From the Guidelines
Management of thoracic spondylosis should initially focus on conservative treatments, including medical management and physical therapy, with imaging considered only after 6 weeks of little or no improvement or in the presence of red flags. The approach to thoracic spondylosis is multifaceted, aiming to alleviate symptoms and improve quality of life. According to the most recent guidelines from the Journal of the American College of Radiology 1, uncomplicated acute thoracic back pain may be a benign, self-limited condition that does not warrant any imaging studies.
Initial Management
Initial management should include:
- Pain control with acetaminophen or NSAIDs for 1-2 weeks
- Physical therapy emphasizing thoracic mobility exercises, postural correction, and core strengthening with 2-3 sessions weekly for 4-6 weeks
- Heat therapy to relax muscles and improve circulation
- Activity modification to avoid exacerbating pain
Considerations for Imaging
Imaging may be considered in patients who have had up to 6 weeks of medical management and physical therapy with little or no improvement, or in those presenting with red flags such as significant trauma, myelopathy, or prior thoracic spine fusion 1. Early imaging should also be considered in patients with known osteoporosis or risk factors such as >65 years of age or chronic steroid use.
Further Interventions
For moderate to severe pain, muscle relaxants may be prescribed for short periods. Epidural steroid injections may provide temporary relief for persistent pain. Surgery is rarely needed but may be considered for severe cases with neurological deficits or intractable pain. The goal of these interventions is to address the degenerative changes in the thoracic spine that cause compression of nerve roots and inflammation, thereby improving morbidity, mortality, and quality of life. Most patients experience significant improvement with consistent adherence to conservative management over 6-12 weeks, as suggested by the guidelines 1.
From the Research
Management of Thoracic Spondylosis
- The management of thoracic spondylosis typically involves conservative management techniques, including physical therapy and restriction of offending activity 2.
- Bracing, such as thoraco-lumbar-sacral orthosis, has been accepted as a mainstay of treatment for symptomatic spondylolysis and grade I spondylolisthesis, but increasing costs and patient noncompliance can make bracing prohibitive and difficult to manage 2.
- Conservative management techniques, such as core strengthening activities, hamstrings stretching, and spine range of motion exercises, can be effective in relieving pain and restoring physical function in patients with symptomatic spondylolysis and grade I spondylolisthesis 2.
- Instruction in exercise and body mechanics, the use of back supports, and job modifications are also documented conservative treatments for spondylolisthesis 3.
- Strengthening of the abdominals and paraspinal muscles, especially in the thoracic area, as well as occupational modifications and instruction in body mechanics, deep-heat therapy, avoidance of maximal forward flexion of the lumbar spine, and in severe cases, bed rest, have been recommended for the conservative management of spondylolisthesis 3.
- For patients with symptomatic lumbar spondylolisthesis, conservative management strategies may include non-narcotic and narcotic pain medications, epidural steroid injections, transforaminal injections, and physical therapy 4.
- Nonoperative measures, such as physical therapy, aerobic exercise, epidural steroid injections, and homeopathic remedies, are often used as the initial treatment for spondylolisthesis, with surgical intervention considered if these treatments fail 5.
- A survey of clinical practice in the UK found that active motion testing, palpation, and postural assessment were commonly used in the management of thoracic spine pain and dysfunction, and that active and passive techniques, such as exercises and mobilizations, were widely used by physiotherapists 6.