Professional Reference articles are designed for health professionals to use. They are written by UK doctors and based on research evidence, UK and European Guidelines. You may find the Thoracic Back Pain article more useful, or one of our other health articles.
Treatment of almost all medical conditions has been affected by the COVID-19 pandemic. NICE has issued rapid update guidelines in relation to many of these. This guidance is changing frequently. Please visit https://www.nice.org.uk/covid-19 to see if there is temporary guidance issued by NICE in relation to the management of this condition, which may vary from the information given below.
What is thoracic back pain?
Thoracic back pain is common throughout life but is not as well studied as neck pain or low back pain. Thoracic back pain is more often due to serious spinal pathology than neck or low back pain but thoracic back pain is also prevalent among healthy individuals without any serious underlying cause.
Thoracic back pain epidemiology
A review found the range of prevalence estimates of thoracic back pain in the general population to be very broad because of many factors, including the different definitions and duration of thoracic back pain included. The results of the review were as follows:
- Prevalence data ranged from 4.0-72.0% (at any one time), 0.5-51.4% (seven-day), 1.4-34.8% (one-month), 4.8-7.0% (three-month), 3.5-34.8% (one-year) and 15.6-19.5% (lifetime).
- Studies reported a higher prevalence for thoracic back pain in children and adolescents, especially for females.
- In children and adolescents, thoracic back pain was associated with female gender, postural changes associated with backpack use, backpack weight, other musculoskeletal symptoms, participation in specific sports, chair height at school and difficulty with homework. Poorer mental health and age transition from early to late adolescence were also significant risk factors.
- In adults, thoracic back pain was associated with concurrent other musculoskeletal symptoms and difficulty in performing activities of daily living.
Thoracic back pain causes
- Thoracic back pain can occur as a result of trauma or sudden injury, or it can occur through strain or poor posture over time.
- Always consider the possibility of shingles, especially in older patients.
- The most common cause of thoracic back pain appears to originate from muscular irritation or other soft tissue problems. These can arise from lack of strength, poor posture, prolonged sitting at a computer, using a backpack, overuse injuries (such as repetitive motion), or trauma (such as a whiplash injury caused by a car accident or as a result of a sports injury).
- A study of cadavers suggests an association between cervical spine stenosis and thoracic spine stenosis.
- Asymptomatic thoracic disc herniations are relatively common but symptomatic disc herniations are rare. They occur in approximately 5 in 1,000 disc herniations presenting in a clinical setting.
- The thoracic spine is a relatively common site for inflammatory, degenerative, metabolic, infective and neoplastic conditions.
- Thoracic back pain and dysfunction are associated with conditions such as primary and secondary osteoporosis (especially vertebral fractures and hyperkyphosis arising from vertebral bone loss), ankylosing spondylitis, osteoarthritis and Scheuermann's disease.
Thoracic back pain symptoms
The presentation of thoracic back pain will depend on the underlying cause.
Thoracic back pain is more likely than neck or low back pain to be caused by serious underlying pathology. However, many patients with thoracic back pain have a benign, mechanical cause. Red flags for possible serious spinal pathology include:
- Recent violent trauma (such as a vehicle accident or fall from a height).
- Minor trauma, or even just strenuous lifting, in people with osteoporosis.
- Age at onset less than 20 or over 50 years (new back pain).
- History of cancer, drug abuse, HIV, immunosuppression or prolonged use of corticosteroids.
- Constitutional symptoms - eg, fever, chills, unexplained weight loss.
- Recent bacterial infection.
- Pain that is:
- Constant, severe and progressive.
- Non-mechanical without relief from bed rest or postural modification.
- Unchanged despite treatment for 2-4 weeks.
- Accompanied by severe morning stiffness (rheumatoid arthritis and ankylosing spondylitis).
- Structural deformity.
- Severe or progressive neurological deficit in the lower extremities.
See the separate Examination of the Spine article.
Intervertebral disc prolapse
- Pain: localised to the spine or also radicular along the relevant dermatome.
- Sensory disturbances:
- Sensory disturbance may occur in a dermatomal distribution.
- Wider distribution of sensory disturbance below the level of pain is consistent with myelopathy due to cord compression.
- Unlikely to be an early presenting problem.
- Weakness in the lower extremities may indicate cord compression.
- Bladder symptoms and incontinence of faeces may indicate cord compression and myelopathy.
- Problems affecting the lung (including a Pancoast tumour), oesophagus, stomach, liver, gallbladder and pancreas can all cause referred pain in the interscapular area.
- Interscapular pain may also be referred from disc prolapse or spinal dysfunction affecting the cervical or lumbar spine.
- As with the lumbar spine, degenerative signs identified in imaging of the thoracic spine are not necessarily associated with pain.
- Investigations are mainly used to explore underlying musculoskeletal or other diseases causing the thoracic back pain.
Thoracic back pain may cause significant restrictions and exclusion of domestic, leisure, educational and employment activities.
Thoracic back pain treatment and management
- Many cases of thoracic pain resolve without treatment.
- Where there is a secondary cause, treatment depends on the underlying pathology.
- Thoracic pain emanating from facet joint pathology may respond to imaging-guided intra-articular injection.
- Surgical treatment of symptomatic thoracic spine herniation has been associated with considerable morbidity and even mortality. However, the technique of percutaneous thoracic intervertebral disc nucleoplasty has been described; it has reduced morbidity and has shorter operating times than traditional methods.
- The prognosis of thoracic back pain will depend on the underling cause and specific circumstances of the individual.
- Thoracic back pain is more likely than neck or low back pain to indicate underlying pathology.
- Many cases of nonspecific thoracic back pain resolve within a few weeks.
Further reading and references
Rizzello E, Ntani G, Coggon D; Correlations between pain in the back and neck/upper limb in the European Working Conditions Survey. BMC Musculoskelet Disord. 2019 Jan 2320(1):38. doi: 10.1186/s12891-019-2404-8.
Milhem M, Kalichman L, Ezra D, et al; Work-related musculoskeletal disorders among physical therapists: A comprehensive narrative review. Int J Occup Med Environ Health. 201629(5):735-47. doi: 10.13075/ijomeh.1896.00620.
Briggs AM, Smith AJ, Straker LM, et al; Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskelet Disord. 2009 Jun 2910:77.
Bajwa NS, Toy JO, Ahn NU; Is congenital bony stenosis of the cervical spine associated with congenital bony stenosis of the thoracic spine? An anatomic study of 1072 human cadaveric specimens. J Spinal Disord Tech. 2013 Feb26(1):E1-5. doi: 10.1097/BSD.0b013e3182694320.
Chua NH, Gultuna I, Riezebos P, et al; Percutaneous thoracic intervertebral disc nucleoplasty: technical notes from 3 patients with painful thoracic disc herniations. Asian Spine J. 2011 Mar5(1):15-9. doi: 10.4184/asj.2011.5.1.15. Epub 2011 Mar 2.
Brant W et al; Fundamentals of Diagnostic Radiology, 2012.
Rawles Z et al; Physical Examination Procedures for Advanced Practitioners and Non-Medical Prescribers, 2015.
Back pain - low (without radiculopathy); NICE CKS, September 2020 (UK access only)
van Tulder M, Becker A, Bekkering T, et al; Chapter 3. European guidelines for the management of acute nonspecific low back pain in primary care. Eur Spine J. 2006 Mar15 Suppl 2:S169-91. doi: 10.1007/s00586-006-1071-2.
Thoracic Disc Herniation; Orthobullets
Peh W; Image-guided facet joint injection. Biomed Imaging Interv J. 2011 Jan-Mar7(1):e4. doi: 10.2349/biij.7.1.e4. Epub 2011 Jan 1.