Keywords; thoracic spine pain, chiropractic help, scheuermanns disease, tietzes syndrome.
Deep upper back pain is rarely serious but frequently can be extremely irritating. Metastases from known cancers of the lungs and breast should be kept in mind, but they are very much the exception that proves the rule.
There are twelve thoracic vertebrae, each attached via three
joints to a rib bilaterally; thus six in total. They are then connected to the breastbone anteriorally. The midback stretches from the base of the neck to the
bottom of the ribcage; that's about a hundred in total.
This means that each thoracic vertebra has twelve joints associated with it.
That's a great many, each with supporting ligaments and muscles, making it a complex and frequently painful area.
The mid back is far stronger than the neck and lumbar spine because of the stabilising effect of the rib cage.
Nevertheless, a good sneeze, particularly if twisting at the time, or a bout of bronchitis may subluxate or sprain one of those joints causing severe pain with each breath. It feels like someone is stabbing you in the back with a rusty knife.
Each vertebra is attached by a rib to the breastbone, sternum, thus giving the whole chest a certain rigidity. This makes it far less liable to the serious disc injuries associated with the neck and the lower back.
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Of course, occasionally tragic things happen in the practice. Right now I'm treating a very elderly lady. Twenty years ago I had to break the news to her husband that his thoracic spine pain was caused by multiple myeloma.
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Thoracic spine pain
Seen from the side, the thoracic spine has a natural curve called a kyphosis.
This "kyphosis" provides the spine with a certain amount of 'give' when for example jumping from a height onto the ground. A straight spine would experience too much axial compression, and fracture the bones.
THORACIC SPINE PAIN CaseFile
The case history of a young rugby player who after a tackle
experienced very severe midback pain. Fracture or subluxation? It can
test every clinician. Hot from the field he enjoyed a glass of our
Lemon drop drink recipe ...
However, the kyphosis can increase for pathological reasons causing thoracic spine pain. The most common is the so called kyphotic, bent, spine of the elderly. It is usually associated with osteoporosis and anterior wedging of the vertebrae, as seen in this MRI of a spine with an anterior compression fracture. For more on the causes of osteoporosis, use the search this site facility.
Another fairly common condition, Scheuermanns disease causes an increased kyphosis affecting teenagers. It results in pain usually between the shoulder blades, and less commonly in the low back, and is the cause of the poor posture and slumped shoulders seen in about five percent of young people.
What is quite often seen in the practice, in young to middle aged adults, is a scheuermann like thoracic deep achy pain. The structural changes, and abnormal cartilage make the spine very stiff. Adjusting the midback feels like thrusting into concrete, and a hard physical manipulation just increases the pain. What's needed is more frequent gentle adjustments.
It has many of the hallmarks of scheuermanns; a stiff and rigid thoracic spine with an increased kyphosis. Sometimes there is a scoliosis and loss of disc space with mild degenerative changes, but without the typical bone changes associated with the disease.
I call it a light form of scheuermanns, as it has so many similar clinical features, but without the gross xray changes, and is managed in much the same way. All disease seems to come in severe and mild forms. Thoracic spine pain is common, and this condition can never be cured. An occasional, but regular treatment is what keeps the pain at bay. How frequent? Talk to your chiropractors. There are so many variables; perhaps four to eight weeks.
There are often objections to regular chiropractic treatment. It's no difference in medicine; patients with incurable diabetes, for example, require regular occasional management by their doctors.
If these joints are not brought into movement, then the hyaline
cartilage, starved of nutrients and oxygen, degenerates and on xray it
just looks like typical osteoarthritis. A stitch in time, or, in our
context, an occasional, but regular chiropractic adjustment in, saves nine barrow loads of thoracic spine pain.
The attachments of the ribs firstly to the spine via the
Both of these joints, at the back between the shoulder blades, and in front at the breastbone are common cause of thoracic spine pain seen in every chiropractic clinic. Sometimes, if it irritates the intercostal nerve, it may follow the rib to the sternum.
This latter condition, sometimes called Tietes syndrome is quite often, if it affects the ribs on the left, confused with a heart attack because the pain is directly over the heart, and may be increased wih exercise which stresses the heart, as in angina, but also the rib sternum joint when breathing deeply.
What may catch any chiropractor out, in it's early stages, and presumably your medical doctor too, is an attack of shingles. This is a viral condition causing a nerve type pain that follows the rib. After a few days the vesicles appearand his her face will be red! But I've never had a case of shingles that I've treated inadvertently, that has gone on to become a chronic nerve pain, as can happen.
Thoracic Outlet Syndrome
The upper thoracic spine is a unique area for two reasons. Firstly,
it is an area of change, where the highly flexible neck meets the very
rigid mid-back. The C6-T2 area is thus very prone to injury and tingling
in the arm. Thoracic outlet syndrome.
The second reason is the presence of the shoulderblades or scapula(e). These large flat bones are the anchor points for many of the large shoulder muscles, shoulder anatomy and are themselves firmly anchored to the thoracic spine.
As you can appreciate, there are a great many muscles, ligaments, joints and bones in the mid-back. The injuries associated with them are not usually serious, but are the cause of many niggling, aching pains between the shoulder blades.
Very occasionally, depending on the society, bacteria may attack the spine. It's a favourite nesting place for people suffering from acquired immuno deficiency syndrome and tuberculosis.
More rarely, an epidural, such as is commonly today used in childbirth, may introduce bacteria to the spinal fluid, where they are free to travel. A recent case, was a puzzler for all concerned.
The key signs for this chiropractor were
She's doing okay, all things considered, but despite extensive antibiotic treatment, the vertebra has crumbled. Even the commonest medical procedures occasionally have devastating side effects. Doctor caused disease is the third most common illness in developed countries like the United States, mostly from medication.
Metastatic bone disease is fortunately an uncommon finding in chiropractic practice, but a case could walk in tomorrow; no doubt we miss them sometimes, especially since chiropractors are taking less xrays since the Lancet report that 7 percent of cancer is caused by ionising radiation.
Both lung and breast cancer have a tendency to metastasise to the ribs and thoracic spine. All doctors, and chiropractors especially, need to be aware that an abnormal presentation, particularly if there is a history of smoking or breast cancer, may indicate something other than routine spinal subluxations.
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Interesting challenges of the day
1. Mr D has very severe midback back. He bent and twisted, feeding his son, and then laughed. Every breath is a nightmare. A sprung rib is every chiropractor's delight. He or she has golden hands. 30 percent better after one treatment.
2. Mrs C has a long history of severe, disabling migraine headaches since having her wisdom teeth removed. She clenches her teeth at night. After six treatments she has no migraines but some jaw joint discomfort remains; a bite plate is in the offing.
3. Mrs U has the trophy for the worst back this year. After major surgery with plates and screws two years later she still had paresis in the lower leg and severe disabling back pain. She's doing far better than expected, in no little part due to a lift in her shoe for a very short leg.
4. Mr V is 86 years old and hurt his back helping his wife into the car. Just one treatment of the sacroiliac joint and he's eighty percent better. It's not always like that.
5. Mr W lay on his back knocking down a pillar. Turning his head causes severe vertigo. He needs the Epley exercises, not pills, research shows. Update, he's fine.
6. I myself had an acute exacerbation of a femoral nerve lesion last year. One immediate treatment by my colleague has fixed the pain in the lower back, but there's some residual numbness in the lower leg; no soaring tomorrow alas.
7. This lady is a 86 year old woman with a 63 scoliosis. Chronic lower back has been her lot in life but she's well pleased with chiropractic and comes for chiropractic help once a month; some conditions you can never cure.
8. She is an 78 year old woman, is doing remarkably well with a bad sciatica. But over 200 pounds she is not losing weight; in fact, gaining despite my suggestions. She's high risk for a stroke. I have referred her to a dietician to crack the whip.
9. A 61 year old man with upper cervical pain yesterday; it's not severe but also not getting better of its own accord. He's afraid it may turn very acute as when I treated him three years ago. Since then it's been fine.
10. A 64 year old woman has had scheuermanns disease; it's left her with a spinal kyphosis and chronic middorsal pain. She responds well to chiropractic treatment provides she come every six weeks or so for maintenance treatment.
11. Mrs C has been having severe headaches, and taking a lot of analgesics. It's a non complicated upper cervical facet syndrome, and she's doing well.
12. Mrs D, a middle aged woman with hip pain of one year duration, despite other treatment. Xrays reveal an impingement syndrome and early hip arthritis. There's much to be done.
13. Mrs B has had one of the nastiest of conditions; vertigo caused by a disturbance in the inner ear. Falling repeatedly and vomiting she consulted her doctor but medication didn't help. After two sessions of the Epley manoeuvres she was 50 percent better. After two weeks 75 percent improved. No longer vomiting all falling. She's not enjoying the Brandt Daroff home exercises.
And so the day goes; chiropractors shouldn't be treating the elderly most medical sites state but that's so much bunkum.
Have a problem that's not getting better? Looking for a different slant on your pain? Want to pose a question?
Greetings, Dr B.
You helped me quite some time back with a soothing and professional response which turned out to be exactly correct. I now consult a local chiropractor. You write a superb newsletter, too.
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