis is important, particularly in patients with a history of carcinomas. General matters such as weight loss, (chronic) coughing, past trauma, thoracic surgery and infections should be explored.

In addition, it is important to ask patients whether they have any complaints in the thoracic spine and/or any pain related to breathing or that becomes worse during coughing.

The precise location of the pain and its radiation has to be explored. The character of the pain and provoking conditions (static and dynamic load) can provide information about the aetiology and nature of the pain (neuropathic versus nociceptive).

The natural course of discogenic thoracic pain can be very erratic, varying from slowly progressive, intermittent, to acute. The pain can be located axially, with or without segmental radiation or bilateral or unilateral non-radicular ischialgia, abdominal pain, sensory deficits, neurogenic claudication, walking disorders, micturition, and defecation disorders.

In particular, in cases of spinal cord compression due to disc prolapse, neurological deficits can occur.

Diagnostics

Physical Examination

Extensive general physical and neurological examinations are always indicated in thoracic pain, particularly in case of dorsal column disorders. The sensitivity of the thorax and abdomen should be examined. Loss of sensitivity indicates whether neuropathic pain is present.
Examination of the thoracic spine is preferably performed with the patient in a sitting positio.n and consists of inspection at rest and palpation of the vertebra and paravertebral structures, such as the costovertebral joints.

 

Provocation of pain by performing passive rotations, forward flexion, backward flexion and lateral flexions in particular, can indicate that the pain has a spinal aetiology.

In upper thoracic and median and paramedian unilateral pain, shoulder function on the same side should also be examined.

Pressure pain in the sternum, sternocostal and costovertebral junctions is usually accompanied by a local pain pattern (e.g., Tietze syndrome), but is sometimes associated with segmental pain.

Pressure pain of the rib(s) can indicate which thoracic level(s) is involved. Segmental translation of the thoracic vertebra (Federung test) in the prone position can indicate the level of the affected segment.

 

Additional Somatic Diagnostics

Since thoracic pain is not a clinical entity and the cause cannot always be determined by anamnesis and physical examination, additional diagnostics are always necessary.

  • In trauma, with or without osteoporosis, X-ray is indicated in order to exclude an impression fracture.
  • When there is a suspicion of malignancy, an MRI scan and/or referral to a specialist is mandatory. Particularly in patients with a history of malignancy with an acute thoracic pain, additional diagnostics are important. The same is true in the case of neurological deficits.
  • When there is a suspicion of pathology in the chest wall and/or pulmonary complaints,  X-ray can be useful,  together with possible referral to a pulmonary specialist.

In case of doubt or if visceral pathology is suspected, ultrasound, CT scan or referral to a specialist should be considered.

Additional Psycho-cognitive Diagnostics

  • RAND-36 (quality of life)
  • VAS-Pain (maximal, minimal, actual, average/week)
  • PCS (catastrophising)
  • HADS (fear and depression)

Multidisciplinary Treatment

Whether or not somatic treatment is indicated is based on the pain diagnosis.  Based on the findings of the pain questionnaires, additional diagnostics and/or multidisciplinary treatment comprising various non-somatic treatments may be necessary.

Non-somatic Treatment

Somatic Treatment

Pharmacological treatment:

Other Treatments

Interventional Pain Treatment

Median Thoracic Pain

Segmental Radiating Thoracic Pain

Invasive Treatment

  • In case of neurological complaints and/or deficits, neurosurgery can be considered