Thoracic Pain

Thoracic pain, also known as mid-back pain or upper back pain, is much less common than low back or Neck Pain. Frequently thoracic back pain has a benign musculosketeletal origin, but may indicate a more serious underlying problem. The word thoracic means “pertaining to the chest” ⁽¹⁾; hence the thoracic spine forms the back of the chest wall. With markedly less mobility than the cervical spine above and lumbar spine below, the thoracic spine’s main function is to provide protection for the vital organs in the chest, such as the heart and lungs, as well as allow stability for standing upright.

The thoracic spine consists of 12 vertebra, 10 of which have ribs attached, intervertebral discs separating each vertebra, supporting soft tissue (muscles, ligaments, and tendons), and twelve thoracic nerves. Five joints, including one facet joint on either side of the vertebra, provide a somewhat mobile connection between each vertebra T1-T12. The spinal canal, which houses the cord, has the same diameter in the thoracic and lumbar spine, but the space around the thoracic spine is narrower than lumbar spine. In view of this limited space, spinal cord compression from a herniated disk is more likely to happen at the thoracic level. Furthermore, only a minimal amount of spinal cord encroachment can lead to significant neurological abnormalities.

Even though majority of mid-back pain is harmless, when present in the following situations an individual should seek medical attention:

• History of a recent infection
• Temperature over 100 F
• IV drug use, which increases risk of an infectious cause.
• Unexplained weight loss, which may be associated with cancer.
• When the following conditions are present, one should seek emergent care:
• Weakness or Paralysis
• Loss of Bowel or Bladder Control
• Prior history of cancer
• Recent significant trauma such as a fall from a height or motor vehicle accident

The incidence of symptomatic thoracic disk disease is estimated to be one in one million ⁽²⁾; accounting for less than 5% of all disc protrusions ⁽³⁾. A third of patients are in their 40s when they present for thoracic disc herniations. Herniation frequently occurs between T8 and T12 (35%) with the most common level being T11-T12 (20%). Fortunately, most symptomatic thoracic disk disease in the absence of neurological signs improves with conservative treatment, up to 77% improvement in one study ⁽²⁾. On the contrary, 60 to 70% of cancer that spreads to the spine is found in the thoracic spine ⁽⁴⁾. Thoracic pain deceptively seems more common than it actually is, due to the fact that cervical back pain is referred downward to the thoracic region. In actuality, it only comprises about two percent of all mechanical back pain ⁽⁵⁾.

Thoracic back pain may come from soft tissues surrounding the spine, intervertebral discs and joints, compression of the spinal cord or nerves, fractures of the vertebra, or referred pain. The pain may be the result of degenerative changes, autoimmune disorders, trauma, infection, or cancer.

Myofascial or soft tissue pain is usually due to a combination of soft tissue sprain and/or inflammation. Thoracic strain is most commonly caused by poor posture and excessive sitting. Poor posture may be related to development of osteoporosis in the elderly. It often results in excessive drooping of the neck and shoulders, and decreased lumbar lordosis, or inward curvature of the low back. As mentioned before, the thoracic spine provides the least amount of mobility to the spine. This is mainly due to the presence of the rib cage and the relatively low disc height. In adolescents and adults who slouch their shoulders there is excessive flexion along with a decrease in rotation and extension. This increase in flexion translates into increased thoracic kyphosis, or hunchback, and excessive strain on the muscles of the spine, rib cage, and abdomen. These patients encounter an increased incidence of rib stress fractures and irritation in the joints between the spine and ribs, which may create trigger points in the muscles of the back. The decreased rotation and extension in these patients will likely translate to additional stress in the lumbar and cervical spine.

Thoracic spine compression fractures frequently occur in patients with osteoporosis. It may only take a small amount of force in this setting to produce a fracture, but fortunately the fractures are usually stable. On the other hand, a fracture that happens in the presence of an exceptionally fragile bone is referred to as a pathologic fracture, and usually occurs from cancer that has spread to the bone from the lung, prostate, or breast. Major trauma, such as a fall or motor vehicle accident, may also cause a thoracic compression fracture, although it usually takes massive forces for a fracture to occur in a healthy vertebra. There is a higher likelihood of spinal cord injury with this type of fracture, secondary to bone fragments being displaced into the spinal canal. Typically in osteoporotic fractures, the front of the vertebrae is affected and multiple fractures may lead to kyphosis. Severe, sharp pain over the affected, vertebrae is the classic presentation, although acute fractures with osteoporosis may result in little discomfort ⁽⁶⁾.

Degenerative disease and trauma are thought to be the most common etiology of thoracic radiculopathy. Narrowing of the intervertebral foramen, or opening between the vertebras, can also cause compression of nerve roots and can lead to radiculopathy. Diabetes is the most common metabolic cause of radiculopathy ⁽⁷⁾. The natural kyphosis (curvature) of the thoracic spine places the spinal cord in close proximity to the back of the intervertebral discs, vertebral bodies, and ligaments. This makes the thoracic cord more susceptible to compression from herniations. Ankylosing spondylitis, which causes vertebra to fuse together, often affects the entire spine with initial restriction of lumbar and chest motion, and later involves the cervical spine.

Pain often is referred from the heart, lungs, gallbladder, liver, kidneys, and gastrointestinal system to the thoracic region since there is overlap of nerve distribution ^{(8, 9)}.

Spinal Cord and Nerve Root Pathology

Such as spinal stenosis or hematoma.

Vertebral Column Disease

Such as osteomyelitis, compression fracture, tumor, scoliosis or kyphosis.

Degenerative and Autoimmune Arthropathies

Thoracic spondylosis is the result of abnormal wear and tear that causes gradual narrowing of the disc space and deformed bone growth (bone spurs). This combination leads to increased pressure on surrounding tissue and nerves causing pain, and possibly weakness, numbness in the arms or shoulders, and even headaches.

Inflammatory Arthritis (Ankylosing Spondylosis)

Discogenic Pain

Caused by degenerative changes, herniations, or infections of the thoracic intervertebral discs. Pain is the presenting symptom in nearly 60% of cases, and may be located in the mid-back, or may manifest as cervical or low back pain. Muscle tightness/spasms or pain radiating into the arms may also be experienced.

Thoracic Facet Syndrome

Commonly caused by trauma and wear-and-tear changes. It often presents as mid-back pain with muscle spasm, and loss of the normal thoracic spinal curve, or occasionally as pain encircling the rib cage. The pain is usually aggravated by spinal extension and rotation.

Diffuse Skeletal Hyperostosis (DISH)

A syndrome of calcification or hardening of the ligaments and tendons of the cervical spine. A minority of patients suffer from stiffness, loss of mobility, and pain.

Thoracic Myofascial Pain

Causes tender areas of muscle that may be referred to as “knots” that are sensitive to touch, and can be the result of injury, stress, anxiety, or depression.

Thoracic Muscle Strain

May be caused by an injury or irritating daily activities, such as, but not limited to, improper posture or poor sleeping position that leads to muscle spasms. The pain is commonly associated with stiffness and tightness in the upper back or shoulder.

Herpes Zoster or Shingles

A painful, blistering skin rash that follows a dermatome, or linear nerve distribution. This infection is caused by the varicella-zoster virus, which also causes chickenpox.

Non-Spinal and Possibly Emergent Causes:

1. Vascular disease (e.g., thoracic aortic dissection, acute coronary syndrome, pulmonary embolism).
2. Thoracic cavity pathology (e.g., pleuritis, pericarditis, pneumonia, esophageal pathology).
3. Intraperitoneal and retroperitoneal abdominal pathology (e.g., peptic ulcer disease, pancreatitis, hepatobiliary disease).

Risk Factors

• Age of 40 years or greater.
• History of injury.
• Deformities (scoliosis or kyphosis), arthritis, or narrowing of the spine.
• Poor posture/excessive sitting.
• Heavy physical work.
• Smoking/drug abuse.
• Poor physical condition and lack of exercise.

Physical Exam Findings Test

A physician will observe the patient’s general gait and posture. In addition, the physician will palpate or feel the spine, surrounding tissue, and joints. Finally, neurologic signs including range of motion, muscle strength, reflexes, and sensory signs are assessed. Tenderness in the middle of the spine is more likely ligament injury as opposed to tenderness to either side of the spine. Patients with thoracic disc herniation may have signs of sensation loss or weakness and abnormalities are common. In the setting of chronic symptoms muscle wasting may be witnessed. Patients with a fractured vertebra will likely have pain when pressure is placed on the injured vertebral body. In addition, a thorough examination of the cardiopulmonary system, abdominal organs, and skin should be performed, particularly in individuals who have sustained trauma.

Imaging

Together with a thorough history and examination, imaging studies may prove to be critical in formulating a differential diagnosis. Imaging modalities that may be used in working up neck pain include cervical radiographs (x-ray), computed tomography (CT), and magnetic resonance imaging (MRI). Imaging studies may be ordered earlier in thoracic back pain of unknown etiology due to the lower incidence of radiculopathy and higher incidence of tumor in this region. In the presence of a compression fracture, radiographic images will typically show a wedge shaped defect, with the anterior height being lower than the posterior. MRI findings must be correlated with a physical exam, since 37% of asymptomatic patients were found to have thoracic disc herniation on MRIs ⁽¹⁰⁾. A bone scan can be of assistance in locating a tumor, infection, and occult fracture. However, a percutaneous biopsy may be needed for making a definite diagnosis.

Neurophysiologic procedures are needed when the exam and imaging studies do not match. Electromyography, nerve conduction studies, and somatosensory evoked responses help to decipher between spine and peripheral problems as well as joint problems from a radiculopathy.

Diagnostic Interventions

Selective Nerve Root Blocks are a local injection procedure used for diagnostic and therapeutic purposes. It has also been used when the clinical exam and imaging studies fail to correlate.

Medications by Class

Nonprescription Medications

• Nonsteroidal Anti-Inflammatory Drugs

  Typically called NSAIDs (Advil®, Nuprin, or Motrin®), may provide good short-term relief of back pain. Because of the risk of ulcers and gastrointestinal bleeding, talk with your doctor about using this medication for a long time.

• Acetaminophen

  The most common form of acetaminophen is Tylenol®, and has been shown to be as effective as ibuprofen in relieving pain.

Prescription Medications

• Muscle Relaxants

  Including diazepam (Valium), cyclobenzaprine (Flexeril), andcarisoprodol (Soma), treat pain spasms.

• Anti-Depressant Medications

  Such as tricyclic anti-depressants and SSRIs, are effective for the treatment of neuropathic pain.

• Narcotic Pain Relievers

  Including codeine, acetaminophen and hydrocodone (Vicodin), aspirin and oxycodone ( Percodan), and acetaminophen and oxycodone (Percocet) are indicated for short-term treatment of severe back pain.

• Lidoderm® Patches

  May be beneficial as a topical pain treatment, and may help with post-shingles pain ⁽¹¹⁾.

• Steroid Medications

  A high-dose, fast-taper course of corticosteroids can be used if there is a strong suspicion of nerve root impingement by disk protrusion or spondylosis.

• Calcitonin Nasal Spray

  Has been used and shows some benefit for painful osteoporotic fractures ⁽¹²⁾.

Minimally Invasive Interventions

Epidural Steroid Injections (ESIs)

Commonly used to treat degenerative and arthritic joint conditions. Often the goal of ESIs is to provide sufficient pain relief to permit more aggressive physical therapy and greater functional recovery. The procedure involves injecting a combination of a corticosteroid and local anesthetic under x-ray guidance into the epidural space, which is the space around the spinal cord. The steroids act at nerve roots as they branch from the spinal cord by decreasing inflammation and irritation.

Percutaneous Vertebroplasty

Has been found to provide significant pain relief in a high percentage of patients with osteoporotic fractures. The procedure has also led to spinal stabilization in patients with malignancies ⁽¹³⁾. In addition, kyphoplasty has the potential to restore lost vertebral height. Candidates for this procedure are patients with imaging evidence of recent fracture who continue to suffer from pain despite conservative management.

Lysis of Adhesions

Also known as the “Racz procedure,” is used to treat post-laminectomy syndrome, radiculopathy, vertebral body compression fractures, and disc disease. It is effective in breaking down and treating excessive epidural scar tissue in patients that fail conservative treatment.

Facet Blocks

Are an injection of local anesthetic and steroid into the facet joint under x-ray guidance. This procedure is effective in treating arthritic pain of originating from the facet joints.

Nerve Blocks

Such as Medial Branch Blocks (MBBs), Peripheral Nerve Blocks, and Sympathetic Nerve Blocks are injections done under x-ray guidance. MBBs block the nerves that innervate the facet joints, and are used to also treat arthritic back pain. Peripheral Nerve Blocks provide pain relief by “blocking” nerves that are beyond the spinal cord. Sympathetic Nerve Blocks reduce pain by working on nerves that normally regulate stress responses (i.e., blood flow, sweating, ect.).

Radiofrequency Ablation

A procedure that targets the same medial branch nerves, and thus, has similar indications as MBBs. However, radiofrequency ablation uses electrical energy to “burn” the nerves’ ability to send pain signals to the brain.

Spinal Cord Stimulation (SCS)

A minimally invasive procedure that involves implanting a device that applies low currents of electrical stimulation through thin cables that are placed under x-ray guidance into the epidural space. Nerve stimulation is referred to by some pain experts as the “pacemaker of pain.” Epidural spinal cord stimulation has proven to be an “effective and safe means of controlling pain on a long-term basis in selected groups of patients” ⁽¹⁴⁾.

Trigger Point Injections

These may help reduce localized pain caused by hyperirritable areas of muscle, called trigger points, by allowing the patient to improve range of motion, postural balance, and strength⁽¹⁵⁾. The procedure involves injecting a local anesthetic and steroid into a trigger point.

Botox

Has been shown in recent studies to provide effective pain relief for generalized myofascial pain syndrome ⁽¹⁶⁾.

Surgical Interventions

Definitive indications for surgery include presence of myelopathy for 6 months or longer, progression of signs or symptoms, difficulty walking, or change in bowel or bladder function.

Typically, surgeons use two surgical techniques for spine surgery:

Spinal Decompression

In which pressure on the spinal cord or spinal nerve roots is reduced by:

1. Removing part or a vertebra (laminectomy) or an entire vertebra (corpectomy).
2. Removing part or all of an intervertebral disc (discectomy).

Decompression may result in an unstable spine, increasing the risk for serious neurological injury and requiring subsequent stabilization surgery.

Stabilization

This particular surgery usually limits motion between vertebra.

1. Artificial Cervical Disc involves implanting a disc after a discectomy is performed.
2. Fusion involves joining selected bones in the spine together using a bone graft, screws, rods, and plates.

Complementary and Alternative Treatment Options

Transcutaneous Electrical Nerve Stimulation (TENS)

A technique that relieves pain by applying mild electric current to the skin at the site of the pain.

Biofeedback

A treatment that teaches a patient to become aware of his/her body processes that are normally thought to be involuntary, such as temperature regulation, heart rate, and muscle tension. A better awareness of one’s body teaches one to effectively relax and can help relieve pain.

Acupuncture

This method involves placing small needles into the skin, and causes release of hormones called “endorphins“, the body’s natural pain reliever and has been shown to be very helpful in those with chronic pain, helping to relieve symptoms ⁽¹⁷⁾.

Physical Therapy

Has shown to be effective at restoring range of motion and muscular strength. This is beneficial in both rehabilitation from an injury and prevention of future injury.

Exercise

Works similar to physical therapy by increasing strength, and also by releasing endorphins.

Proper Nutrition

Prevents nutritional deficits, which may lead to accelerated degenerative disease.

Yoga

A program of exercises that has been found to help improve flexibility, leading to a decrease in stress and maintenance of health. The basic components of yoga are proper breathing and posture.

Massage

Massage of the tender areas may help relieve muscle spasms or contractions and provide pain relief.

Chiropractic Manipulations

If done correctly as targeted adjustments may significantly reduce neck pain when combined with other modalities of treatment.

Prolotherapy

Also known as Regenerative Injection Therapy, this is a technique of injecting non-pharmacological, irritant solution into the body, generally in the region of tendons or ligaments with the aim of strengthening weakened connective tissue and alleviating pain.

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