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The maladies that afflict the clerks aforesaid arise from three causes; first constant sitting, secondly the incessant movement of the hand and always in the same direction, and thirdly the strain on the midline from the effort not to disfigure the books by error or cause loss to their employers.
THE PHYSICIAN RAMAZZINI 1713
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In this chapter, back (spinal) pain will encompass pain in the thoracic (upper or dorsal) spine through to the lumbosacral spine. Disorders of the cervical spine presenting as neck pain has a relative unique set of pain syndromes and will be presented in the following chapter.
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Thoracic (dorsal) or upper back pain, which is defined as pain localised between the neck and above the costal margin, is common in people of all ages. It accounts for 10–15% of all spinal pain and has a 1-year prevalence in 20% of adults.1 Dysfunction of the joints of the thoracic spine, with its unique costovertebral joints (which are an important source of back pain), is commonly encountered in medical practice, especially in people whose lifestyle creates stresses and strains through poor posture and heavy lifting. It is also referred to as non-specific thoracic spinal pain. Muscular and ligamentous strains may be common, but they rarely come to light in practice because they are self-limiting and not severe.
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This dysfunction can cause referred pain to various parts of the chest wall and can mimic the symptoms of various visceral diseases, such as angina, biliary colic and oesophageal spasm. In similar fashion, heart and gall bladder pain can mimic spinal pain.
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A DIAGNOSTIC APPROACH
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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 overly 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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Serious disorders not to be missed
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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. In particular, myocardial infarction and dissecting aneurysm must be considered. A complex problem described by neurosurgeons is the presentation of severe sudden thoracic back pain caused by an epidural haematoma related to aspirin or warfarin therapy. Visceral disease causing a rupture or leakage should be kept in mind.