Chest and back pain
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Understanding Chest and Back Pain: Causes, Diagnosis, and Management
Common Causes of Chest and Back Pain
Acute Aortic Syndrome and Aortic Dissection
Acute aortic syndrome, including aortic dissection, is a critical condition that can present with severe chest pain radiating to the back. This condition often mimics other serious conditions like acute coronary syndrome and pulmonary embolism, but requires different management strategies. Aortic dissection is particularly common in men aged 55-65 and presents with symptoms such as sudden onset chest pain, radiating to the back, and may include neurological deficits like limb weakness.
Musculoskeletal Causes
Musculoskeletal issues, such as hyperactivity of the dorsal scapular nerve or long thoracic nerve, can lead to chest and back pain. This pain is often localized to the rhomboid or serratus anterior muscles and may be due to spasms of the scalenus medius muscle. Treatments like trigger point injections, physical therapy, laser therapy, or NSAIDs can be effective in managing this type of pain.
Spondyloarthritis and Anterior Chest Wall Pain
In patients with inflammatory back pain suggestive of spondyloarthritis (SpA), anterior chest wall (ACW) pain is a common symptom. This pain is associated with more severe disease features, including enthesitis, thoracic spine involvement, and radiographic sacroiliitis. ACW pain can be a diagnostic feature for ankylosing spondylitis (AS).
Diagnostic Approaches
Physical Examination Tests (PETs)
Physical examination tests are crucial for screening and referral of patients with chest or back pain caused by serious pathology. Common tests include cardiac and pulmonary auscultation, lung percussion, and blood pressure measurements. However, the utilization of these tests varies among healthcare professionals, with doctors and nurses less frequently assessing the range of motion of the thoracolumbar spine and hip.
Imaging and Laboratory Tests
For acute conditions like aortic dissection, imaging such as computed tomography (CT) scans of the chest and abdomen are essential for diagnosis. Initial blood investigations, including cardiac enzymes, may remain within normal limits, making imaging crucial for accurate diagnosis. In cases of chest pain with atypical presentations, such as those seen in women with acute myocardial infarction, additional tests like ECG and troponin levels are important.
Case Studies
Case of Aortic Dissection
A 26-year-old male presented with severe chest pain radiating to the upper back, described as a tearing sensation. His examination revealed a diastolic murmur and a widened mediastinum on chest x-ray, indicative of aortic dissection. Another case involved a 55-year-old man with similar symptoms, who developed left arm weakness and absent pulses, further supporting the diagnosis of aortic dissection.
Case of Musculoskeletal Pain
A 22-year-old male with a history of right upper back pain and dilated veins over his chest was found to have a mass in the right atrium. This case highlights the importance of considering musculoskeletal and other non-cardiac causes of chest and back pain.
Conclusion
Chest and back pain can arise from a variety of causes, ranging from life-threatening conditions like aortic dissection to musculoskeletal issues. Accurate diagnosis requires a combination of physical examination tests, imaging, and laboratory investigations. Understanding the underlying cause is crucial for effective management and treatment. Further research and standardized reporting of physical examination tests are needed to improve diagnostic accuracy and patient outcomes.
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