What to consider with mid back pain and swelling?

Mid Back Pain and Swelling: Evaluation and Management

Mid back pain with swelling requires thorough evaluation for potentially serious underlying causes, with initial management focusing on noninvasive nonpharmacologic approaches and appropriate nonopioid medications while ruling out red flag conditions. 1, 2

Initial Assessment and Red Flags

When evaluating mid back pain with swelling, prioritize assessment for these red flags:

• Progressive neurological deficits
• Fever or signs of infection
• Constant pain unrelieved by position change
• Night pain
• Bowel/bladder dysfunction or saddle anesthesia
• History of cancer
• Significant trauma
• Swelling (particularly concerning as it may indicate infection, inflammation, or vascular pathology) 2

The presence of swelling with mid back pain raises concern for conditions beyond routine musculoskeletal pain, including:

1. Infection (abscess, osteomyelitis)
2. Vascular issues (aortic pathology such as penetrating atherosclerotic ulcer) 3
3. Inflammatory conditions
4. Malignancy
5. Trauma with hematoma formation

Diagnostic Approach

• Imaging: MRI of the thoracic spine without IV contrast is the preferred initial imaging modality when red flags are present 2
• For suspected vascular causes, CT aortography should be considered, especially if pain radiates to the lateral chest area 3
• Plain radiographs with flexion and extension views may be helpful to assess for segmental motion issues 2
• Laboratory studies including complete blood count, erythrocyte sedimentation rate, and C-reactive protein should be obtained if infection or inflammation is suspected

Treatment Approach

Noninvasive Nonpharmacologic Approaches (First-Line)

1. Heat therapy: Particularly effective for acute back pain 1
2. Physical activity: Maintain tolerable physical activity and avoid prolonged bed rest 2
3. Exercise therapy: Focus on proprioception, strength, coordination, and function 2
4. Manual therapy: Spinal manipulation for back pain with radiculopathy 1, 2
5. Massage: Beneficial for musculoskeletal pain 1, 2
6. Acupressure: Recommended for acute musculoskeletal pain 1

Pharmacologic Management

For persistent pain after ruling out serious pathology:

1. First-line medications:

   • Topical NSAIDs with or without menthol gel (strongest benefit-harm ratio) 1, 2
   • Oral NSAIDs (if no contraindications) 1, 2
   • Acetaminophen (up to 3000mg/day) 2

2. Second-line medications:

   • Consider gabapentin or pregabalin if neuropathic pain component is present 2
   • Short-term muscle relaxants (2-3 weeks maximum) 2

3. Avoid opioids as first-line treatment due to risks generally outweighing benefits 1, 2

Special Considerations for Swelling

The presence of swelling with mid back pain is atypical for routine mechanical back pain and warrants special attention:

• If swelling is significant or progressive, urgent imaging is indicated
• Monitor for signs of systemic illness (fever, malaise)
• Consider vascular causes - a case report highlights that penetrating atherosclerotic aortic ulcer can present as mid back pain with radiation to the chest and may be missed during initial evaluations 3
• Soft tissue infections require prompt antibiotic therapy and possibly surgical drainage

Follow-up and Specialist Referral

• Consider specialist referral if pain and swelling persist beyond 4-6 weeks despite conservative treatment 2
• Urgent referral is needed for:
  • Progressive neurological deficits
  • Suspected vascular pathology
  • Signs of infection
  • Cauda equina syndrome

Caution and Pitfalls

1. Don't miss vascular pathologies: Mid back pain with swelling can be the presentation of aortic pathology, which can be life-threatening if missed 3

2. Avoid RICE protocol: The British Journal of Sports Medicine no longer recommends Rest, Ice, Compression, and Elevation due to lack of evidence 2

3. Don't rely solely on plain radiographs: A negative plain film x-ray does not rule out serious pathology 4

4. Don't prescribe opioids as first-line treatment: NSAIDs have been found to be more effective than opioids for many types of back pain 1

5. Don't delay imaging when red flags are present, especially with the unusual finding of swelling 2