1.Department of Internal Medicine, Suwa Central Hospital, Chino, Japan; 2Department of Internal Medicine, Hyogo Prefectural Tamba Medical Center, Tamba, Japan; 3Division of Community Medicine and Career Development, Kobe University Graduate School of Medicine, Kobe, Japan

Contact: Hiroshi Shiba Department of Internal Medicine, Suwa Central Hospital 4300 Tamagawa, Chino, Nagano-ken 391-803 Japan Phone +81-0266-72-1000 Fax +81-0266-72-4120 email: [email protected[email protected]

Abstract An 17-year old female child came in with their mother at our hospital after a two-month history of chest pain on the left and a week-long history of mid back pain. We identified the condition as straight back syndrome based upon the radiographic findings of the chest and thoracic and signs that included chest pain, palpitations and dyspnea. We assured the patient that the disease was not serious and suggested she begin and maintain chiropractic treatment. The symptoms, which included back pain, were gone within three weeks. It is believed that straight back syndrome is not well-known and back pain isn’t as well-known as a sign of the illness.

Keywords: straight back syndrome, middle back pain, chest pain, palpitations, dyspnea


Straight back syndrome is a congenital condition that was first identified by Rawlings in the year 1960. 1,2 It is most common in thin, young people with a decreased size of the thoracic girdle because there is no normal thoracic and thoracic kyphosis in the dorsal mid-upper spine. 3 It was thought to be a frequent occurrence. 4 In the case series of 50 patients of which 36 were males with an average time of age 28 (range from 15 to 72) and a average length at 1.71 millimeters (range 1.45-1.89 meters) and a the mean weight was 69.9 kilograms (range 49.3-111.5 kilograms). The majority of patients showed a straightening of the dorsal upper spine and two suffered from mild pectus excavatum. 5 However its prevalence is undetermined, partly due to the being under-diagnosed. 6 A diagnosis is established by the detection of a straight dorsal spine with chest radiography. DeLeon et al 7 initially proposed the criteria in the early 1990s, and Davies et al 8 changed the criteria. Other chest radiography findings are “pancake” appearance and simulated cardiomegaly, an evoposition in the heart and prominence of the major pulmonary blood vessel. 8 Thoracic computed tomography may also be used to determine the presence of. 9,10

Straight back syndrome is harmless and typically asymptomatic it could result in cardiovascular manifestations that mimic the symptoms of a heart disease that is organic. 7 Symptoms are thought to be caused by the compression of the heart as well as great blood vessels. 11 Straight back syndrome can manifest in conjunction with “cardiac” symptoms like dyspnea, chest pain, etc. 8 We discuss an instance with straight back syndrome that is characterized by intermittent middle back discomfort because, to our knowledge the symptom has not been documented by the scientific literature.

Case Presentation

A 17-year-old female teenager presented at our hospital with 2 month history of chest pain on the left and a week-long background of left-sided back pain that was located at the level of T7. This chest discomfort was caused by dyspnea and palpitations occurring every 3-4 days during the week. After a week, prior to the initial visit the dyspnea and palpitations decreased in frequency and she experienced a regular, dull and constant pain on the left chest and the middle back with no radiation in the majority of cases. The course of the clinical manifestations is illustrated in Figure 1. The pain was felt both during work and when at rest and lasted for several hours with no relief or aggravating causes. She described pain intensity as 2-6 on a scale of 10 points. The intensity fluctuated in the course of an attack but the median was four. She was otherwise healthy. She was not restricted in the daily routine. She went to a local doctor about a month before coming to our clinic. Holter electrical cardiograph and lab tests were normal. Her medical history includes migraine for 3 years. Her usual medications included lomerizine and the naratriptan drug, and loxoprofen for the prevention and treatment of migraine. Her migraine was easily controlledand she never suffered attacks. She denied any trauma or previous operations. She denied any suspected symptoms or family history of inflammation or autoimmune conditions.

1. Course in clinical.

The blood pressure of her was 107/60 mmHg , and her the rate of pulse was 62 beats per minute. She measured 162 centimeters high and 43 kilograms in weight. She had an index of body mass 16.4 kg/m 2.. There was no arrhythmia or murmur heard during her cardiology exam. The the lungs were in good condition to be auscultation bilaterally. The chest felt palpated and caused no-reproducible local discomfort at the lower joint of the sternocostal. the horizontal arm traction move as well as the turning rooster movement resulted in no discomfort. The patient did not feel any tenderness of bones or muscles of the upper part of the body.

Laboratory and electrocardiographic findings that included thyroid function were in good order. A thoracic and chest radiographic examination revealed a straightening of the upper thoracic spine and loss of normal curvature of the kyphotic region (Figure 2.). Radiographs of the lower ribs showed no pneumothorax or fracture. We were concerned about the possibility of straight back syndrome, based on the two distinct diagnostic criteria developed by Davies and colleagues 8. and DeLeon and colleagues 7. (Table 1.). The distance from the midpoint between the frontal border of T8 and the vertical line that connects T12 to T4 was 0.91 centimeters. Its anteroposterior size was 74.0 cm, while its transverse dimension was 243.2 cm. The doctor advised the patient to begin and keep up chiropractic treatment to improve the thoracic Kyphosis. We waited with a watchful eye for one month for outpatient therapy.

Table 1. The Diagnostic Criteria of Straight Back Syndrome

2. Radiographs of the chest.

Notes: (A) Anteroposterior view demonstrates clear lung fields. ( B) Lateral view shows the straight the thoracic spine and a small anteroposterior dimension.

After the initial visit, chest and back pain eased gradually. The dyspnea and heart palpitations were not frequent. The symptoms went away within three weeks. Following a follow-up appointment of one month an echocardiogram was taken which revealed minor mitral regurgitation, but no prolapse. We confirmed the diagnosis as back syndrome. back syndrome. We assured that the patient’s condition isn’t serious as well as advised her to keep chiropractic treatment. She hasn’t experienced a any relapses of severe symptoms, and has not had to go to the hospital. She did not visit our clinic again in the next year.


We have discussed an instance with straight back syndrome, which is characterized by periodic Middle back pain. Through its course, the illness and treatment, the back pain subsided along with chest pain. We were able to diagnose straight back syndrome on the basis of radiographic findings as well as the signs that include chest pain and palpitations and dyspnea. Common symptoms have been observed. They include chest pain, palpitations (38 percent) as well as chest pain (29 percent) and dyspnea (19 percent). 8 While back pain is the primary sign, its frequency is not known. 12-14 In our case, three common symptoms were accompanied by the three typical symptoms were accompanied by back pain. According to our experience, we could be able to attribute the back discomfort due to the straight back syndrome, based on the convergence projection model. The cause of straight back syndrome is still to be determined, however, chest pain may be explained as a result of pressure on the heart or the great vessels.11 In rare instances it is possible that straight back syndrome may cause the pathological Q wave seen on electrocardiography, accompanied by normal serum cardiac biomarkers and myocardial injury manifesting by an acute myocardial infarction.15,16 Patients suffering from acute coronary syndromes may suffer from referred pain on their back as well as the jaw.17 This is caused by convergence projection theories by the fact that the convergence of somatic and visceral triggers can result in to somatic pain.17 Females are much more likely to experience back pain that radiates into the back during myocardial infarction (34.2 percent vs. 17.4%).18 It is impossible to state that our patient had acute myocardial infarction. However it is logical for us to believe that straight back syndrome could cause middle back discomfort as well as chest pain. Because the back pain is usually associated with chest pain irrespective of movement the pain is more likely to be the result of joints or muscles.

The diagnosis early of straight back syndrome can be the first step towards the early detection and appropriate management of the valvular heart disease. The symptoms of the straight back syndrome can range from being asymptomatic to a broad variety of symptoms related to numerous abnormal cardiac manifestations. 19 This may be the cause for the under-diagnosis. It is believed that the diagnosis for straight back syndrome is generally determined by clinical signs and chest radiography. However echocardiography is suggested to determine the presence of organic heart disease. 5 It is due to the fact that it is because straight back syndrome is frequently related to valvular heart diseases and mitral valve prolapse. Davies et al 8 discovered the 67% patients showed an echocardiographic or clinical sign of prolapsed mitral valve. Ansari and colleagues 5 found the finding that 58% patients have an echocardiographic sign of prolapsed mitral valve. In our instance an echocardiogram found no sign of mitral regurgitation, but no withral valve prolapse. This did not explain the chest symptoms , and therefore needed no further treatment.

Treatments include patiently watching, conservative treatments and surgical treatment. The condition is usually harmless, even when there are the subjective signs. 3 Recent studies have demonstrated that chiropractic therapy for improving the symptoms of thoracic-kyphosis can be effective. 12-14 Some patients suffering from severe airway pressure require surgical treatment. 20 We discovered that the patient’s condition was not too severe to require surgery. We advised her to do an active pectoralis muscles stretch that involves shoulder extension and the scapular retracting. The patient’s symptoms went away with the use of this chiropractic treatment.


We have described an instance with straight back syndrome, which is associated with mid back pain. Straight back syndrome can occur more often and is ignored due to the mistaken diagnosis. By highlighting the problem, it will give healthcare professionals with more information on diagnosis and treatment of the disease. For patients suffering from middle back pain that is coupled with chest pain, we recommend taking into consideration whether there is a possibility for the straight back syndrome.

Data Sharing Statement

All the data collected or analyzed in this study are included in the published paper.

Ethics Approval, Consent and Permission to Publication

The ethics approval is not valid. The written permission was sought from both the patient as well as the mother of the patient for publication of the case report as well as accompanying photographs.


The study did not receive any particular grant from any funding agency from the commercial, public or not-for-profit industries.


The authors state that they do not have any competing interest.


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