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A summary of the diagnostic strategy model is presented in TABLE 37.1.
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Probability diagnosis
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The commonest cause of thoracic back pain is musculoskeletal, due usually to musculoligamentous strains caused by poor posture. However, these pains are usually transitory and present rarely to the practitioner. The problems that commonly present are those caused by dysfunction of the lower cervical and thoracic spinal joints, especially those of the mid-thoracic (interscapular) area.
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Arthritic conditions of the thoracic spine are not relatively common although degenerative osteoarthritis is encountered at times; the inflammatory spondyloarthropathies are uncommon.
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The various systemic infectious diseases such as influenza and Epstein–Barr mononucleosis can certainly cause diffuse backache but should be assessed in context.
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A special problem with the thoracic spine is its relationship with the many thoracic and upper abdominal structures that can refer pain to the back. These structures are listed in TABLE 37.2 but, in particular, myocardial infarction and dissecting aneurysm must be considered. A complex problem described by neurosurgeons is the patient presenting with severe sudden thoracic back pain caused by an epidural haematoma related to aspirin or warfarin therapy.
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Cardiopulmonary problems
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The acute onset of pain can have sinister implications in the thoracic spine where various life-threatening cardiopulmonary and vascular events have to be kept in mind. The pulmonary causes of acute pain include spontaneous pneumothorax, pleurisy and pulmonary infarction. Thoracic back pain may be associated with infective endocarditis due to embolic phenomena. The ubiquitous myocardial infarction or acute coronary occlusion may, uncommonly, cause interscapular back pain, while the very painful dissecting or ruptured aortic aneurysm may cause back pain with hypotension.
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Osteoporosis, especially in people over 60 years, including both men and women, must always be considered in such people presenting with acute pain, which can be caused by a pathological fracture. The association with pain following inappropriate physical therapy such as spinal manipulation should also be considered.
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Infective conditions that can involve the spine include osteomyelitis, tuberculosis, brucellosis, syphilis and Salmonella infections. Such conditions should be suspected in young patients (osteomyelitis), farm workers (brucellosis) and migrants from South-East Asia and third world countries (tuberculosis). The presence of poor general health and fever necessitates investigations for these infections.
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Fortunately, tumours of the spine are uncommon. Nevertheless, they occur frequently enough for the full-time practitioner in back disorders to encounter some each year, especially metastatic disease.
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The three common primary malignancies that metastasise to the spine are those originating in the lung, breast and the prostate (all paired structures). The less common primaries to consider are the thyroid, the kidney and adrenals and malignant melanoma.
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Reticuloses such as Hodgkin lymphoma can involve the spine. Primary malignancies that develop in the vertebrae include multiple myeloma and sarcoma.
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Benign tumours to consider are often neurological in origin. An interesting tumour is the osteoid osteoma, which is aggravated by consuming alcohol and relieved by aspirin.
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The tumours of the spine are summarised in TABLE 37.3.
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The symptoms and signs that should alert the clinician to malignant disease are:
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back pain occurring in an older person
unrelenting back pain, unrelieved by rest (this includes night pain)
rapidly increasing back pain
constitutional symptoms (e.g. unexplained weight loss, fever, malaise)
a history of treatment for cancer (e.g. excision of skin melanoma)
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Red flag pointers for thoracic back pain1
The red flag pointers are similar to those for low back pain (see CHAPTER 38).
Fracture pointer
Major trauma
Minor trauma:
osteoporosis
female >50 years
male >60 years
Malignancy pointer
Age >50
Past history malignancy
Unexplained weight loss
Pain at rest
Constant pain
Night pain
Pain at multiple sites
Unresponsive to treatment
Infection pointer
Fever
Night sweats
Risk factors for infection
Other serious conditions
Chest pain/heaviness
Shortness of breath, cough
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FBE, ESR, CRP and a plain X-ray of the thoracic spine should be the initial screening test in the presence of these pointers.
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A common trap for the thoracic spine is lung cancer, such as mesothelioma, which can invade parietal pleura or structures adjacent to the vertebral column.
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Pitfalls include ischaemic heart disease presenting with interscapular pain, herpes zoster at the pre-eruption stage and the various gastrointestinal disorders. Two commonly misdiagnosed problems are a penetrating duodenal ulcer presenting with lower thoracic pain and oesophageal spasm, which can cause thoracic back pain.
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Inflammatory rheumatological problems are not common in the thoracic spine but occasionally a spondyloarthropathy such as ankylosing spondylitis manifests here, although it follows some time after the onset of sacroiliitis.
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Seven masquerades checklist
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Spinal dysfunction is the outstanding cause in this checklist, but urinary tract infection may occasionally cause lower thoracic pain. Depression always warrants consideration in any pain syndrome, especially back pain. It can certainly cause exaggeration of pre-existing pain from vertebral dysfunction or some other chronic problem.
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Psychogenic considerations
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Psychogenic or non-organic causes of back pain can present a complex dilemma in diagnosis and management. The causes may be apparent from the incongruous behaviour and personality of the patient, but often the diagnosis is reached by a process of exclusion. There is obviously some functional overlay in everyone with acute or chronic pain, hence the importance of appropriate reassurance to these patients that their problem invariably subsides with time and that they do not have cancer.