Thoracic pain is described as pain at the front and/or back of the chest with the hips as the lower limit. The aetiology can be very diverse, ranging from cardiac, vascular, infectious, spine related, costal, metastases, carcinoma, pulmonary, pleural, to visceral and tissue scars.
Intercostal neuralgia is a painful disorder of the nerves running between the ribs, and is caused by damage to one of those nerves and/or loss of function of that nerve.
Thoracic pain is relatively rare, and is only seen in an estimated 3-22% of patients referred to pain clinics. The prevalence of thoracic pain in the general population is about 15%.
Chronic post-thoracotomy and post-thoracoscopy pain has a prevalence of 40%, and half these cases are neuropathic in character. Intercostal neuralgia is the most frequent form.
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 must also 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).
In intercostal neuralgia, serious pain, shooting and sharp in character, is found in the area of the intercostal nerve. This pain is independent of posture and segmental manipulation.
Extensive general physical and neurological examinations are
always indicated in thoracic pain, particularly when dorsal column
disorders are present. The sensitivity of the thorax and stomach
should also be examined. Loss of sensitivity indicates
whether or not the pain is neuropathic pain.
Examination of the thoracic spine is preferably performed with the patient in a sitting position and comprises 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 uncomplicated intercostal neuralgia, additional diagnostics are not necessary.
- In trauma with or without osteoporosis, X-ray is indicated in order to exclude an impression fracture.
- When there is suspicion of a malignancy, MRI scan and/or referral to a specialist is mandatory. Particularly in patients with a history of malignancy with acute thoracic pain, additional diagnostics are important. The same is true in the case of neurological deficits.
- When there is suspicion of pathology in the chest wall and/or there are pulmonary complaints, X-ray can be useful, together with possible referral to a pulmonary specialist.
- When there is any 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)
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.
- Psychological Treatment
- Depression Treatment
- Cognitive-Behavioural Treatment
- Rehabilitation Treatment
- Tricyclic antidepressants
- Anticonvulsives: carbamazepine, oxcarbazepine, gabapentine en pregabaline.
Interventional Pain Treatment