Thoracic back pain

What is thoracic back pain?

Thoracic back pain is common throughout life but has not been as extensively 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.¹

For further information on causes, differential diagnosis and management of back pain, see the separate Low back pain and sciatica and Neck pain (cervicalgia) and torticollis articles.

How common is thoracic back pain? (Epidemiology)¹

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. 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.

Causes of thoracic back pain (aetiology)

• 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.²

• 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.³

• The thoracic spine is a relatively common site for inflammatory, degenerative, metabolic, infective and neoplastic conditions.⁴

• 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.¹

Symptoms of thoracic back pain

The presentation of thoracic back pain will depend on the underlying cause.

Red flags^{5 6}

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:⁷

• 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, intravenous 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.

Examination

See the separate Examination of the spine article.

Intervertebral disc prolapse⁸

• 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.

• Weakness:

  • 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.

Differential diagnosis

• 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.

Investigations for thoracic back pain

• As with the lumbar spine, degenerative signs identified in imaging of the thoracic spine are not necessarily associated with pain.¹

• Investigations are mainly used to explore underlying musculoskeletal or other diseases causing the thoracic back pain.

Complications of 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.⁹

• 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.³

Prognosis

• The prognosis of thoracic back pain will depend on the underlying 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.