From the Guidelines
For a 43-year-old male with thoracic back pain and MRI findings showing moderate neural foraminal stenosis at T4-5 (right) and T8-9 (left) with minimal spinal canal stenosis, I strongly recommend starting with conservative management. This approach is supported by the American College of Radiology Appropriateness Criteria for thoracic back pain, which suggests that imaging may not be necessary for uncomplicated acute thoracic back pain and/or radiculopathy, and that conservative treatment should be considered first 1.
The patient's condition, characterized by degenerative changes and moderate neural foraminal stenosis without fractures or significant listhesis, is likely to benefit from conservative management. This can include:
- Over-the-counter pain relievers such as ibuprofen (400-600mg three times daily with food) or naproxen (500mg twice daily) for 1-2 weeks to reduce inflammation
- Physical therapy focusing on thoracic mobility exercises and core strengthening, attending 2-3 sessions weekly for 4-6 weeks
- Heat therapy for 15-20 minutes several times daily to relax muscles and improve blood flow
If pain persists after 2-3 weeks of consistent treatment, it is recommended to consult with a spine specialist to consider more targeted interventions such as thoracic epidural steroid injections 1. The neural foraminal stenosis identified on the MRI indicates narrowing of the spaces where spinal nerves exit the spine, which can cause pain when nerves become compressed. However, the absence of fractures or significant listhesis and only minimal spinal canal stenosis suggests that with appropriate management, the patient should experience improvement in symptoms without requiring surgical intervention.
From the Research
Thoracic Back Pain Management
- The patient's MRI results show moderate neural foraminal stenosis on the right at T4-5 and on the left at T8-9, with no fracture or significant listhesis 2.
- A study on the management of thoracic spine pain and dysfunction found that active motion testing, palpation, and postural assessment were commonly used by physiotherapists, and that exercise was widely used in all areas of practice and across all levels of expertise 2.
- Another study on chronic low back pain found that any exercise is beneficial for reducing back pain, but that the current literature is insufficient to evaluate the superiority of an exercise protocol for low back pain treatment 3.
Treatment Options
- A case report on the improvement in chronic low back and intermittent chronic neck pain found that a multi-modal regimen focused on strengthening postural muscles, specific spine manipulation, and Mirror Image® traction was effective in improving spine integrity and reducing pain 4.
- A review of non-steroidal anti-inflammatory drugs for acute low back pain found that NSAIDs are slightly more effective than placebo for short-term pain reduction and disability improvement, but that the magnitude of the effects is small and probably not clinically relevant 5.
- A literature review on the optimal duration of conservative management prior to surgery for cervical and lumbar radiculopathy found that there are limited studies supporting any optimal duration of conservative treatment, but that surgical intervention within 8 weeks of symptom onset may be appropriate for both cervical and lumbar radiculopathy 6.
Considerations for Treatment
- The patient's age and symptoms should be taken into account when considering treatment options, as well as the potential risks and benefits of each treatment 3, 5.
- A thorough assessment of the patient's condition, including a physical examination and review of their medical history, is necessary to determine the best course of treatment 2, 4.