Chronic chest pain is one of the common clinical complaints in cardiology, thoracic surgery or pain clinic. Most patients may be due to heart and vascular system problems. Although some patients have done various routine examinations of the heart or lungs, there is no obvious abnormality. Patients can have recurrent attacks for a long time, and the longest medical history can exceed 10 years. This part of patients with chronic or recurrent chest pain often rush between clinical departments, which makes diagnosis difficult and patients can not be treated in time for a long time. People have also given many names: idiopathic chest pain, thoracic nerve root neuralgia, spinal nerve root neuralgia and so on. Physiological characteristics of thoracic spine The spine is the central pillar of human body, and its main functions include bearing, supporting, balancing and conducting the weight of head, trunk and upper limbs and additional gravity movements. Flexion, extension, rotation and lateral flexion, absorbing shock, stress and vibration, protecting and regulating the spinal cord; The appearance of thoracic vertebra is short column, its sagittal diameter is slightly longer than its transverse diameter, the pedicle is short and thin, the vertebral foramen is small, the spinous process is long, it extends backward and outward, and the articular process of thoracic vertebra is similar to the frontal surface, so it is not easy to dislocation. The transverse process is cylindrical, the end is blunt and round, and there is a depression in front called the transverse process costal recess, which forms a joint with the costal tubercle. The first thoracic vertebra looks like a cervical vertebra, and its spinous process is long and horizontal, sometimes longer than the spinous process of the cervical vertebra. The twelfth thoracic vertebra is similar to the lumbar vertebra, with horizontal spinous process and short transverse process. Functional unit of thoracic vertebra The functional unit of thoracic vertebra consists of two adjacent vertebral bodies and an intervertebral disc in the middle. Each functional unit of the spine contains the tissues and supporting structures needed for all functional activities of the spine as a whole, and any part of the injury can affect the functional activities of the whole system, and most of these tissues are sensitive to noxious stimuli and are one of the sources of pain. The front part of the functional unit of thoracic vertebra (vertebral body and intervertebral disc) is a load-bearing structure, which has the functions of buffering, supporting and loading; The posterior part (lamina, facet joint, spinous process and sternoclavicular joint) is a non-load-bearing part, which contains and protects the central nervous system and nerve roots, and directly participates in the composition of the thoracic cavity and the movement of the spine (including bending, rotation, lateral bending, etc.). The functional units of the spine include vertebral body, intervertebral disc, intervertebral joint, nerve, muscle and ligament. The main sensory innervation comes from recurrent Lou's nerve, and part of the sensation is transmitted through the somatic nerve on the dorsal pleural ganglion of the spinal cord. Clinical manifestations and characteristics The clinical manifestations are 1. Slow onset, long medical history ≥ one year; 2. The proportion of young and middle-aged people is the largest; 3. Most patients have no obvious inducement; 4. Vulnerable to external stimuli (such as weather changes, obvious emotional changes, fatigue or catching cold, pain attacks or symptoms aggravated after getting wet. Features 1. Long-term, chronic or repeated persistent chest pain or paroxysmal pain; 2. There is no obvious abnormality in routine examination of chest organ systems such as heart and lung; 3. Pain can occur on one side or both sides, with no fixed tenderness area and variability; The nature of pain is mainly persistent dull pain, swelling pain and tight bundle pain. 4. Pain often aggravates or recurs after fatigue, cold, humidity and emotional upheaval, which has no obvious relationship with the amount of exercise; 5. Pain attack may be accompanied by chest and back pain or discomfort; 6. Pain attacks or long-term non-healing are often accompanied by emotional changes (such as anxiety, depression, irritability or insomnia, abnormal personality, etc.). ), and the use of commonly used drugs has no obvious effect. 7. Although no local signs were found in physical examination, abnormal changes of superficial sensation sometimes occurred in the corresponding innervation areas. Differential diagnosis Because the anatomical position of chest and back is close to and protects important organs such as heart and lung, and the relationship between thoracic vertebra and sympathetic nerve is also very close, the clinical symptoms of chest pain are more complicated, which can be manifested as chest wall pain or chest organ diseases, so we should first distinguish them from some common clinical diseases. 1. Angina pectoris is one of the diseases that need to be differentiated most clinically, because the treatment and clinical results of angina pectoris are completely different from those of back and chest pain. Once the diagnosis is wrong, the consequences will be more serious. Clinically, we should focus on age, past history, electrocardiogram and other information. Typical angina pectoris is usually a short-term attack with a history of heart disease. Abnormal ECG changes during the attack period are the most obvious feature, followed by obvious inducement, which is obviously related to exercise. At the same time, patients are often accompanied by the horror of dying, and they are extremely uneasy and forced to stop all actions. So some books list the attack of angina pectoris as "exercise-paroxysmal pain-quietness-analgesia". 2. Late posterior mediastinal or posterior segment lung tumors can also cause chest pain when they invade thoracic vertebrae or nerve roots. At first, the nature of pain is sometimes similar to this disease, which can be manifested as persistent pain or paroxysmal aggravation, but generally speaking, the degree of tumor pain is much heavier than back chest pain, and it is gradually aggravated with the extension of illness time. If it is not drug control, there is little or only short-term relief. It often affects the rest of patients, and in severe cases, they can't sleep at night. The reference signs are that there may be abnormal changes and obvious imaging positive findings invading the corresponding dominant area of spinal ganglion during physical examination. 3. Costochondritis Costochondritis will also have similar pain, which is manifested as a feeling of tightness in the chest. The pain will get worse when you take a deep breath, and the repeated attacks of the disease can last for months or years. It is characterized by obvious tenderness points in the affected area, long-term local swelling and sometimes radioactive pain. However, the second sternoclavicular joint (which accounts for about 70% of cases) and the costal arch are usually the most common parts, and clinical differentiation can be referred to. 4. Intercostal Neuralgia Intercostal Neuralgia is sometimes difficult to distinguish from back chest pain, especially when intercostal Neuralgia involves multiple ganglion segments. However, intercostal neuralgia usually occurs in a single branch, showing severe radiation pain along the direction of the invaded intercostal nerve. Most of the pain is tingling or burning, which is paroxysmal or persistent paroxysmal aggravation, but most intercostal neuralgia is secondary, such as some infections, diabetes, trauma or intercostal tissue inflammation, tumors and metastatic lesions. Single intercostal nerve block is helpful for diagnosis or differential diagnosis. 5. Chest herpes zoster chest acute herpes zoster pain Before herpes appeared, some patients may have similar chest pain, but the pain degree of most herpes zoster is obviously heavier than that of dorsal chest pain, showing spontaneous and severe knife-like or lightning-like pain, and there are many precursor symptoms before the onset. Some patients with pain after herpes zoster sometimes cause trouble, and most of them have local scars or pigment changes. Without the above characteristics, the history of herpes zoster is unclear and it is difficult to make a diagnosis. Special attention should be paid to asking about the medical history. 6. Chronic chest pain in recessive depression is one of the main reasons for most patients with recessive depression to see a doctor, and it is also the first complaint after coming to the clinic. But besides complaining about chronic chest pain, other accompanying symptoms are also very obvious. Most patients will repeatedly talk about their medical history and other discomforts, mainly including hypochondriasis, sleep problems, general malaise, abnormal mood, decreased self-confidence, apathy and decreased work ability. Careful inquiry shows that before or during the onset, there are some inducements or accompanying events, such as mild trauma history, emotional problems, stress of life and work, family or social tension, and marital problems. Clinical physical examination is inconsistent with the degree of patients' complaints, and most of them have no obvious positive signs. Hamilton Depression Scale (HAMD) was listed as the diagnostic criteria. Most projects in HAMD adopt a five-level score of 0-4, and the scoring standards at all levels are: 0= none; 1= mild; 2= medium; 3= serious; 4= Extremely heavy. Based on the total score evaluation results and analysis, it is generally considered that the first 17 items are more than 24 for severe depression; 17-24 was classified as moderate depression; Greater than 7 is classified as mild depression; Analyze the changes of total score before and after treatment, and evaluate and judge the therapeutic effect. Because it takes about 20 minutes to score the 24 items of HAMD, it is very inconvenient in clinic, especially in outpatient service. Because the grading time is too long, patients can't accept it, and other patients are unwilling to wait. After practice, we combined some related contents, such as 4, 5, 6 (difficulty in falling asleep, lack of sleep, early awakening), 10,1,9 (mental anxiety, physical anxiety, agitation), 15, 24, 2. It is combined into 1 1 (see table 2), which not only saves some time, but also achieves the purpose of clinical evaluation. The items in the improved HAMD scale are depression 0 1 2 3 4 hypochondriasis, guilt 0 2 4 6 8 difficulty in falling asleep, deep sleep, early awakening 0 2 4 6 8 work and interest 0 1 2 3 4 delay 0 1 2 3 4 mental anxiety, aggressive suicidal thoughts 0 2 4 6 8 0 1 Appetite, gastrointestinal symptoms and weight loss 0.24 Systemic symptoms 0 1 2 Sexual symptoms 0 1 2 Other diseases such as pulmonary infectious diseases, lung tumors, thoracic aortic aneurysms, etc. Often accompanied by different degrees of chronic chest pain. For this type of patients with chronic chest pain in clinic, as long as the consultation and treatment of specialists are paid attention to first, there will generally be no mistakes in diagnosis or treatment.

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