What are the treatment options for thoracic spine pain radiating down the back of the right shoulder and posterior arm?

Treatment of Thoracic Spine Pain Radiating to Posterior Shoulder and Arm

Begin with conservative management including physical therapy, manual therapy, and exercise without imaging, as this presentation represents thoracic radiculopathy that is typically self-limiting and responsive to non-surgical treatment within 4 weeks. 1

Initial Clinical Assessment

Screen for red flags immediately to determine if urgent imaging or intervention is needed 1, 2:

• Age >65 years, chronic steroid use, or known osteoporosis (compression fracture risk) 1, 2
• History of cancer, unexplained weight loss, or constant pain (malignancy concern) 1, 2
• Fever, recent infection, immunosuppression, or IV drug use (infection/abscess) 1, 2
• Myelopathy signs: spasticity, hyperreflexia, positive Babinski, bladder dysfunction 1
• Progressive motor weakness or sensory deficits in dermatomal distribution 1
• Significant trauma history 2, 3

Conservative Treatment Protocol (No Red Flags Present)

First-line management for 4 weeks 1, 4:

• Exercise therapy: Active motion exercises are used by >85% of practitioners and should be the cornerstone of treatment 4
• Manual therapy: Spinal manipulation shows statistically significant improvement in pain and range of motion compared to placebo 5
• Medications: Follow WHO pain ladder - NSAIDs, acetaminophen, consider short-term muscle relaxants 6
• Physical therapy modalities: TENS may provide adjunctive benefit 6

Do not order imaging during this initial 4-week period unless red flags develop, as thoracic disc abnormalities are common in asymptomatic patients and imaging provides no clinical benefit for uncomplicated radiculopathy 1

When Conservative Treatment Fails (4-12 Weeks)

If symptoms persist beyond 4 weeks or worsen, proceed with MRI thoracic spine without contrast as the imaging study of choice 1, 2:

• MRI identifies: disc herniations (most common below T7), nerve root compression, spinal stenosis, facet arthropathy 1, 2
• Thoracic disc herniations occur in 76% of symptomatic cases with midback pain, often calcified (20-65%), typically in patients aged 30-50 years 1, 2

Interventional Treatment Options (After Failed Conservative Care)

For persistent thoracic radicular pain 6, 7:

• Pulsed radiofrequency treatment of the dorsal root ganglion: Recommended (2C+ evidence) as first interventional option 6
• Thoracic transforaminal epidural steroid injection: Shows 30% success rate (≥50% pain relief) at short-term follow-up, with better outcomes in disc herniation (36%) versus degenerative stenosis (21%) 7
• Conventional radiofrequency ablation of the DRG: Consider if pulsed RF provides short-lasting relief, though requires extensive skills above T7 and should be performed in specialized centers 6

For thoracic facet-mediated pain (if paravertebral pain worsens with standing, hyperextension, or rotation) 6:

• Radiofrequency treatment of the medial branch of thoracic dorsal rami is recommended (2C+ evidence) 6

Critical Pitfalls to Avoid

Immediately obtain MRI without contrast if 1, 2:

• Myelopathy develops: spasticity, hyperreflexia, gait disturbance, bladder dysfunction 1
• Progressive neurologic deficits emerge during conservative treatment 1

Order MRI with and without contrast if 1, 2:

• Red flags for malignancy or infection develop at any point 1, 2

Consider costotransverse joint pathology if pain localizes between medial scapular borders at T7-T10, as this is an overlooked pain generator that may respond to intra-articular steroid injection or radiofrequency ablation 8

Recognize that thoracic radiculopathy requiring surgery is rare (1-2% of all discectomies), with surgery indicated only for severe intractable pain or progressive/severe myelopathy 1