Thoracic Back Pain

Thoracic pain accounts for less than 2% of spinal pain. However disorders of the thoracic spine are as disabling as those in the cervical and lumbar spine and therefore deserve wider recognition than they often receive. As a consequence of having a low incidence, diagnosis and treatment often remain a challenge. Pain may be due to soft tissue, visceral, disc or structural etiologies. Pain from thoracic spine lesions may present as pain in the anterior and/or posterior thorax, lumbar spine and extremities.

Aetiology of thoracic back pain

  • Disc herniation
  • Spinal stenosis
  • Osteoarthritis
  • Infection: Osteomyelitis, tuberculosis, discitis
  • Fractures: Traumatic, stress, osteoporotic,
  • Tumours: Primary, secondary, multiple myeloma
  • Neuralgia: Intercostal neuralgia, postherpetic neuralgia
  • Post-thoracotomy pain syndrome
  • Spinal abnormalities: Kyphosis, scoliosis
  • Muscular: non specific pain
  • Inflammatory conditions: Ankylosing spondylitis, rheumatoid arthritis, costochondritis, Tietze’s syndrome

Thoracic disc herniation

Most major thoracic disc lesions occur in the lower thoracic spine, but minor thoracic disc lesions occur in the upper and middle regions. Thoracic disc disease usually affects adults in the fourth through sixth decades of life, in some cases following spinal trauma. Seventy percent of these herniations occur in a posterolateral direction. Onset can be acute, subacute, or chronic.

Thoracic spinal canal stenosis

Spinal canal stenosis in the thoracic area often stems from facet hypertrophy combined with hypertrophy of the posterior longitudinal ligament and/or ligamentum flavum hypertrophy. Thoracic facet joint disease is most common at T3–T5 segment. The incidence of thoracic canal stenosis is approximately 2%.

Thoracic spinal fractures

Thoracic spine fractures of various causes may also lead to significant thoracic spinal pain. Thoracic spine fractures are unique due to the anatomy of the thoracic spine and its biomechanics. Fractures can cause neurological compromise because of the small size of the thoracic spinal canal relative to the spinal cord. Fractures may be due to compression of the vertebral body compounded with or without compression of neural elements. Disorders known to contribute to fractures include osteoporosis, tumours such as primary spinal cord lesions, systemic disease such as multiple myeloma and metastatic disease such from breast, lung, or prostate cancer.

Osteoporosis

Osteoporosis can lead to significant back pain, kyphosis, impaired respiratory function, and quality of life, as well as morbidity. Fractures due to osteoporosis occur in the spine (especially thoracolumbar), hip, and distal forearm. The lifetime risk of clinically diagnosed vertebral fractures is approximately 15% in Caucasian women. Vertebral body height reduction by 20% or 4 mm can be considered a vertebral compression fracture. Three types of vertebral fractures in osteoporosis are described: wedge, crush, and biconcave.

Most common are wedge fractures (collapsed anterior border with almost intact posterior border), which occur mostly in the midthoracic and thoracolumbar regions. In crush fractures, the entire vertebral body is collapsed. Biconcave fractures collapse in the central portion of the vertebral body and are more commonly seen in the lumbar region.

Costochondritis

Costochondritis is an inflammation (without swelling) and Tietze’s syndrome (with swelling) at the costochondral junction where two different tissue types merge, especially in an area stressed by repetitive movement. Costochondritis usually occurs in ribs two through five and is provoked by movement.

Myofascial pain

This syndrome is characterized by regional pain, usually in the neck and upper back, with presence of trigger points. The most commonly affected areas of pain and trigger points include the levator scapulae muscles and the upper and lower trapezius.

Imaging

Radiological evaluation of patients with thoracic pain includes plain films, CT, and/or MRIs. Common radiographic findings in thoracic disc herniation include disc space narrowing, osteophyte formation, kyphosis, and calcification.

MRI of the spine is most useful in evaluation and determining vertebral fracture age and for selecting appropriate treatment. In an acute fracture, MRI shows low-intensity signal changes on T1-weighted images and high-intensity signal changes on T2-weighted images, indicating bone edema. As the fracture becomes chronic, a linear area of low intensity signal change replaces the geographic area on T1-weighted images. The MRI findings of osteoporotic and metastatic spine fractures are decreased signal intensity on T1-weighted images and increased signal intensity on T2-weighted images. Pedicle involvement or involvement of other posterior elements and presence of lesions in the epidural space or paraspinal regions are suggestive of malignancy rather than osteoporosis. Bone scans are sensitive and can be used to identify and discriminate acute from chronic fractures; however, they have low specificity for the diagnosis of the underlying process.

DIFFERENTIAL DIAGNOSIS

Thoracic disc herniation can be confused with esophagitis, nephritis, gastrointestinal ulcers and cholecystitis. Some patients with T1 herniation may present with Horner’s syndrome and T11 herniation with testicular pain. Thoracic nerve root dysfunction may be diagnosed as abdominal pain unless a careful history and physical examination are performed.

Patients with inflammatory diseases such as rheumatoid arthritis and ankylosing spondylitis may have distinct radiographic presentations. For instance, in rheumatoid arthritis, radiographic images show juxta-articular osteoporosis. In ankylosing spondylitis, radiological changes reflect the disease process and sacroiliitis is usually detectable in the early stages of ankylosing spondylitis.

Treatment options for thoracic back pain

Conservative management

The goal of conservative is to improve posture, joint and spinal mobility and flexibility, to strengthen musculature such as the trapezius, rhomboids and latissmus dorsi and to prevent deconditioning.

Non pharmacological treatments

TENS and acupuncture can be successful in symptomatic management of thoracic back pain.

Interventional treatments

  • Thoracic facet joint injections
  • Thoracic medial branch blocks
  • Thoracic radiofrequency denervation
  • Paravertebral blocks
  • Thoracic nerve root blocks
  • Thoracic dorsal root ganglion block
  • Intercostal nerve blocks
  • Pulsed radiofrequency lesioning of intercostal nerve
  • Trigger point injections
  • Botox injections

Pain Spa management protocol for thoracic back pain

  • Rule out red flags (serious causes of back pain)
  • Address yellow flags (factors that impede progress)
  • Consider imaging if indicated (MRI, CT-scans, X-rays)
  • Management of pain (Non pharmacological, medications, interventional treatments)
  • Improve patient understanding and allay fears regarding exercise
  • Rehabilitation (Physiotherapy, Hydrotherapy)
  • Psychotherapeutic options

Summary

Thoracic pain may be due to a variety of causes. It is helpful to categorize the pain into axial and nonaxial components. Aetiologies of thoracic axial pain may be due to disc herniation, osteoarthritis and canal stenosis, fractures due to trauma, and primary and secondary tumours as well as osteoporosis. Nonaxial aetiologies can be stress fractures, intercostal neuralgia, post-thoracotomy pain syndrome, postherpetic neuralgia, and inflammatory disorders such as costochondritis and Tietze’s syndrome. Postural abnormalities, muscle strains, and muscle pain syndromes are also in the differential. Based on the diagnosis, appropriate management can lead to more effective pain control and functional improvement.

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