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Probability diagnosis

Musculoligamentous strains (mainly postural)

Vertebral dysfunction

Serious disorders not to be missed


  • myocardial infarction

  • dissecting aneurysm

  • pulmonary infarction

  • epidural haematoma (blood-thinning agents)


  • myeloma

  • pancreas

  • lung (with infiltration)

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


  • epidural/subdural abscess

  • infective discitis

  • pleurisy

  • infectious endocarditis

  • osteomyelitis

  • pyelonephritis


  • pneumothorax

  • osteoporosis

Pitfalls (often missed)


Gastrointestinal disorders

  • oesophageal dysfunction

  • peptic ulcer (penetrating)

  • hepatobiliary

  • pancreatic

Herpes zoster



  • Tietze syndrome

Fibromyalgia syndrome

Notalgia parasthetica

Polymyalgia rheumatica

Chronic infection:

  • tuberculosis

  • brucellosis

Masquerades checklist


Spinal dysfunction


Is the patient trying to tell me something?

Yes, quite possible with many cases of back pain.

Key history

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

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

Key examination

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

   The movements and their normal ranges are:

  • extension 30°

  • lateral flexion (right and left) 30°

  • flexion 90°

  • rotation (right and left) 60°.

Key investigations


  • FBE


  • 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.

Diagnostic tips

  • 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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