Thoracic back pain (approach)

The regional hub for thoracic back pain. Because the thoracic spine is splinted by the rib cage, mechanical disease is less common here — always actively exclude visceral and serious causes.

Red flags

Chest pain/heaviness, dyspnoea/cough; fracture risk (major trauma, or minor trauma with osteoporosis / female >50 / male >60); malignancy (age >50, cancer history, weight loss, rest/night pain, unresponsive); infection (fever, night sweats, IVDU).

Examination and investigations

Look/feel/move: palpate spinous processes, facet joints and ribs; rotation commonly reproduces facet/costovertebral pain; dermatomal sensory testing. Facet-loading manoeuvres can also help distinguish facet-joint-mediated pain from disk-related pain. Imaging: X-ray/MRI are not useful in non-specific thoracic back pain; X-ray to exclude fracture (pathological/osteoporotic), kyphosis/scoliosis, or a lytic lesion.

Non-specific thoracic back pain

The commonest cause in adults (peak 20–40). Dull ache ± sharp pain related to activity. Management: reassurance (spontaneous resolution likely), stay active, analgesia, and extension/rotation exercises ± physiotherapy.

Discogenic thoracic pain

Uncommon, because the rib cage splints the thoracic spine against the disk degeneration and translational stress that drives lumbar disease. Thoracic disk lesions most often occur in the lower thoracic spine — roughly 75% below the level of T8, with T11–12 the most common level. Most are asymptomatic and found incidentally on MRI; unlike lumbar and cervical herniations, a symptomatic thoracic disk often presents atypically and is frequently diagnosed by exclusion rather than a clean dermatomal picture. When symptomatic: back pain ± dermatomal radicular pain, managed as for discogenic low back pain — analgesia, activity as tolerated, physiotherapy-guided exercise.

Because the thoracic canal is narrower relative to the cord than the lumbar canal, a large central herniation carries a real, if uncommon, risk of cord compression rather than a simple radiculopathy. Warn patients to report painless weakness, loss of bowel or bladder control, or involuntary movements — possible signs of myelopathy — and fever, chills or night sweats, which instead suggest infection; either warrants urgent imaging/referral rather than a trial of conservative care. Reassuringly, most acute disk-related symptoms — over 85% — resolve within 8–12 weeks with conservative management alone, so first-line care stays analgesia, activity modification and physiotherapy; surgical or interventional referral is for an abnormal neurological exam or failure to improve.

Costochondritis (and Tietze syndrome)

Worth its own note, since it is one of the commonest of the pitfalls” listed above and a frequent reason for an anxious presentation. “Costochondritis is a benign, self-limited condition causing localised anterior chest wall pain from inflammation at the costochondral or costosternal junctions — most often idiopathic, occasionally following infection, repetitive trauma, seronegative spondyloarthropathy or intravenous drug use. It most commonly affects adults aged 40–50 and, because it can mask cardiac pathology, must be actively distinguished from acute coronary syndrome rather than assumed on first impression. Pain typically involves the 2nd–5th costochondral junctions, worsens with movement, deep breathing, coughing or stretching, and is usually reproducible by mild-to-moderate palpation — but ACS pain is occasionally reproducible too, so reproducibility alone does not exclude a cardiac cause. Vital signs are normal in costochondritis; tachycardia or hypotension should prompt a search for an alternative diagnosis. Tietze syndrome is a related but distinct entity causing visible or palpable swelling of the costosternal, sternoclavicular or costochondral joints, usually around the 2nd–3rd ribs — plain costochondritis is not swollen or erythematous, so swelling or warmth should prompt reconsideration of the diagnosis. Costochondritis is a diagnosis of exclusion, made only after ruling out chest pain causes with higher morbidity/mortality. It is a self-limited condition: over 90% of patients experience symptomatic improvement within 3–4 weeks, with topical heat/analgesics and oral NSAIDs or paracetamol first-line and rheumatology referral reserved for refractory or recurrent cases.

Other causes

• Syringomyelia (syrinx) — a fluid-filled cavity in the cord, often an incidental MRI finding (usually cervical, extending down) as MRI use for back/neck pain has increased — around a fifth of patients are asymptomatic. The single most frequent underlying cause is a Chiari I malformation; tumour, trauma and arachnoiditis are other recognised causes. When symptomatic, the commonest features are radicular pain, gait ataxia, sensory disturbance, dysaesthesia, motor weakness and spasticity, classically a dissociated sensory loss (pain/temperature lost, touch/vibration preserved) in a cape-like upper-limb distribution. Progressive scoliosis in a young person is a recognised presentation and should prompt syrinx imaging, since early treatment can reverse the deformity. Refer to neurosurgery if symptomatic and to exclude an associated tumour.
• Scapular winging — the scapula lifts off on a wall push-up, from long thoracic nerve injury causing serratus anterior palsy: the scapula translates superiorly with the inferior angle rotating medially (medial winging), and forward shoulder flexion beyond 120° is impaired. (Lateral winging, from spinal accessory nerve injury and trapezius palsy, is the other main pattern and needs distinguishing on exam.) EMG and nerve conduction studies can confirm the diagnosis and which nerve is involved. Neuropraxia is the commonest cause and usually resolves within 6–9 months. Nonsurgical management (physiotherapy to maintain shoulder range of motion) is first-line, with 1–2 years allowed to observe nerve recovery before considering surgery. Around a quarter of cases still have persistent winging despite conservative management, at which point dynamic muscle transfer is the usual surgical option.