History and Examination

As in any disorder, the consulting chiropractic practitioner must explore a thorough history when investigating thoracic pain. One should diligently question the patient about viscerogenesis, being mindful of systemic signs of disease and visceral referral patterns in somatic pain syndromes. The clinician must be ever alert to the possibility of cardiac or lung pathology that gives rise to symptoms of a suspected cervicogenic dorsalgia, especially when results of testing of the relevant musculoskeletal structures are normal. Lack of reproducible symptoms on stress testing all relevant musculoskeletal structures is a definite worry to an astute clinician as is any diagnosis that relies solely on the palpation of a tender point in a soft tissue structure.

Beware the empty orthopedic examination. Radiographs of the cervicodorsal region showing degenerative change and or structural malpositions may prove misleading, especially when stress tests of the relevant structures prove negative. It has been observed that a lesioned gut, for example, a duodenal ulcer, is one of the most frequent progenitors of viscerogenic thoracic pain, with cholecystic disease a more distant second. Clinically, herpes zoster has often arisen as a nonmusculoskeletal cause of dorsalgia. Grouped vesicular lesions or a nest of small ruptured vesicles often bears witness to the herpetic origin of the dorsal pain. The greatest diagnostic difficulty arises when there is no apparent development of a herpetic dermatologic lesion or the lesions rise and pass undetected by the patient or his or her doctor. Occasionally in herpes zoster, pain precedes the vesicular eruption by a number of months even in the relatively young adult. The vesicular lesion when it does arise may be so insignificant as to be dismissed as nothing more than a small pimple.

From a historical perspective there is occasionally an obvious clue as to the cervical origin of the patient’s dorsal complaint: “Doctor, when I turn my head to the left I get a stabbing pain in my left shoulder blade.” or “Doctor, I have a heavy pain in my mid back and my neck is stiff and hurts to move in all directions.” This type of historical comment is most often encountered when dorsal pain is of recent origin.

Much less obvious is the chronic cervicogenic dorsalgia of four to five years or more duration or the low-grade subacute case of several months duration wherein neck symptoms are entirely denied or passed off as insignificant. A methodical search of the patient’s history for incidents of neck trauma, such as motor vehicle accidents, sports injuries, or ancillary symptoms such as recurrent headaches, upper extremity pain, paresthesia, or chest pain of unknown origin, may often prove rewarding! If no overt trauma is encountered in the history, often a clue may be obtained by exploring the nature of the patient’s employment. In the chronic cases of cervicogenic dorsalgia, the patient is often engaged in a desk-computer type occupation or some other vocation of static effort, with the cervical spine flexed, shoulders sloped, elbows unsupported, and the suspensory apparatus of the neck and upper back unduly taxed. Often, the patient seeks relief of the painful dorsalgia by abandoning the irritating posture in favor of walking about or lying down. Most cervicogenic dorsalgia is eased by rest, although the occasional case is exacerbated by eccentric postures of the neck while sleeping.

Etiological Mechanism

Each cervical nerve innervates structures derived from the same somite (embryological origin), i.e., dermatomal (skin), myotomal (muscle), and sclerotomal (bone). The final locations of the dermatome, myotome, and sclerotome may be remote from each other. Referred pain due to cervical spine dysfunction may be perceived in any or all of the various somatic components of a nerve root.

The widespread distribution of signs and symptoms resulting from spinal muscle and joint dysfunction, including subluxation syndromes, may be explained by this mechanism. For example, pain or paresthesia perceived in the anterior or posterior chest, the shoulder, and/or down the arm may be due to irritation of the C7 zygapophyseal joint. Terrettt³ notes that “the posterior thorax is interesting in that interposed between the thoracic dermatome (the skin) and the thoracic sclerotome and myotome (the ribs and intercostal muscles) lies part of the C5-C7 sclerotome (Figure 21-1) and C3-C6 myotome (Figure 21-2).”

Figure 21-1 C5, C6, C7 sclerotomes of the scapula.

(From Terrett AGJ, Terrett RG. Chiro J Aust 2002;32:42-51.)

Figure 21-2 C3, C4, C5, C6 myotomes of the posterior thorax.

(From Terrett AGJ, Terrett RG. Chiro J Aust 2002;32:42-51.)

Pain Referral Patterns

Pain referral patterns have been mapped in studies involving irritation of posterior rami innervated tissues at the C4-5, C5-6, and C6-7 levels. Figures 21-3, 21-4, and 21-5 illustrate these referral patterns. On the left of each diagram are the referral pain patterns from irritation of paravertebral muscles,^4,5 and on the right side are the referral pain patterns from irritation of the zygapophyseal joints.^6–8

Figure 21-3 Left side: Referred pain pattern from irritation of paraspinal tissues between C4 and C5.^4,5 Right side: Referred pain pattern from irritation of zygapophyseal joints between C4 and C5 levels.^7,8

(From Terrett AGJ, Terrett RG. Chiro J Aust 2002;32:42-51.)

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