SPINE
The assessment of
thoracic pain
Antony Louis Rex Michael
James Newman
Abhay Seetharam Rao
Abstract
Patients with thoracic back pain are proportionately far more likely to
have serious spinal pathology than in patients with cervical or lumbar
back pain. Thoracic back pain should therefore always be thought of as
a ‘red-flag’. The symptom of thoracic back pain may be the first present-
ing feature of spinal infection, thoracic disc prolapse or neoplasm. It is
vital that any practicing orthopaedic surgeon is able to make a thorough
assessment of this patient group. As in all medical conditions, a good
idea of the diagnosis can usually be obtained with a detailed history
and examination. In the case of spinal disease further investigations
are of vital importance in order to confirm the diagnosis and to demon-
strate neural as well as vertebral involvement. Management will vary
depending on the aetiology and presentation.
This article will outline a safe and thorough approach to the diag-
nostic pathways and management of these patients.
Keywords degeneration; infection; thoracic; trauma; tumour
Introduction
Back pain is a common complaint and a large proportion of the
population will suffer with it at some point in their life. Although
the majority of patients will have self-limiting musculoskeletal
pain, a small but important sub-group will have a serious
underlying cause. The Royal College of General Practitioners
published clinical guidelines in order to help family doctors
identify these patients. Within these guidelines are the so-called
‘red flag signs’.1,2 These red flags are important symptoms or
examination findings that should alert the doctor to a more
serious underlying pathology (Table 1). Patients who demon-
strate red flag signs are proportionately more likely to have
a serious cause for their back pain.
Antony Louis Rex Michael DNB (T&O) FRCS (Ed) MMedSc (Trauma) FRCS (T&O)
National Spine Fellow at the Leeds General Infirmary, Great George
Street, Leeds LS1 3EX, UK.
James Newman MRCS FRCS (T&O) Specialist Registrar in Trauma and
Orthopaedics at the Leeds General Infirmary, Great George Street,
Leeds LS1 3EX, UK.
Abhay Seetharam Rao MS (Ortho) FRCS FRCS (T&O) Consultant Orthopaedic
Spinal Surgeon at the Leeds General Infirmary, Great George Street,
Leeds LS1 3EX, UK.
ORTHOPAEDICS AND TRAUMA 24:1
Given that thoracic back pain is in itself a ‘red-flag’, a patient
presenting with thoracic back pain should be considered to have
serious spinal pathology until proven otherwise. Patients with
thoracic pain therefore have to be subjected to a thorough
assessment, including a full history and examination. Specific care
should be taken to elucidate the presence of other red flags, fol-
lowed by appropriate investigations before a diagnosis of benign
mechanical pain can be made. Several serious conditions may
present with an insidious onset that can lull the unwary into a false
sense of security. Early diagnosis of these conditions may prevent
unnecessary intervention in the form of invasive surgery or alter
the long term outcome and survival, e.g. tumours, infections.
Most of the conditions causing thoracic pain may be grouped
under developmental, degenerative, traumatic, infective,
inflammatory, neoplastic and miscellaneous groups. Each
condition has to be kept in mind when assessing a patient with
thoracic pain. There is a tendency for each condition to affect
different age groups. A logical and systematic assessment is
required to reach a diagnosis and avoid missing serious
pathology.
Clinical assessment
History
A thorough and detailed history is vital in arriving at a differen-
tial diagnosis which in turn leads to appropriate examination and
further investigations. The key points that should be covered in
the patient with thoracic back pain are as follows.
Pain: the history of the patient’s pain should be taken, with
specific questions about its site, severity, nature, radiation,
presence of rest or night pain, relieving or aggravating factors
and the temporal history. Rest and night pain are themselves red
flag symptoms and imply non-mechanical pain. The timing of the
patient’s pain gives a good indication of the seriousness of the
underlying problems. A patient who has had thoracic back pain
for 20 years is clearly less worrying than the patient with acute
onset pain.
Injury: ask about preceding injury, no matter how trivial. A
minor injury may be relevant in the patient with osteoporosis or
ankylosing spondylitis. High energy trauma is more likely to lead
to significant injury to the spine.
Associated features: ask about associated neurological features
such as limb weakness and sensory changes. Often a good
historian will be able to describe changes consistent with
a dermatome or myotome. This will begin to identify the
approximate location of the lesion and any neurological distur-
bance. Motor abnormalities may also lead to an alteration in the
patient’s gait. Ask about new walking aid usage. Changes in the
patient’s bowel or bladder control are considered a red flag
symptom and imply significant cord compression and the
potential need for urgent decompression surgery.
Past medical history: ask the patient about previous back
disorders. Ask specifically about a previous diagnosis of malig-
nancy. Enquire further about the primary, what treatment has
been received and the prognosis if relevant. A history of previous
63 Ó 2009 Elsevier Ltd. All rights reserved.
 SPINE

Gait should be assessed as compressive lesions of the thoracic

Red flag signs spinal cord will cause myelopathy and associated gait changes.
Look for walking aids.
C Age of onset less than 20 years or more than 55 years
C Constant progressive, non-mechanical pain (no relief or Examination of the spine
worsened with bed rest) Inspection: the spine should be examined in its entirety
C Thoracic pain systematically. Inspect for scars, sinuses and swellings. Look
C Past medical history of malignant tumour specifically for markers of neurofibromatosis and deformity in
C Prolonged use of corticosteroids the coronal or sagittal plane. A gibbus (sharp angular kyphosis)
C Drug abuse, immunosuppression, HIV is classically seen in tuberculosis of the spine (Pott’s disease).
C Systemically unwell
C Unexplained weight loss Palpation: palpate for any abnormal contour, warmth and
C Widespread neurological symptoms (including cauda equina tenderness. Whilst palpating the tender areas ascertain exactly
syndrome) from where the pain is originating. Is it diffuse or localized,
C Structural deformity superficial or deep? Can it be localized to the facet joints or to the
C Fever paraspinal muscles? Are there any trigger points?

Percussion: this is useful in the spine to elicit deep tenderness

Table 1
suggestive of infection, trauma, tumour or inflammatory condi-
tions. It is quite non-specific but may be indicative of structural
surgery should be sought. Remember that abdominal structures
disease.
such as the stomach, liver and pancreas refer pain to the thoracic
region. Ask about a previous diagnosis of arthropathy. Ask about
Movement: both active and passive movement should be
any prior investigations that have been carried out, their result
recorded. Normal costo-vertebral expansion is 3e7.5 cm. Chest
and what treatment if any has been received so far (especially
expansion should be specifically tested as restriction is an early
antibiotics and their duration).
sign for ankylosing spondylitis. With the exception of Schober’s
test for examination of the lumbar spine flexion, it is very diffi-
Drug history: steroid or immunosuppressive medication is
cult to accurately quantify the range of motion. Finger floor
important, as are anticoagulants if you are considering the
distance is often measured in lateral bending and forward
patient for surgery.
flexion. This is patient-specific and serves to provide documen-
tary evidence of change in range of motion when following up
Family history: ask about inflammatory arthropathy, Scheuer-
a patient in clinic. Table 2 shows the normal range of motion of
mann’s kyphosis and ankylosing spondylitis.
the thoracic spine.3

Systematic review: a history of weight loss is very important. Neurological examination

Also enquire about night sweats and fevers. Ask screening Neurological examination should be thorough. There is a wide
questions about the other body systems in the case of undiag- variation and cross over in the description of neurological
nosed primary malignancy. Symptoms of any inflammatory myotomes and dermatomes in the text books. It is advisable to use
condition such as early morning joint stiffness, eye symptoms, the American Spinal Injuries Association neurological assessment
urethritis, dermatitis and gastroenteritis are relevant. chart (http://www.asia-spinalinjury.org/publications/2006_
Classif_worksheet.pdf) to ensure that all findings can be docu-
Examination
mented immediately and accurately. Tone, co-ordination and
Knowledge of the anatomy is essential to properly examine the
proprioception should also be documented. Abdominal and lower
thoracic spine. There are 12 thoracic vertebrae, the 1st, 11th and
limb reflexes should be examined and characterized. The plantar
12th are considered atypical. There are 12 pairs of costo-vertebral
reflex is particularly important in assessing spinal cord function.
joints which are synovial plane joints between the ribs and verte-
Examination aids such an aesthesiometer, tuning forks and two
bral bodies. There are ten pairs of costo-transverse joints, these
point discriminators improve clinical accuracy. Assessment of
being absent in the 11th and 12th levels. Each thoracic vertebra
also articulates with the cephalic and caudal vertebra by means of
the facet joints (zygapophyseal joints). The 1st articulates with the
7th cervical vertebra and the 12th with the 1st lumbar vertebra. Normal range of thoracic spine movement
The nerve roots exit immediately below the pedicle of the named
thoracic vertebrae. The nerve roots at this level are relatively Movement Normal range/degrees
horizontal. This means that for thoracic disk prolapse there is no
Forward flexion 20e45
difference in the neural compression if the disk is far lateral.
Extension 25e45
Lateral flexion 20e40
General examination
Rotation 35e50
Start with a thorough examination of the whole patient looking
for signs of generalized disease such as pyrexia, malaise, muscle
wasting, nutritional status and signs of inflammatory arthritis. Table 2

ORTHOPAEDICS AND TRAUMA 24:1 64 Ó 2009 Elsevier Ltd. All rights reserved.

anal tone, sensation and voluntary contraction is very important.
Remember to get consent and have a chaperone if appropriate
before examining patients.
Special tests
The slump test (sitting dural stretch test) indicates impingement
of the dura and spinal cord or nerve roots. The patient sits on the
examining table and is asked to ‘‘slump’’ so that the spine flexes
and the shoulders sag forward while the examiner holds the chin
and head erect. Symptoms of sciatic pain or reproduction of the
patient’s symptoms indicates a positive test. If there are any
symptoms in the cervical or lumbar spine these areas should also
be examined.3
Investigations
A thorough history and clinical examination will often narrow
down the possible diagnoses. It is now important to carry out
appropriate investigations to confirm the diagnosis. An algo-
rithmic approach to the assessment of the thoracic spine has
been suggested by the authors in this situation and has been
described in the form of a flow chart. Patients with thoracic pain
and no other red flags or worrying features may be reassured and
advised physical therapy and if they improve may be observed
and subsequently discharged. If there is no improvement referral
to pain clinics for further management may be appropriate. If
there are red flags suggestive of serious pathology then they
should be appropriately investigated and managed (Figure 1).
Blood tests
The routine blood tests are a full blood profile, urea and elec-
trolytes. Inflammatory markers such as ESR and CRP are very
useful in detecting an infective or inflammatory condition. Blood
cultures are mandatory in infections. Myeloma screening tests
should be carried out in all cases of suspected tumour (plasma
electrophoresis and urinary Bence-Jones protein). Rheumatoid
factor and HLA-B27 are requested in suspected inflammatory
spondylarthropathies. Liver function tests are useful for baseline
measurement and monitoring treatment. Bone profile can pick
up abnormalities of bone metabolism and give some clues to
the underlying condition. Peripheral blood smears and bone
marrow studies are useful in the diagnosis of haematological
malignancies.
Plain radiographs
These are often the first line radiological investigations carried
out on patients. There is concern that they are not sensitive
enough to exclude disease. They are however useful in advanced
disease states and in the preoperative planning in some situa-
tions. It is important that they are of adequate quality with regard
to the area of interest, adequate views and exposure.
Computed tomography (CT)
This is a more sensitive investigation and gives good bone detail.
The ability to reconstruct the images in the sagittal plane and
coronal plane is very helpful. CT myelography is an alternative
investigation in patients who have contra-indications to Magnetic
Resonance Imaging (MRI). It however does not give good soft
tissue detail especially of the spinal cord and hence may miss
myelomalacia. It is useful in preoperative planning as the
ORTHOPAEDICS AND TRAUMA 24:1
SPINE
dimensions of various vertebral components can be accurately
determined aiding implant placement. Three dimensional
reconstruction can demonstrate bony destruction and deformity
in very good detail.
Ultrasound
This is of limited benefit in the thoracic spine due to the bony
elements precluding ultrasound examination. It is however
useful in assessment of paraspinal masses, collections and
intraoperative localization of intra-dural spinal tumours. It is
useful to assess intra-abdominal pathology.
Isotope bone scan
This is a very useful modality due to its sensitivity and capability
to screen the whole body. It plays an important role in staging
disease and detecting multifocal disease in the skeleton in
inflammatory, traumatic, neoplastic and infective pathology.
Labelling of leucocytes can localize infections more precisely and
differentiates them from other causes of increased uptake.
MRI
This modality has revolutionized the investigation and manage-
ment of several conditions of the thoracic spinal column. There is
some concern that it is too sensitive thus giving rise to false
positive findings. In most instances it can reliably distinguish
between infection, fracture and tumour. It has also been recently
used in distinguishing between old and new fractures or fracture
non-unions in the thoracic spine with the STIR (Short Tau
Inversion Recovery) sequence enabling effective use of cement
augmentation. It gives good detail of the spinal cord thus
showing up myelomalacia which is seen in chronic compressive
lesions. Wood et al. carried out an MRI study in 90 patients with
no thoracic pain. 60 of these patients had no thoracic or lumbar
pain, 30 had low back pain only. 73% of the patients had positive
anatomical findings at one or more levels of the thoracic spine
including herniation of the disc in 37%, bulging of a disc in 53%,
annular tear in 58%, deformation of the spinal cord in 29% and
Scheuermann-type end-plate changes or kyphosis in 38%.4
It is important that the history, clinical examination and
imaging findings are correlated in coming to a diagnosis.
Differential diagnosis
Benign thoracic pain
This is diagnosis by exclusion and can only be made after thor-
ough investigation. It is a reasonably well defined entity and
appears more commonly in females in the third decade and is
believed to be due to poor posture. It is usually managed by
postural advice and physical therapy. Dreyfuss et al. performed
a study on nine asymptomatic volunteers demonstrating that
intrarticular injection into the thoracic zygapophyseal (facet)
joints can cause both local and referred pain.5 Keating et al.
showed that thoracic tenderness is not a normal finding in
asymptomatic subjects.6 Stolker et al. have reported on the result
of facet denervation in chronic thoracic spinal pain in 40 patients.
Patients had pain of more than 12 months duration with failed
conservative treatment. A diagnosis of thoracic facet syndrome
was made based on clinical criteria and a positive response to
a prognostic blockade of the medial branch of the dorsal ramus of
the thoracic spinal nerve. The treatment was by percutaneous
65 Ó 2009 Elsevier Ltd. All rights reserved.
 SPINE

Thoracic back Pain

Improved

Red Flag Signs No Reassure, follow up, Not Improved Pain clinics,
present? physical therapy injections, etc

Yes

Image and manage Positive – Treat osteoporosis

Red Flags Signs of accordingly consider cement augmentation
High Velocity
Trauma Screen for Negative – consider cement
osteoporosis augmentation
Low Velocity
Stage and manage Palliative surgery +/-
accordingly radio/chemo therapy
Primary
Tumours Tokuhashi Radical surgery +/-
scoring radio/chemo therapy
Metastatic

Antibiotics and
Stable spine monitor

Infection (confirm
by biopsy)
Stable spine +/ Surgical debridement, stabilisation,
neurological deficit antibiotics, monitor

Medical management. Physical therapy if no

Inflammatory deformity or neurological deficit
Conditions

Surgery for deformity (variable) or

neurological deficit

Scheuermann
Kyphosis/ Monitor – consider surgery for
Scoliosis deformity +/ neurological deficit

Neurology Surgical
symptoms decompression

Disc prolapse
No Neurology Observe
symptoms

Figure 1 Algorithm for the assessment and management of thoracic spine pain.

radiofrequency denervation of the facet joints. At follow-up of
18e54 months 44% were pain free and 39% had more than 50%
pain relief.7
Deformity
Scheuermann’s kyphosis may be a cause of pain. There are two
types. Type 1 is thoracic and produces more deformity than
pain. Type 2 (apprentice’s spine) is thoracolumbar and produces
more pain than deformity. Idiopathic scoliosis is generally
a painless condition. There is a wide variation in symptoms
reported in the literature. Murray et al.8 reported on the natural
history and long term follow-up of Scheuermann’s kyphosis. The
patients who had Scheuermann’s kyphosis had more intense
back pain, jobs that tended to have lower requirement for
activity, less range of motion of extension of the trunk and less
strong extension of the trunk and differential localization of the
pain. No significant differences between the patients and the
control subjects were demonstrated for level of education,
number of days absent from work because of back pain, extent
that the pain interfered with activities of daily living, presence of
numbness in the lower extremities, self-consciousness, self-
esteem, social limitations, use of medication for back pain or
level of recreational activities. Also the patients reported little
preoccupation with their physical appearance. Normal or above
normal pulmonary function was found in patients in whom the
kyphosis was less than 100 . Patients in whom the kyphosis was

ORTHOPAEDICS AND TRAUMA 24:1 66 Ó 2009 Elsevier Ltd. All rights reserved.

more than 100 and the apex of the curve was in the first to
eighth thoracic segments had restrictive lung disease. Five
patients had an unexplained mildly abnormal neurological
examination. Mild scoliosis was common and spondylolisthesis
was not observed. They concluded that although patients who
have Scheuermann’s kyphosis may indeed have some functional
limitations, they do not have major interference with their lives.
Their patients who did not have an operation for the kyphosis,
adapted reasonably well to this condition. They recommended
that the use of operative treatment for Scheuermann kyphosis
should be carefully reviewed.
The prevalence of back pain in children who have idiopathic
scoliosis has been reported by Ramirez et al.9 in a study of 2442
patients. 23% of their patients had back pain at the time of
presentation and an additional 9% had back pain during the
period of observation. There was a significant association
between back pain and an age of more than 15 years, skeletal
maturity, post-menarchal status and a history of injury. There
was no association with gender, family history of scoliosis, limb
length discrepancy, magnitude or type of curve or spinal align-
ment. 9% of the patients who initially presented with back pain
had an underlying pathological condition. They concluded that
‘‘when a patient with scoliosis has back pain, a careful history
should be recorded, a thorough physical examination should be
performed and good quality plain radiographs should be made. If
this initial examination reveals normal findings, a diagnosis of
idiopathic scoliosis can be made, the scoliosis can be treated
appropriately and non-operative treatment can be initiated for
the back pain. It is not necessary to perform extensive diagnostic
studies to evaluate every patient who has scoliosis and back
pain’’.9 It has to kept in mind that infections and tumours of the
spine may present with deformity which may or may not be
painful.
Infections
Discitis with vertebral osteomyelitis (DVO) can present insidi-
ously with low grade thoracic pain and pyrexia though this is not
a constant feature. The classic triad of pain, temperature and
local tenderness may be seen. There may be a history indicating
immunocompromise. Evidence of vertebral osteomyelitis has
been found in prehistoric man as far back as 7000BC. Hippo-
crates was the first to describe this infection of the vertebral
column, subsequently Galen related this infectious process to the
development of spinal deformity. Servino and Pott later charac-
terized and described the pathology of tuberculosis infection of
the spine. In 1879 Lanelonge described bacterial osteomyelitis as
we recognize it today.10
Pyogenic spinal infection encompasses septic discitis, verte-
bral osteomyelitis and epidural abscess.10 Paraspinal abscesses
could also result from spinal infection with spread anteriorly and
or posteriorly. Although surgery is rarely required unlike with
tuberculosis infection.
Approximately 95% of pyogenic vertebral osteomyelitis
involves the anterior elements with only 5% involving the
posterior elements of the spine. This is due to the voluminous
blood supply to the vertebral body in conjunction with its rich
cellular marrow. Predisposing factors for spinal infection include
advancing age, malnutrition, immunocompromise, intravenous
drug abuse, Human Immunodeficiency Virus infection,
ORTHOPAEDICS AND TRAUMA 24:1
SPINE
malignancy, chronic steroid usage, renal failure, septicaemia,
recent spinal surgery and intravascular devices.10 Tuberculous
spine infection is rising in incidence and may be preceded by
pulmonary infection. Tuberculosis in general seems to be
increasing in incidence despite the introduction of effective
chemotherapy.11 Tuberculosis of the spine or Pott’s disease
occurs in less than 1% of patients with tuberculosis. Concurrent
infection of the spine with mycobacterium and pyogenic bacteria
has been reported but is not common.11 There may be localized
tenderness and deformity which is usually a localized angular
kyphosis (gibbus). Neurological deficit may be present initially
or develop during treatment and has to be looked for. It may vary
from meningitis, nerve root compression with radiculopathy,
lower extremity weakness and paraplegia. Presentation with
neurological deficit warrants surgery for decompression and
stabilization. The prognosis for neurological recovery is much
better than with tumour.
Pyogenic discitis if detected early responds well to isolation of
the causative organism and appropriate antibiotic therapy.10 A
short course of empirical antibiotic therapy may lead to negative
culture on blood and biopsy making management difficult. An
uncomplicated course may result in bony ankylosis across the
infected level.9 Late presentation is usually with destruction of
the vertebral end-plate and adjacent bodies resulting in insta-
bility and/or neurological compromise due to deformity or
epidural abscess.12 This may require surgery for decompression
for the neural elements and restoring stability with instrumen-
tation of the affected segments. Haematogenous Meticillin
Resistant Staphylococcus Aureus (MRSA) spondylodiscitis
(DVO) has been reported in 13 patients by Al-Nammari et al.13
All their patients presented with back pain, spinal tenderness and
systemic upset. The thoracic spine was most commonly affected
(53%) compared to lumbar (33%), thoracolumbar junction (7%)
and the cervical spine (7%). They had a mortality of 38%,
neurological deficit was present in 50% of survivors and at 1 year
29% of survivors had MRSA bacteraemia and recurrence of
spondylodiscitis. Biopsy and cultures are important because
occasionally the spinal infection may be caused by unusual
organisms and may not respond to conventional treatment.
Biopsy for presumed infection has occasionally proved to be
tumour.14 Non-operative treatment consists of prolonged courses
of intravenous antibiotics guided by sensitivities if available. The
current recommendation is for 6 weeks of intravenous antibi-
otics.15 In advanced disease states with paraspinal and or
epidural abscess surgical debridement and evacuation of the
abscess followed by instrumented fusion and long term intrave-
nous antibiotics will give the best results. Paraspinal abscesses
without spine instability may be treated by percutaneous image-
guided drainage.
Childhood spinal infection is extremely rare. A true infective
discitis is possible in children due to the persistence of blood
supply to the intervertebral disc. However childhood discitis
presents a non-uniform picture with non-specific and usually
mild symptoms, making it difficult to diagnose. It is more often
non-infectious. Kayser et al.16 have described their series of 25
children treated non-operatively with long term follow-up. Ten of
their patients had thoracic spine involvement. On average their
patients had a delay in diagnosis of 14 weeks. This emphasizes
the need for a high index of suspicion in children presenting with
67 Ó 2009 Elsevier Ltd. All rights reserved.

non-specific symptoms. Figure 2 demonstrates the appearance of
DVO with destructive changes.
Tumours
The thoracic spine is affected by both primary and metastatic
tumours. Primary tumours may be benign or malignant. The
benign primary tumours may be osteogenic such as osteoid
osteoma and osteoblastoma which are more common in the
posterior elements or arise from haematological tissue present in
the vertebral column such as haemangioma, Langerhans cell
histiocytosis. Non-ossifying fibromas may arise from the
connective tissue elements. Malignant primary tumours such as
osteogenic sarcoma, Ewing’s sarcoma, chondrosarcoma and
multiple myeloma may occur.12 Rare tumours such as hae-
mangiosarcomas and malignant haemangiopericytomas are also
occasionally seen. Intra-dural tumours of the spinal cord and the
meninges should also be kept in mind.
Metastatic tumours are the commonest form of malignant
tumour affecting the spine. The published series by Tokuhashi
et al.17 demonstrated that thoracic spine metastases were the
commonest region for all spinal metastatic tumours (cervical
46, thoracic 111, lumbar and sacral 59 out of 183 patients).
MRI of discitis with vertebral osteomyelitis.
Figure 2
ORTHOPAEDICS AND TRAUMA 24:1
SPINE
The primary site may be in the breast, lung, intestine, kidneys
or prostate. Gastro-intestinal tumours are unusual but
rising in incidence. Table 3 shows the location of the primary
tumour in Tokuhashi’s series of 183 patients with spinal
metastasis.17
The National Institute of Clinical Excellence (NICE) has issued
guidelines on the diagnosis and management of suspected
metastatic spinal lesions and spinal cord compression (http://
www.nice.org.uk/nicemedia/pdf/CGFullGuideline.pdf). The guide-
lines state that patients with a known malignant tumour com-
plaining of back pain should be considered to have metastatic
spinal disease until proved otherwise. These patients should
have access to a liaison nurse who should assess patients and
refer for MRI scanning and subsequently arrange a spinal surgery
consultation. They recommend that a liaison nurse, MRI scan-
ning and spinal surgery should be available round the clock.
These Regional Centres guidelines are very comprehensive,
unfortunately the infrastructure required to comply fully is still
not available in all centres. Some patients present with spinal
involvement without a previous diagnosis of tumours elsewhere.
The principles of management of spinal tumours are no different
from bone tumours elsewhere. The priority is to confirm the
68 Ó 2009 Elsevier Ltd. All rights reserved.
 SPINE

Fractures
Location of primary in Tokuhashi’s series High velocity injuries are easy to diagnose based on the history
and clear clinical symptoms and signs. High velocity unstable
Location of primary Number of patients Percentage fractures are generally managed with internal fixation which may
tumour site be posterior alone or combined anterior and posterior. Fusion
across the unstable segments is carried out when there is
Lung 46 25.1
significant soft tissue injury that will not be stable after bony
Kidney 22 12.0
union. Figure 4 shows a CT reconstruction of a high velocity
Prostate 20 10.9
thoracic spine fracture.
Breast 14 7.7
Osteoporotic vertebral compression fractures however may
Liver 13 7.1
present as thoracic back pain with no clear history of trauma and
Stomach 6 3.3
may present with an acute or insidious onset of pain. These
Rectum 6 3.3
patients may be elderly and confused. Younger patients at high
Colon 5 2.7
risk of osteoporosis should also be assessed with this possibility
Pancreas 5 2.7
in mind. Early diagnosis and appropriate management may avoid
Thyroid 4 2.2
prolonged pain and loss of sagittal balance.20
Ovary 4 2.2
Osteoporotic fracture treatment has undergone a revolution
Oesophagus 3 1.6
since the advent of cement augmentation. Fractures that do not
Bladder 3 1.6
become pain free in a designated period of time can be
Other 16 8.7
augmented with bone cement (Poly Methyl Methacrylate) giving
immediate stability and pain relief. There is still heated debate on
Table 3 the relative merits of vertebroplasty vs. kyphoplasty. Verte-
broplasty is believed to be cheaper and needs less operative time
but does not significantly restore vertebral height. Kyphoplasty is
diagnosis and grade with biopsy, stage the disease and carry out more expensive and time consuming but restores vertebral
definitive management. Various scoring systems are available to height to some extent and is also believed to reduce the risk of
guide the management of metastatic spinal tumours such as the cement extravasations.20 Cement augmented restoration of
Tokuhashi prognostic scoring system. The Tokuhashi system of vertebral height ideally with a bioactive cement combined with
scoring gives points for various attributes of the patient and the instrumented fixation is also done in some centres with the aim
type of tumour, which guides in decision-making regarding non- of achieving and maintaining improved sagittal alignment. The
operative treatment, palliative surgery or tumour excision. main concern with cement augmentation is the reported occur-
They have shown good correlation with real and predicted rence of cement leaks which may be epidural (occasionally
outcome. Table 4 summarizes the indications for either non- needing surgical evacuation), into the disc, into the root foramen
operative or operative management in their series. and the para-vertebral veins. Embolization of cement and
The management of primary malignant tumours is complex marrow to the lungs is also an area of concern leading some
due to the presence of the neural elements. Radical curative authors to suggest that no more than three levels should be
excision of a primary tumour or isolated metastasis involves treated at any one time.
complete excision of the involved vertebra (spondylectomy).
This often requires a combined anterior and posterior surgery Degenerative conditions
with risk of neurological deficit and other systemic complica- Degenerative disc disease is unusual in the thoracic spine. The
tions. Tumour-like lesions are rare. Sarcoidosis of the thoracic lower thoracic spine is more prone to develop this condition. The
spine occurring in the vertebral body and extending posteriorly thoracic spine has a physiological kyphosis and the canal is also
has been reported in the literature.18 Sarcoidosis has also been relatively narrow and therefore any prolapse of the thoracic
reported to occur as an intra-dural extra-medullary mass.19 intervertebral disc has the potential to cause spinal cord
Figure 3 demonstrates the MRI appearance of a metastatic spine compression. The literature appears to suggest that most patients
lesion with spinal cord compression and post-operative radio- with a thoracic intervertebral disc prolapse are asymptomatic,4
graphs after decompression and fixation. however there are several papers documenting the catastrophic

Indications for non-operative management Indications for operative management

High sensitivity to hormone therapy or radiotherapy with less Pain and/or paralysis due to collapse of the spine
than 6 months life expectancy
Poor general condition Pain and paralysis due to tumour invasion of the spinal cord
Patient does not demonstrate will to live Radio resistant cancers
Did not consent to surgery

Table 4

ORTHOPAEDICS AND TRAUMA 24:1 69 Ó 2009 Elsevier Ltd. All rights reserved.

MRI of metastatic spinal tumour.
Figure 3
effects of thoracic intervertebral disc prolapse.21,22 In this situa-
tion prompt diagnosis and decompression are required for a full
neurological recovery. The gloom which surrounded the condi-
tion of thoracic disc protrusion has lightened, and in part with
improved diagnostic facility, in part with the development of new
surgical techniques. The earliest record of a patient treated by
operation was that of Adson in 1922 at the Mayo clinic, reported
by Love and Schorn in 1965.22
The surgical treatment of the prolapsed symptomatic inter-
vertebral disc has undergone significant evolution. Early
surgeons attempted to remove them posteriorly through a lam-
inectomy and decompression but this was associated with a high
incidence of failure to recover and some deterioration in
neurology.22 Newer techniques have approached the spine from
the front or laterally. More recently video-assisted thoracic
decompression is gaining favour in areas where this is avail-
able.23 Benson and Byrnes described a series of 22 patients22 of
whom only 11 patients complained of back pain and this was
poorly localized. The back pain when present was typically not
severe and was relieved by rest, it invariably preceded the signs
of cord compression. Leg pain was common but followed no
ORTHOPAEDICS AND TRAUMA 24:1
SPINE
specific pattern, most frequently aching pain was felt at one or
both knees. Pain at the hip, ankle or foot was also mentioned.
The quality of the pain was also variable. It was sometimes
constant, cramping or spasmodic. It could be dull, burning or
lancinating. One third of patients experienced girdle pain. Most
patients complained of sensory symptoms other than pain. These
were usually of numbness or coldness in the legs. Patients rarely
complained of paresthesiae. All but one patient complained of
weakness or heaviness in the legs. Bilateral weakness was twice
as common as unilateral weakness. Weakness was progressive in
every patient. Examination showed that power was impaired in
all but two patients. Weakness of the lower abdominal muscles,
well demonstrated when the umbilicus is seen to rise as the
patient attempts to sit upright, was a frequent observation. Most
patients had increased lower limb muscle tone. Lower abdominal
reflexes were absent, knee and ankle responses were exaggerated
and the plantar responses were extensor. Symptomatic patients
with neurological involvement should have surgical decom-
pression to improve the prognosis. Figure 5 shows MRI images of
a patient with significant spinal cord compression from
a prolapsed thoracic intervertebral disc.
70 Ó 2009 Elsevier Ltd. All rights reserved.

Chance fracture of thoracic spine (CT).
Figure 4
The management of prolapsed thoracic intervertebral disc in
our institution is based on the location of the prolapse. The trans-
thoracic route is used in predominantly central prolapses.24
Figure 6 demonstrates the trans-thoracic approach before and
after excision of the prolapsed disc.
Ossification of the posterior longitudinal ligament (OPLL):
This can present as vague pains and usually comes to medical
attention with neurological impairment with a change in gait and
progressive neurological deficit. It is a very rare condition and is
more often seen in countries of the far east. Adequate decom-
pression is necessary for improvement in neurology deficit. As
the compression is predominantly anterior it is best approached
Prolapse of thoracic intervertebral disc.
Figure 5
ORTHOPAEDICS AND TRAUMA 24:1
SPINE
anteriorly. In Japan OPLL has been officially recognized as
a difficult disease by the Public Health Bureau of the Ministry of
Health and Welfare of the Japanese government. Hanai et al.25
have described anterior decompression in 12 patients with
thoracic OPLL good results were seen in patients with complete
removal of the ossification. Both Hanai et al. and Yamazaki et al.
have reported that laminectomy alone is not effective in this
condition.25,26
Spondylarthropathies
The spondylarthropathies have been defined as the presence of
inflammatory spinal pain or synovitis and one or more of the
following.27
71 Ó 2009 Elsevier Ltd. All rights reserved.

Trans-thoracic decompression of intervertebral disc prolapse.
Figure 6
1. Positive family history in first or second degree relatives of
patients with ankylosing spondylitis, psoriatic arthropathy,
acute iritis, reactive arthritis or inflammatory bowel disease.
2. Psoriasis
3. Inflammatory bowel disease
4. Alternating buttock pain
5. Enthesitis
6. Acute diarrhoea
7. Urethritis
8. Sacro-iliitis: bilateral Grade 2e4 changes or unilateral 3e4
changes.
The most common of this group of diseases is ankylosing
spondylitis (AS). It affects approximately 1 in 200 adults with
a variable prevalence. Symptoms usually start in the low back and
with time ascend to the thoracic spine. It is associated with
morning stiffness and restriction of chest expansion due to
involvement of the costo-vertebral joints. Patients develop acute
iritis at some stage in the disease process. Bones become osteo-
porotic and patients with AS are five times more likely to get
fractures than the general population. These fractures may be
overlooked or attributed to exacerbation of the AS. These fractures
are prone to pseudarthrosis and may cause neurological deficit if
unstable. Immobilization of these patients on a rigid spinal board
may also cause neurological deficit if their usual spine shape is not
respected. Inflammation of the disc (aseptic) may occur more
commonly in the mid-thoracic spine and is usually asymptomatic
and noticed as an incidental finding on imaging.
Other associated conditions are
1. The arthritis associated with chronic inflammatory bowel
disease such as ulcerative colitis and Crohn’s disease and
with psoriasis
2. Juvenile chronic arthritis
3. Reactive arthritis such as Reiter’s syndrome
4. Undifferentiated forms
Summary
Thoracic back pain is not a complaint to take lightly. Patients
who present with this system should be thoroughly assessed and
referred appropriately and in a timely manner. A 2: 226e37.
ORTHOPAEDICS AND TRAUMA 24:1
SPINE
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