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Probability diagnosis

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Musculoligamentous strains (mainly postural)

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Vertebral dysfunction

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Serious disorders not to be missed

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Cardiovascular:

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  • myocardial infarction

  • dissecting aneurysm

  • pulmonary infarction

  • epidural haematoma (blood-thinning agents)

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Neoplasia/cancer:

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  • myeloma

  • pancreas

  • lung (with infiltration)

  • metastatic disease (e.g. lung, breast)

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Infection:

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  • epidural/subdural abscess

  • infective discitis

  • pleurisy

  • infectious endocarditis

  • osteomyelitis

  • pyelonephritis

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Other:

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  • pneumothorax

  • osteoporosis

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Pitfalls (often missed)

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Angina

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Gastrointestinal disorders

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  • oesophageal dysfunction

  • peptic ulcer (penetrating)

  • hepatobiliary

  • pancreatic

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Herpes zoster

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Spondyloarthropathies

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Costochondritis:

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  • Tietze syndrome

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Fibromyalgia syndrome

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Notalgia parasthetica

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Polymyalgia rheumatica

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Chronic infection:

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  • tuberculosis

  • brucellosis

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Masquerades checklist

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Depression

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Spinal dysfunction

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UTI

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Is the patient trying to tell me something?

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Yes, quite possible with many cases of back pain.

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Key history

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Take a history analysing pain characteristics to differentiate between chest pain due to vertebral dysfunction (musculoskeletal strain) and that caused by myocardial ischaemia.

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Also drug history, family history, occupational history and questions about red flags that point to serious disease.

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Key examination

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The LOOK, FEEL, MOVE, MEASURE clinical approach applies to the thoracic spine. The emphasis is on palpation-central and laterally.

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   The movements and their normal ranges are:

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  • extension 30°

  • lateral flexion (right and left) 30°

  • flexion 90°

  • rotation (right and left) 60°.

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Key investigations

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Consider:

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  • FBE

  • ESR/CRP

  • alkaline phosphase

  • A plain X-ray is the main investigation, which may exclude the basic skeletal abnormalities and diseases such as osteoporosis and malignancy. If normal and disease is suspected a radionucleide scan or MRI is advisable.

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Diagnostic tips

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  • The commonest site of pain is the costovertebral articulations of the spine.

  • Pain of the thoracic spine origin may be referred anywhere to the chest wall.

  • The older patient should be regarded as having a cardiac cause until proved otherwise.

  • Thoracic back pain is frequently associated with cervical lesions that refer to the upper back.

  • The thoracic spine is the commonest site in the vertebral column for metastatic disease.

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