What is the initial approach to managing thoracic back pain?

Differential Diagnosis for Thoracic Back Pain

The differential diagnosis for thoracic back pain must be systematically approached by first identifying red flags that indicate serious pathology requiring urgent evaluation, then categorizing pain generators as either spinal or non-spinal in origin. 1

Red Flag Conditions (Require Urgent Evaluation)

These conditions warrant early imaging and immediate attention due to potential for significant morbidity and mortality:

• Malignancy - Primary or metastatic disease to the thoracic spine 1
• Infection - Osteomyelitis, discitis, epidural abscess 1
• Fracture - Particularly in patients >65 years, chronic steroid use, or known osteoporosis (thoracic spine is a common site for osteoporotic compression fractures) 1
• Spinal cord compression/myelopathy - Presents with motor/sensory deficits, spasticity, hyperreflexia, positive Babinski sign, or bladder dysfunction 1
• Significant trauma - Any history of major trauma 1
• Prior thoracic spine fusion - Altered anatomy requiring different evaluation 1

Spinal Pain Generators

Neurologic Causes

Thoracic radiculopathy:

• Mechanical nerve root compression from degenerative disease 1
• Characterized by radiating pain in the distribution of an intercostal nerve 2
• Most commonly occurs below T7 level 1

Thoracic myelopathy:

• Most commonly due to compressive etiologies including spinal canal stenosis, cord compression/deformity 1
• Causes include disc herniations (often calcified 20-65%, sometimes intradural 5-10%), facet arthropathy, or ligamentum flavum ossification 1
• Symptomatic thoracic disc herniations present with thoracic midback pain (76%), motor/sensory deficit (61%), spasticity/hyperreflexia (58%), positive Babinski sign (55%), or bladder dysfunction (24%) 1

Mechanical/Degenerative Causes

Thoracic disc disease:

• Less common than cervical or lumbar disc disease due to rib cage stabilization and limited thoracic mobility 1
• Symptomatic herniations more common in third to fifth decades of life, often associated with trauma history 1
• Critical caveat: Thoracic disc abnormalities (herniations, bulges, annular fissures, cord contour deformity) are common in asymptomatic patients and may not correlate with pain 1, 3

Facet joint arthropathy:

• Paravertebral pain aggravated by prolonged standing, hyperextension, or rotation of thoracic spine 2
• Important note: Morphologic imaging changes of osteoarthritis do not correlate with pain 1

Costotransverse joint pathology:

• Small synovial joints that may be overlooked pain generators 4
• Can cause severe pressure sensation and dull pain in the thoracic region 4

Costovertebral joint pathology:

• Another potential source of thoracic pain amenable to interventional treatment 5

Soft Tissue Sources

• Ligamentous injury 5
• Fascial pain 5
• Muscular pain (including erector spinae) 5

Non-Spinal Causes

Inflammatory arthropathies:

• Ankylosing spondylitis 1
• Psoriatic spondylitis 1
• Reactive arthritis 1
• Inflammatory bowel disease-related spine disorders 1

Systemic conditions:

• Intrathoracic pathology (cardiac, pulmonary) 1
• Renal pathology 1
• Vascular etiologies (aortic dissection) 1
• Gastrointestinal etiologies (pancreatitis, peptic ulcer disease) 1

Clinical Approach Algorithm

Step 1: Screen for red flags 1, 3

• If present → Early imaging (MRI for myelopathy/radiculopathy, radiography for fracture risk)
• If absent → Proceed to Step 2

Step 2: Assess duration and neurologic symptoms 1

• Acute (<4 weeks) without red flags → Conservative management first-line, no imaging
• Subacute (4-12 weeks) or chronic (>12 weeks) without red flags → Conservative therapy first-line, no imaging
• Any duration WITH myelopathy or radiculopathy → MRI thoracic spine without contrast 1

Step 3: If midline tenderness present 3

• Consider vertebral fracture, especially with risk factors (osteoporosis, age >65, chronic steroids)
• Initial imaging: Thoracic spine radiography (X-ray) 3

Step 4: Consider non-spinal causes 1

• If clinical presentation suggests systemic pathology, evaluate accordingly

Common Pitfalls to Avoid

• Over-imaging uncomplicated thoracic back pain: Imaging provides no clinical benefit in acute/subacute/chronic thoracic back pain without red flags or neurologic deficits 1
• Attributing pain to imaging findings: Thoracic disc abnormalities and facet arthropathy are common in asymptomatic individuals 1, 3
• Missing costotransverse/costovertebral joint pathology: These are frequently overlooked pain generators that require specific imaging (CT) to identify 4
• Failing to recognize red flags: Delay in identifying serious pathology (malignancy, infection, fracture, myelopathy) can lead to significant morbidity 1