Introduction

Thoracic back pain is common but is not as well studied as neck pain or low back pain. Persistent 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 (Rizzello et al 2019). It is therefore vital to make a thorough assessment of this patient group.

History

• Pain site, severity, nature, radiation, presence of pain at rest, morning or night pain, relieving or aggravating factors and the temporal history. Particular attention to postural causes (occupational or recreational).
• Any preceding injury. Minor injury may be relevant in the patient with osteoporosis or ankylosing spondylitis.
• Radiculopathy symptoms (injury or damage to nerve roots in the area where they leave the spine)
  • Shooting or toothache type pain and / or sensory disturbance (paraesthesia / numbness) in dermatomal fashion (Thoracic Radiculopathy)

• Myelopathy symptoms (spinal cord pathology)
  • Lower limb weakness or altered sensation, loss of balance/ coordination when walking, disturbance of bowel or bladder function (See Red Flags)

Risk Factors/Past Medical History

• Age of onset (insufficiency fracture more common over 50)
• Previous trauma, fractures, or surgery
• Previous cancer (risk of metastatic pathology in thoracic spine)
• Smoking
• Immunocompromise (IVDU, HIV/AIDS, chemotherapy, steroid use)
• TB
• Osteoporosis (particularly in minor trauma)
• Recent bacterial infection
• Relevant viscera (stomach, liver, pancreas) or vascular cause (thoracic aorta) that can refer pain to thorax
• Personal/ family history inflammatory Spondyloarthropathy
• Scoliosis
• Scheuermann’s disease (juvenile kyphosis)

Examination

• Observation and range of motion of whole spine including chest expansion, muscle wastage, deformity, skin rashes, heat, tenderness, upper and lower limb range, pain behaviour & neurological examination including gait.
• Pain on percussion over spinous process may indicate vertebral pathology such as a fracture.

Tests for Thoracic Myelopathy (cord pathology)

• Tandem walking, Romberg’s, hyperreflexia, up going plantars, hypertonia, clonus, Babinski sign.

Differential Diagnosis – include:

• Non-specific mechanical causes e.g., strains, poor posture, lack of exercise

Thoracic Back Pain (Causes, Symptoms, and Treatment) (patient.info)

• Intervertebral disc prolapse
  • Pain localised to the spine and also radicular along the relevant dermatome.
  • Sensory disturbances may occur in a dermatomal distribution (wider distribution of sensory disturbance below the level of pain is consistent with myelopathy due to cord compression)

• Degenerative causes affecting discs and joints

• Deformity (e.g., kyphosis and scoliosis)
  • usually, long standing and benign
  • most will not require investigation and will be manageable with conservative treatment such as physiotherapy.
  • Progressive pain and/ or deformity should be referred to interface service

• Fracture

Acute high velocity injury (e.g., road traffic collision) is not covered in this CRG and would be managed by the trauma team.

Insidious/low velocity osteoporotic (insufficiency) fractures

Royal Osteoporosis Society - Spinal fractures

• should be considered as cause of severe and sudden onset of thoracic pain particularly if pain well localised and focal on palpation.
• risk factors that increase the likelihood of spinal fracture include:
  • female aged over 50 years
  • previous diagnosis of Osteoporosis / Osteopenia
  • previous insufficiency fractures (if previous fracture due to osteoporosis, then the person has a 5.4 times increased risk of vertebral fracture)
  • excessive alcohol consumption (risk increases when drinking greater than 3 units per day)
  • vitamin D deficiency, long-term corticosteroid use (greater than 5 or 7.5mg per day over a 3-month period)
  • rheumatoid arthritis
  • smoking (greater than 20 cigarettes per day)
  • dietary restriction, eating disorders, absorption disorders (e.g., Crohn’s disease)
  • endocrinological causes such as hyperparathyroidism and diabetes and menopause.

Pathological fracture

• can also present acutely in a similar fashion to osteoporotic fractures
• risk factors include:
  • known primary cancer with possibility of spinal metastasis (lung, breast, prostate, kidney, thyroid, GI) particularly if high grade with lymph node involvement
  • spinal primary such as myeloma or lymphoma.

• investigation and management - see below

Inflammatory Spondyloarthropathy

NICE guideline [NG65] - Chapter/recommendations

• typified by pain and stiffness worse in bed, at rest or in morning relieved by movement/ exercise.
• other signs include sacroiliac / back pain for longer than 3 months in onset below 40 years
• comorbid IBD, Psoriasis, Uveitis, enthesitis

Infection (see Red Flags)

Visceral Referral

Problems affecting the lung, oesophagus, mediastinum, stomach, liver, gall bladder and pancreas can all cause referred pain in the interscapular area.

Shingles

NHS Condition - Shingles

Myelopathy: Presence of symptoms of thoracic spinal cord compression lower limb weakness or altered sensation thorax, abdomen or legs, loss balance/ coordination when walking, disturbance of bowel or bladder function. See referral section.

Infection: Discitis with vertebral osteomyelitis can present insidiously with low grade thoracic pain and pyrexia. The classic triad of pain, temperature and local tenderness may be seen. There may be a history indicating immunocompromised state. Note fever can be absent in approximately 50% of patients with spondylodiscitis so clinicians should not be reassured by its absence (Yusuf et al 2019). See referral section.

Cancer: Raised suspicion in presence of past history of cancer (see pathological fracture), weight loss (5-10% in 3-6 months more suspicious), unremitting non-mechanical or night pain, night sweats, band-like or unfamiliar pain should be considered a concern. Refer to appropriate Urgent Suspected Cancer Pathway.

No immediate investigations are required for localised non-progressive thoracic pain in the absence of red flags or any suspicion of fracture.

Thoracic X-Ray is appropriate and sensitive to check for spinal fracture. Chest x-ray if suspicious of TB.

Blood tests are appropriate in some patients to exclude differential diagnoses:

• FBC - white blood cell (WBC) count is less useful than CRP, as the presence of a normal WBC count does not exclude the diagnosis of spinal infection (Lener 2018)
• Inflammatory markers, such as CRP, are useful in detecting an infective or inflammatory condition.
• Renal Function Tests
• Myeloma screening should be carried out in all cases of suspected tumour
• Bone profile can pick up abnormalities of bone metabolism and give some clues to the underlying condition.

MRI - refer to spinal interface service if MRI may be required:

• most sensitive test for infection, malignancy (whole spine) and identification of cause of neurological symptoms (disc bulge, stenosis, tumour).
• MRI with STIR sequence is also required to age any fractures if surgical treatment to be considered and useful investigation in infection or haematoma.

Many cases of thoracic pain resolve without treatment.

a) Advice and education - lifestyle changes including:

• posture/ ergonomic advice
• regular change in position if sedentary
• increased exercise
• identification of psychosocial barriers (anxiety / depression)
• signpost to information sites such as MyHealth Devon

b) Pharmacological interventions:

• analgesia – as appropriate, prescribed at the lowest dose and shortest possible period of time.

See Formulary pages on appropriate analgesia prescribing, including:

Acute Pain - South & West

Acute Pain - North & East

c) Physiotherapy:

• consider referral to physiotherapy if not improving after 4-6 weeks.

d) Safety Netting and Review:

• clinical review if not improving and reassess for red flags or neurological symptoms and signs.
• worsening thoracic pain should be considered a red flag and instigate further referral & appropriate investigation.

Osteoporotic Compression Fracture

• If new fracture identified further investigations may be required including bloods, DEXA scan and referral to local fracture liaison service. See NICE guideline Osteoporosis - assessing the risk of fragility fracture. See Formulary page - Management of osteoporosis

• Most vertebral fractures will improve over 6-12 weeks, advice regarding appropriate exercise may be required (see Royal Osteoporosis society www.theros.org.uk). It may take up to 9-12 months to fully settle. They may heal over in wedged position leading to kyphotic deformity. Royal Osteoporosis Society - Exercises for back pain after spinal fractures

• Consider referral to spinal interface service if 3+ months post fracture with persistent or deteriorating focal pain at fracture site, sufficient to consider surgical intervention (vertebral body augmentation in the form of vertebroplasty/kyphoplasty).

• Give Booklet “Vertebral Compression Fracture: Vertebroplasty and Kyphoplasty” from the British Association of Spine Surgeons

1) Refer to the Spinal Interface Service

The Spinal Interface Service will complete a comprehensive assessment, refer for diagnostic tests or refer onto pain management and spinal surgeons via the Spinal MDT where appropriate.

Urgent – patients without red flags requiring same-day assessment who have:

• progressive and worsening thoracic pain with/ without neurological symptoms.

• a vertebral compression fracture identified AND persistent severe pain focal to fracture site minimum 3 months post fracture AND patient willing to consider surgical treatment:

Routine - patients without red flags or urgent features who have:

• persistent non- progressive thoracic pain

Referrals made outside of these referral criteria will be triaged based on the information provided and managed appropriately. To facilitate this process and maintain patient safety, please ensure that the reason for referral and clinical concerns are clearly stated in the referral letter.

2) Refer to Emergency Department – patients with:

• symptoms and signs suggestive of infective cause of thoracic pain.

• thoracic pain and recent rapidly progressive symptoms and neurological signs of deteriorating myelopathy e.g. suddenly unable to mobilise / sudden loss of sphincter control. This could be due to neoplastic or degenerative pathology.

3) Refer Urgently to Rheumatology – patients with:

• symptoms and signs of inflammatory back pain (inflammatory spondyloarthropathy)

Referral Instructions

Refer to the Spinal Interface Service via e-RS
Specialty: Orthopaedics
Clinic Type: Spine – Back Pain (not scoliosis/deform)
Service: DRSS-Western Back Pain – Devon ICB / DRSS-Western Back Pain-Cornwall-Devon ICB

Refer to Rheumatology via e-RS
Specialty: Rheumatology
Clinic Type: Musculoskeletal
Service: DRSS-Western-Rheumatology- Devon ICB -15N

Referral Form

DRSS Referral Form

GP Information

Finucane, L., Downie, A., Mercer, C., Greenhalgh, S., Boissonnault, W., Pool-Goudzwaard, A., Beneciuk, J., Leech, R. and Selfe, J., 2020. International Framework for Red Flags for Potential Serious Spinal Pathologies. Journal of Orthopaedic & Sports Physical Therapy, 50(7), pp.350-372.

Lener S, Hartmann S, Barbagallo GM V, et al. Management of spinal infection: a review of the literature. American Society of Anaesthesiologists. 2018;487–96.

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.

Yusuf M, Finucane L, Selfe J. Red flags for the early detection of spinal infection in back pain patients. BMC Musculoskeletal Disorders. 2019;20(1):1-10

Patient information/doctor - Thoracic back pain

UHP NHS Trust - Healthy Bones

Antony Louis Rex Michael, James Newman and Abhay Seetharam Rao. The assessment of thoracic pain. Orthopaedics and Trauma, 2010-02-01, Volume 24, Issue 1, Pages 63-73,

Patient Information

Patient information - Thoracic back pain

Royal Osteoporosis Society - Spinal fractures

Pathway Group

Mr S Pritchard. Neurosurgical Spinal Extended Scope Physiotherapist (Neurosurgery Department University Hospitals NHS Trust)

Mr Himanshu Sharma. Consultant Orthopaedic Spinal Surgeon. (Neurosurgery Department University Hospitals NHS Trust)

Publication date: October 2024