Symptoms and Management of Thoracic Radiculopathy
A pinched thoracic spinal nerve (thoracic radiculopathy) primarily presents with band-like pain around the chest or abdomen following a specific dermatome, along with potential sensory changes, motor weakness, and reflex abnormalities in the affected area. 1
Location-Specific Symptoms of Thoracic Radiculopathy
Primary Symptoms
- Band-like pain: Follows the specific thoracic dermatome, wrapping around the chest or abdomen in a circumferential pattern
- Sensory disturbances: Numbness, tingling, or burning sensation along the affected dermatome
- Motor weakness: Weakness in the intercostal or abdominal muscles corresponding to the affected level
- Referred pain: May radiate to the back in the paraspinal region
Specific Thoracic Level Manifestations
- Upper thoracic (T1-T6): Pain and sensory changes in the upper chest, potentially radiating to the inner arm
- Mid-thoracic (T7-T9): Band-like discomfort around the mid-chest and upper abdomen
- Lower thoracic (T10-T12): Pain and sensory changes in the lower abdomen and upper lumbar region
Diagnostic Approach
Imaging
MRI of the thoracic spine without IV contrast is the preferred initial imaging for thoracic radiculopathy, as it allows for evaluation of potential compressive etiologies affecting nerve roots 1, 2. This modality is particularly useful for identifying:
- Disc herniations (often calcified in the thoracic region)
- Facet arthropathy
- Ligamentum flavum ossification
- Spinal stenosis
- Neoplastic lesions
In cases where MRI is contraindicated, CT myelography of the thoracic spine can provide excellent assessment of spinal canal patency 1, 2.
Electrodiagnostic Studies
EMG/NCS can help differentiate thoracic radiculopathy from other conditions and localize the site of nerve compression 2.
Management Algorithm
1. Initial Management (First 6 Weeks)
- Medications: NSAIDs as first-line for pain management
- Physical therapy: Focused on thoracic mobility and core strengthening
- Activity modification: Avoiding activities that exacerbate symptoms
2. Persistent Symptoms (Beyond 6 Weeks)
For patients with persistent or progressive symptoms after 6 weeks of conservative management:
- Diagnostic/therapeutic injections: Selective nerve root blocks can both confirm diagnosis and provide therapeutic benefit 3
- Advanced imaging: If not already performed, obtain MRI of thoracic spine without IV contrast 1
3. Surgical Consideration
Surgery may be indicated for:
- Progressive neurological deficit
- Significant disc herniation with persistent symptoms
- Failed conservative management after 6-12 weeks
Important Clinical Considerations
Differential Diagnosis
It's crucial to differentiate thoracic radiculopathy from:
- Thoracic myelopathy: Presents with bilateral symptoms, spasticity, hyperreflexia, positive Babinski sign, and bladder dysfunction 2
- Cardiac or pulmonary conditions: May mimic thoracic radiculopathy symptoms
- Abdominal pathology: Can refer pain to the thoracic region
Common Pitfalls
Overreliance on imaging: MRI studies of asymptomatic individuals show high prevalence of anatomical irregularities (73%), including disc herniations (37%) and spinal cord deformation (29%) 4. Clinical correlation is essential.
Overlooking extraforaminal causes: Entrapment of thoracic dorsal rami by bone spurs or ligamentous structures can cause symptoms similar to radiculopathy 5, 6.
Missing red flags: Urgent evaluation is needed for:
- Progressive neurological deficits
- Suspected malignancy
- Signs of infection
- Bladder/bowel dysfunction
Prognosis
The natural history of thoracic radiculopathy is generally favorable with conservative management, though recovery may be slower than in cervical or lumbar radiculopathy due to the biomechanical constraints of the thoracic spine and rib cage 1.
Symptomatic thoracic disc herniations requiring surgery are rare, accounting for only 1-2% of all discectomies 1.