Osteoarticular pain in the thoracic spine and chest

Chest pain is a very common symptom that causes great concern. After all, we all know that this is how diseases of the cardiovascular system manifest themselves. But in reality, this symptom may indicate other disorders in the body, in particular pathologies of the gastrointestinal tract, respiratory system and even the spine. In any case, such a sign cannot be ignored, especially with acute pain, since extremely dangerous conditions, for example, pulmonary embolism and myocardial infarction, can manifest themselves in this way. With them, the patient’s life directly depends on the urgency of providing qualified medical care. Let's look at the main causes of chest pain and their distinctive signs.

Diseases of the cardiovascular system

Pathologies of the heart and blood vessels still remain among the most common, which is largely due to the lifestyle of modern people. The most common causes of chest pain are:

• angina pectoris;
• myocardial infarction;
• pericarditis.

Angina pectoris

Angina pectoris is one of the clinical forms of coronary heart disease (CHD). It is a consequence of a decrease in the amount of oxygen entering the heart muscle (myocardium) due to impaired blood flow in the arteries (ischemia). This may be the result of the development of atherosclerosis of the coronary arteries, which leads to a decrease in their lumen, spasm of blood vessels or thrombosis and other disorders. The consequence in all cases is a deficiency of oxygen in the myocardium, which provokes the occurrence of characteristic symptoms:

• dull, pressing or pulling pain behind the sternum (sometimes it is localized in the region of the heart), tending to radiate to the left shoulder and the inner surface of the left arm, less often to the neck, right arm and stomach and passes when physical activity stops and the transition to a calm state, so attacks usually last less than 5 minutes;
• dyspnea;
• increased diastolic (lower) blood pressure.

A distinctive sign of angina pectoris is the occurrence of an attack during physical activity, transition from heat to cold, especially in strong winds. But the most pathognomonic symptom is the rapid elimination of pain after taking nitroglycerin.

Myocardial infarction

Myocardial infarction is a condition that requires emergency medical attention. It is a consequence of the progression of coronary artery disease, and in some cases the disease begins with it. This is a severe complication of myocardial ischemia, in which foci of necrosis, i.e., tissue death, form in it. This most often results from rupture of an atherosclerotic plaque. This triggers a whole chain of changes, the result of which is occlusion (blocking) of the coronary artery, which leads to the cessation of nutrition of the corresponding section of the myocardium and the development of ischemic necrosis.

Myocardial infarction is accompanied by severe, excruciating pain behind the sternum, which in nature can be either pressing, bursting or squeezing, or burning, stabbing, or felt like a blow to the heart. It is in many ways similar to an attack of angina, but is much stronger and more often accompanied by a fear of death. The pain is localized in the area behind the sternum and usually spreads to the left, less often it covers the entire surface of the chest and radiates to the stomach, reminiscent of appendicitis, exacerbation of gastric ulcer, etc.

Pain during myocardial infarction radiates to the left shoulder, forearm, hand, and more often it radiates to the little finger and ring finger. They can also radiate to the right hand or to the stomach area, under the shoulder blades, the left side of the neck, jaw, or ear.

The attack can last 15-30 minutes, but more often it drags on for several hours up to 24 hours. In addition to chest pain, this may be accompanied by:

• decreased blood pressure;
• nausea, vomiting;
• shortness of breath;
• severe weakness, combined with increased emotional arousal due to fear of death;
• dizziness;
• cold sweat;
• feeling of heartbeat;
• headache;
• pallor, marbling of the skin;
• tremor.

Shortly before the onset of pain, the following may be observed:

• varying degrees of chest discomfort or pain, as with angina pectoris, but occurring against the background of complete calm or with little physical activity;
• dyspnea;
• weakness;
• dizziness.

Myocardial infarction differs from an attack of angina pectoris in the severity of pain and the duration of its persistence. Also, during a heart attack, taking nitroglycerin leads to only a slight improvement or has no effect at all.

Pericarditis

Pericarditis is a disease accompanied by inflammation of the pericardial sac. Most often, its development is caused by concomitant disorders (viral, bacterial, fungal infections, in particular tuberculosis and borreliosis, as well as metastatic lesions, metabolic disorders), although it can also be a consequence of exposure to ionizing radiation, trauma, or occur in the absence of visible signs. causes (idiopathic pericarditis).

There are acute and chronic pericarditis. In the first case, the following are observed:

• pressing pain in the chest in the area of ​​the heart of varying degrees of intensity, sometimes radiating to the left arm;
• increased pain when taking a deep breath, coughing and swallowing;
• reduction of pain when taking a sitting position, slightly leaning forward, and intensification in a supine position.

With chronic pericarditis, moderate chest pain and shortness of breath are observed. Often, patients previously noticed an increase in body temperature, weakness, muscle discomfort and other typical symptoms of infectious diseases.

With pericarditis, pain is relatively constant, and its severity increases gradually. Taking nitroglycerin does not eliminate the ailment, although NSAIDs (ibuprofen and others) help improve well-being.

Treatment

Help before diagnosis

A person with pain syndrome needs to be seated, freed from restrictive clothing, and provided with access to fresh air. If the patient suffers from cardiovascular pathology and is prescribed treatment, in case of exacerbation it is necessary to take nitroglycerin or other drugs as recommended by the doctor. In all situations where there is pain in the left chest, consultation with a specialist is required who can exclude or confirm serious cardiac and respiratory diseases.

Conservative therapy

For severe pain caused by myocardial infarction or pulmonary embolism, narcotic analgesics are indicated to help prevent the development of painful shock. Further therapy depends on the diagnosis. In case of cardiac pathology, the time of initiation of treatment is important; a delay of several hours can cause serious complications. For etiotropic treatment of diseases that manifest themselves as pain in the left areas of the chest, medications such as:

• Antianginal agents
  . As first aid for a painful attack of angina, nitroglycerin is prescribed under the tongue or intravenously. Beta blockers, calcium antagonists, myotropic antispasmodics increase blood supply to the myocardium and reduce its need for oxygen.
• Anticoagulants
  . The drugs improve the rheological properties of blood and inhibit the activity of the hemostatic system, thereby reducing the risk of thrombosis and myocardial infarction. Heparin and its low molecular weight fractions are used, and acetylsalicylic acid is taken in low doses for a long time.
• Thrombolytics
  . The indication for their use is pain in the left chest due to a heart attack in the first 6 hours after the onset of symptoms. The drugs increase the activity of the fibrinolytic system and stimulate thrombus lysis. They contribute to the complete restoration of blood flow in the affected vessel.
• Lipid-lowering drugs
  . The drugs normalize the concentration of cholesterol and low-density lipoproteins, which cause the appearance of atherosclerotic deposits in the vessels. They are prescribed in long courses in combination with a special diet that includes limiting animal fats.
• Antibiotics
  . For pneumonia and exudative pleurisy, antibacterial agents from the group of cephalosporins and macrolides are effective. For severe lobar pneumonia, combinations of two medications are indicated. To treat infective endocarditis, penicillin is administered over a course of at least 4 weeks.
• Antidepressants
  . To eliminate the psychogenic cause of left chest discomfort, selective serotonin receptor agonists are recommended. Medicines normalize mood and eliminate apathy. If necessary, the drugs are combined with weak psychostimulants and tranquilizers.

Surgery

To restore arterial patency in patients with coronary artery disease and myocardial infarction, endovascular technologies are used - angioplasty and stenting under the control of selective angiography. In case of extensive changes in the intima of the vascular wall, coronary artery bypass grafting is performed, which improves blood supply to the heart. For diaphragmatic hernias, the following surgical interventions are used: suturing the hernial orifice and strengthening the ligamentous apparatus (crurorrhaphy), fixation of the stomach in the abdominal cavity (gastropexy), elimination of gastroesophageal reflux.

Gastrointestinal pathologies

Diseases of the gastrointestinal tract, or more precisely the esophagus, can also provoke the appearance of chest pain. In such cases, they often radiate to the back, to the right and left of the sternum, and in most cases they are associated with food intake and are associated with swallowing disorders.

Swallowing problems are called dysphagia.

Most often, patients with complaints of chest pain are diagnosed with:

• esophageal diverticulum;
• gastroesophageal reflux disease (GERD);
• hiatal hernia;
• spasm of the esophagus (esophagospasm).

Esophageal diverticulum

A diverticulum of the esophagus is a protrusion of its wall with the formation of a kind of “pocket” in which food accumulates. Clinical manifestations of the disease usually occur when the size of the diverticulum is more than 2 cm. In such cases, periodic pain in the sternum and back is observed, as well as regurgitation of chewed food. Sometimes the body temperature also rises to subfebrile levels.

GERD

GERD is a chronic disease accompanied by the reflux of stomach contents into the esophagus, and in some cases, the contents of the duodenum. This causes irritation of the mucous membrane and its inflammation.

With GERD, chest pain is localized in the center and left, which often causes concern in patients. In some cases, they spread to other parts of the sternum. The intensity of pain can vary from mild discomfort to quite severe pain. Their appearance is associated with food, but sometimes they also occur after smoking, and some patients complain of chest pain when they lie down, including at night.

Also with GERD the following may be observed:

• heartburn that occurs when the body bends forward or in a lying position;
• belching of air or food;
• feeling of heaviness, bloating;
• fast saturation;
• dysphagia or pain when swallowing.

A characteristic feature of GERD is the onset of all symptoms directly during or immediately after eating. Also a pathognomonic manifestation is improvement in well-being after taking antacids and changing body position to vertical and walking.

Hiatal hernia

A hiatal hernia means a displacement into the chest cavity of those anatomical structures that should normally be located underneath it, in particular the abdominal segment of the esophagus, the cardia of the stomach, or even intestinal loops. With age, the risk of developing pathology progressively increases; as a result, it is found in 69% of people over 70 years of age.

A diaphragmatic hernia is not always accompanied by chest pain. In fact, very often it is asymptomatic and is discovered by chance during an examination regarding complaints of other disorders of the gastrointestinal tract. But in about 50% of cases, a hiatal hernia leads to pain in the central abdomen just below the ribs, spreading along the esophagus or radiating to the area between the shoulder blades and the back. Less often, they are encircling in nature or localized only behind the sternum, thereby resembling the clinical picture of pancreatitis or angina pectoris, myocardial infarction.

Another symptom of the disease may be heart rhythm disturbances. This leads to fairly frequent diagnostic errors, and therefore the prescription of treatment that does not lead to improvement. To avoid this, it is important to trace the conditions for the onset of pain. The presence of a diaphragmatic hernia is indicated by:

• the appearance of pain after eating, during physical activity, coughing and lying down;
• reduction or complete disappearance of discomfort after belching, taking a deep breath, changing body position, or after the patient drinks a glass of water;
• increased pain when bending forward;
• the occurrence of swallowing disorders, especially when consuming liquid and puree foods, very cold or, conversely, very hot drinks, as well as when rushing while eating.

A hernia is dangerous due to strangulation. In this case, severe cramping pain occurs in the chest, radiating to the back. This is accompanied by nausea, vomiting, often with blood, as well as increased heart rate, decreased blood pressure and shortness of breath.

Also, the disease is often complicated by the development of GERD. Therefore, the characteristic signs of reflux are subsequently added to the existing symptoms.

Esophagospasm

The spasm occurs at the junction of the esophagus and the stomach. This is accompanied by symptoms very similar to those of angina pectoris. The pain can be quite severe. They are localized in the heart area, but can radiate to the neck, lower jaw and shoulders, but unlike angina, they appear during meals and can persist not only for several minutes, but also for hours. This is accompanied by dysphagia and a feeling of difficulty passing food, which can quickly subside after drinking warm drinks, in particular tea or water.

Esophagospasm has a reflex origin and usually accompanies other diseases of the gastrointestinal tract, including GERD, peptic ulcer of the stomach and duodenum, hiatal hernia, cholecystitis, etc.

But esophagospasm can be relieved by taking nitroglycerin, since the esophagus is also formed by smooth muscle fibers.

Diagnostics

Complaints of pain in the sternum are grounds for visiting a general practitioner. The specialist carries out a primary examination to determine the cause of chest pain: collecting data on the time of onset and dynamics of development of the disorder, conducting standard laboratory and clarifying instrumental methods. The greatest diagnostic value is:

• Electrocardiography
  . An ECG is necessary to confirm or exclude an ischemic cause of chest pain. Disturbances in the functioning of the heart are indicated by expansion and deformation of the ventricular complexes, changes in the length of intervals, and their shift relative to the isoelectric axis. To exclude pathology of the heart valve apparatus, echocardiography is prescribed.
• Radiography
  . On a standard x-ray, the OGK looks for signs of widening of the mediastinum and displacement of organs from the center of the sternum. An indirect sign of bronchitis is increased bronchial pattern and deformation of the roots of the lungs. For a detailed study of the identified tumor or granulomatous neoplasm, spiral CT of the chest cavity is used.
• Gastroscopy
  . Pain that is felt in the middle of the sternum after eating is an indication for endoscopic examination of the esophagus and stomach. In the case of GERD, upon examination, a specialist notices hyperemia and swelling of the esophageal mucosa, erosion or ulcer of the esophagus. The EGDS method is informative for diagnosing destructive processes and ruptures of the esophagus.
• Lab tests
  . To exclude myocardial infarction, a troponin test is recommended to determine the level of creatine phosphokinase. Multiple bacteriological culture of sputum is necessary if tuberculous lesions of the mediastinal organs are suspected. A standard clinical blood test can detect leukocytosis and the presence of immature cells.

Electrocardiography is a method of differential diagnosis of chest pain

Diseases of the respiratory system

Pathologies of the pleura and pleural cavity, as well as the lungs themselves, can provoke pain in the chest. A distinctive feature of these diseases is the presence of a connection between pain and breathing: it increases with inhalation and decreases with exhalation. This causes an involuntary decrease in breathing rate - it becomes frequent and superficial. Most often, chest pain in such situations is caused by pneumonia, pleurisy, pleural empyema and tumors of the bronchopulmonary localization and pleura.

Pneumonia

Pneumonia is inflammation of the lungs that occurs as a result of damage to the lung tissue by a variety of bacteria, viruses or fungi. Most often, it is a consequence of acute respiratory infections, including infection with a new strain of coronavirus, which is accompanied by a deterioration in the patient’s condition after a temporary improvement.

As a result, pneumonia has typical symptoms characteristic of most respiratory infections:

• rapid increase in body temperature to 38 °C and above;
• chills;
• headache;
• decreased appetite;
• cough is initially dry, and then with sputum, less often hemoptysis;
• dyspnea;
• superficial or deep pain in the chest, which tends to intensify with coughing and breathing;
• muscle weakness, joint discomfort;
• general weakness, depression.

Today, diagnosing pneumonia is not difficult and is usually detected during the initial examination of the patient.

Pleurisy

Pleurisy is inflammation of the pleural layers covering the surface of the lungs and chest wall. This is accompanied by the formation of fibrinous deposits or the accumulation of liquid exudate in the cavity formed by two layers of the pleura. This may be a consequence of an infectious lung infection, in particular tuberculosis, although it also occurs with bacterial, viral and fungal infections of other origins. Also, pleurisy can develop against the background of rheumatism, after myocardial infarction, as well as with gastrointestinal pathologies and in some other cases.

There are dry and exudative pleurisy, and the second form is often a consequence of untimely treatment of dry pleurisy. In such cases the following are observed:

• intermittent chest pain, aggravated by deep breathing, coughing, swallowing, and in some cases, by tilting the body in the opposite direction;
• pain radiating to the stomach, shoulder;
• severe, prolonged hiccups;
• lag of the affected half of the chest when breathing;
• dry cough;
• dyspnea;
• weakness, decreased performance;
• increase in body temperature to subfebrile values;

With pleurisy, there is often a friction noise between the layers of the pleura, which resembles the creaking of snow underfoot. Moreover, if you place your palm on your chest, you can feel their friction.

With exudative pleurisy, pain is present at the beginning of the development of the disease and at the end. But after a sufficient volume of exudate accumulates in the pleural cavity, they disappear. The remaining symptoms are generally similar to those of dry pleurisy.

Empyema of the pleura

Pleural empyema, in fact, is one of the variants of the course of pleurisy, but unlike other forms, it is characterized by the accumulation of pus in the pleural cavity. It can be a consequence of pneumonia (pneumonia), the formation of tumors, cysts, bronchiectasis and other disorders of the lungs, less often in the abdominal organs.

The pathology is characterized by:

• chest pain;
• dyspnea;
• fever;
• chills;
• decreased appetite;
• forced position of the body (lying on the sore side).

The development of pleural empyema requires hospitalization in the surgical department.

Tumors of the lungs and pleura

There are many types of benign and malignant neoplasms that can affect the lungs, bronchi and pleura. They are often accompanied by recurrent pleurisy with constantly increasing pain on the affected side. But direct chest pain caused by a neoplasm, especially a malignant one, occurs after it reaches a large size. This significantly worsens the prognosis, although today there are methods for treating even large tumors that were previously considered inoperable.

Spine pathologies

When chest pain appears, it is difficult to immediately suspect its cause in the development of spinal diseases. Nevertheless, osteochondrosis of the thoracic region and intercostal neuralgia can also make themselves felt in a similar way.

Osteochondrosis of the thoracic spine

Osteochondrosis is the process of dehydration of intervertebral discs and the occurrence of degenerative changes in them. Damage to the thoracic region is much less common than to the cervical or lumbar, and the symptoms are largely reminiscent of angina pectoris and gastrointestinal pathologies. Therefore, patients are often falsely diagnosed with other diseases, and treatment that does not bring results is prescribed.

The risk of developing osteochondrosis directly depends on lifestyle. Therefore, if previously it was mainly found in older people, today it is often detected in young people. Prolonged, regular sitting increases the likelihood of dehydration and progressive degeneration of the discs in the thoracic spine. Therefore, it is most often diagnosed in people who are forced to sit for a long time at a computer, behind the wheel of a car, at a machine, etc.

Osteochondrosis of the thoracic region can manifest itself:

• constant dull pain between the shoulder blades;
• girdle pain localized at the level of the armpits;
• pain in the heart and behind the sternum;
• burning sensation in the back.

A characteristic feature is the occurrence of painful sensations after prolonged sitting, at the end of the working day.

The main danger of osteochondrosis is its steady progression, especially in the absence of comprehensive treatment. As a result, over time, the affected disc, which is a dense cartilage with a jelly-like internal content, becomes deformed and bulges, usually towards the spinal canal. This is called protrusion. Subsequently, it can transform into an intervertebral hernia, which means the final rupture of the outer dense ring of the disc, through which the jelly-like internal contents (nucleus pulposus) can exit into the spinal canal. This is dangerous due to the infringement of the spinal roots passing here and even the spinal cord itself, which will lead to disruptions in the functioning of the internal organs innervated by them, shooting pains, numbness and other sensitivity disorders.

Intercostal neuralgia

Intercostal neuralgia is a consequence of damage to the peripheral nerves passing through the tissues in the area of ​​the intercostal spaces. This may be due to their mechanical compression, herpetic infection, hypothermia, exposure to toxic substances, injuries and other factors.

With intercostal neuralgia, the pain is lumbago-like or burning. They spread along the ribs to the sternum. They can be either short-term or last for hours or even days. When touching the skin in the intercostal spaces, changing body position, walking, deep breathing, coughing, the pain intensifies.

Tactics for determining the cause of chest pain

When discomfort or chest pain occurs, patients often initially turn to a therapist, which is very rational. At the appointment, the doctor initially finds out the nature of the complaints. Much attention is paid to:

• localization of pain (left, right, center or girdling, deep or superficial);
• intensity (the severity of painful sensations is not always equivalent to the existing threat);
• character (squeezing, pressing, dull, aching, stabbing, shooting, etc.);
• conditions of occurrence (during physical activity, eating, transition from heat to cold, at rest, when taking a horizontal position, etc.);
• conditions of termination (after rest, when walking, after eating, drinking, drinking nitroglycerin, when lying on the sick or healthy side, after belching, vomiting);
• duration;
• accompanying symptoms;
• irradiation (in the left arm, neck, jaw, between the shoulder blades, in the stomach, etc.);
• the duration of the pain.

The doctor must find out whether there have been recent injuries to the chest or spine. Mention of such episodes makes it possible to simplify diagnosis and quickly determine the cause of chest pain.

Physical examination

The second stage of diagnosis is a physical examination. It involves sequential execution:

• examination of the skin and mucous membranes for rashes, color changes, and signs of cyanosis;
• assessment of pulse in the radial and femoral arteries;
• blood pressure measurements;
• palpation of the chest, muscles, spinous processes of the vertebrae, identifying symptoms of radicular syndrome;
• percussion (tapping) of the chest;
• auscultation of the heart and lungs (heart sounds are assessed, murmurs, wheezing in the lungs, the sound of pleural friction are detected);
• palpation of the abdomen;
• examination of the lower extremities for signs of varicose veins, thrombophlebitis.

The suspected cause of pain can be detected at any stage of the examination. As a result, the patient receives an appointment for laboratory and instrumental diagnostics.

Causes

The list of main causes of intercostal neuralgia includes:

• degenerative-dystrophic diseases of the spine: osteochondrosis, arthrosis, hernias and protrusions of discs, etc.;
• uneven or excessive load on the spine and back muscles (due to carrying heavy objects, poor posture, etc.);
• spinal column deformities (primarily scoliosis);
• diseases of the nervous system, in particular multiple sclerosis;
• infectious lesions: tuberculosis, herpes zoster, influenza;
• injuries of the spine and chest, surgical interventions in this area;
• tumors in the ribs, sternum, spinal column;
• taking certain medications;
• increased load on the respiratory muscles and abdominal muscles;
• increased intra-abdominal pressure, including during pregnancy.

In addition, intercostal neuralgia can occur secondary to other diseases, for example, pleurisy, pathology of the digestive system, kidney disease, thyrotoxicosis, and immunodeficiency states. Adolescents during the period of active skeletal growth may also experience similar symptoms.