What is the best course of treatment for a patient with burning thoracic pain below the scapula and a history of scoliosis?

Management of Burning Thoracic Pain Below Scapula with History of Scoliosis

For a patient with burning thoracic pain below the scapula and scoliosis history, initial management should focus on conservative treatment with NSAIDs and physical therapy, while simultaneously ruling out red flag conditions through clinical examination and selective imaging if neurologic symptoms are present. 1

Initial Clinical Assessment

Red Flag Evaluation

Immediately assess for the following urgent indicators that would alter management:

• Neurologic deficits: Check for focal weakness, abnormal reflexes, muscle weakness, sensory changes, or pes cavus 2
• Myelopathy signs: Evaluate for spasticity, hyperreflexia, positive Babinski sign, or bladder dysfunction 3
• Rapid progression indicators: Document if pain is functionally disruptive or associated with new neurologic symptoms 2, 4
• Atypical curve patterns: Left thoracic curves or short segment curves suggest secondary causes requiring different workup 2

Pain Characterization

The burning quality suggests either:

• Thoracic radiculopathy: Pain radiating in a dermatomal distribution along an intercostal nerve 1
• Thoracic facet pain: Paravertebral pain worsened by prolonged standing, hyperextension, or rotation 1
• Muscular pain: Related to asymmetric loading from scoliotic deformity 5, 6

Imaging Strategy

Without Red Flags or Neurologic Deficits

• No initial advanced imaging is indicated for chronic thoracic back pain without red flags 3
• Plain radiographs of the thoracic spine can document current scoliosis severity and assess for progression if prior films available 2, 4
• Thoracic spine radiographs have limited diagnostic utility for scoliosis assessment due to overlying structures but can identify other pathology 3

With Myelopathy or Radiculopathy

• MRI thoracic spine without contrast is the initial imaging of choice if neurologic symptoms develop 3
• MRI identifies compressive etiologies including disc herniations (often calcified in thoracic region), facet arthropathy, or ligamentum flavum ossification 3
• CT myelography serves as complementary imaging for presurgical planning or when MRI contraindicated 3

Conservative Treatment Algorithm

First-Line Management

• Analgesics following WHO pain ladder: Start with NSAIDs as first-line pharmacologic treatment 1
• Physical therapy with manual therapy techniques: Addresses muscular imbalance and asymmetric loading from scoliosis 6, 1
• TENS (transcutaneous electrical nerve stimulation): Consider as adjunctive non-pharmacologic option 1

The evidence shows that in adult scoliosis patients with chronic pain, asymmetric degeneration creates increased asymmetric load, perpetuating both degeneration and deformity 5. Conservative treatment targeting flexibility and muscle balance can provide sustained pain relief 6.

Treatment Duration and Expectations

• Trial conservative management for adequate duration before considering interventional options 1
• Approximately 5% of pain clinic referrals involve thoracic pain, indicating this is a recognized but challenging condition 1
• Pain in adult scoliosis often results from muscular overuse/imbalance or nerve root compression, making it resistant to standard analgesics 6

Interventional Options if Conservative Treatment Fails

For Thoracic Radiculopathy

• Pulsed radiofrequency treatment of the dorsal root ganglion (DRG) is recommended when conservative treatment fails 1
• If pulsed RF has short-lasting effect and pain is segmental, conventional radiofrequency treatment of DRG can be performed 1
• Critical caveat: Above T7 level, this procedure requires extensive skills and should only be performed in specialized centers 1

For Thoracic Facet Pain

• Radiofrequency treatment of the medial branch of thoracic dorsal rami is recommended for facet-mediated pain 1

Monitoring and Reassessment

Scoliosis-Specific Considerations

• Serial radiographic monitoring every 12-18 months for stable curves in adults 7
• Adult scoliosis can progress due to asymmetric degeneration, particularly in post-menopausal women with osteoporosis 5
• Surgical intervention typically reserved for curves >50° with documented progression or intractable pain 4, 5

When to Escalate Care

• Immediate orthopedic/spine referral if patient develops new neurologic symptoms, functionally disruptive pain not responding to conservative measures, or rapid progression 4
• Consider specialized pain management referral if conservative treatment fails after adequate trial 1

Common Pitfalls to Avoid

• Do not assume pain is solely from scoliosis: Thoracic disc herniations, though rare (1-2% of all discectomies), can present with burning pain and are often calcified 3
• Do not overlook thoracic outlet syndrome: Recent evidence shows cervicothoracic scoliosis can contribute to TOS, causing severe pain and paresthesias in the limb 8
• Do not order MRI routinely: Without red flags or neurologic deficits, advanced imaging is not supported and unlikely to change management 3
• Do not delay evaluation of new symptoms: Development of myelopathic signs requires urgent imaging and potential surgical evaluation 3, 4