What causes upper back pain that worsens when lying in a supine position?

Upper Back Pain Worsened by Lying Supine

Upper back pain that worsens when lying supine is a red flag symptom that demands immediate evaluation for serious pathology, particularly spinal metastases, aortic dissection, or inflammatory spondyloarthropathy, rather than benign musculoskeletal causes which typically improve with rest.

Critical Life-Threatening Causes to Rule Out First

Spinal Metastases

• Back pain when lying down (during sleep) that disappears when sitting up is a cardinal alarm symptom for spinal metastases in patients with known cancer 1
• This positional pain pattern indicates potential spinal instability and/or myelum or cauda compression requiring urgent evaluation 1
• Full spinal column MRI with T1 and T2-weighted images should be performed within 12 hours if there is clinical suspicion of metastatic epidural spinal cord compression (MESCC), or within 2 weeks if only local back pain is present 1
• Patients with bone metastases and their general practitioners must be informed about alarm symptoms and provided with contact information for urgent assessment 1

Aortic Dissection

• Sudden onset of severe "ripping" thoracic back pain radiating between shoulder blades, particularly after physical exertion or in patients with hypertension, suggests aortic dissection 2, 3
• The American College of Cardiology recommends immediate emergency department evaluation with CT angiography of the chest with IV contrast as the definitive diagnostic test 2, 3
• Check bilateral arm blood pressures and pulses in all extremities; a systolic differential >20 mmHg or pulse deficit strongly suggests dissection 3
• Do not administer aspirin, P2Y12 inhibitors, or anticoagulation if aortic dissection is suspected 3

Inflammatory Spondyloarthropathy

• Low back pain in patients under 45 years, lasting more than 3 months, that is worse in the latter part of the night and improved with exercise (not relieved by rest) suggests axial spondyloarthropathy 1
• Morning stiffness lasting more than 30 minutes is another key feature 1
• MRI scanning (sagittal images of cervicothoracic and thoracolumbar regions with T1 and STIR images, and coronal/oblique sacroiliac joints) is required, as plain radiography will miss most early disease 1
• HLA-B27 is less often positive in IBD-associated axial arthropathy 1

Red Flag Assessment Algorithm

Immediate Red Flags Requiring Urgent Imaging (within 12-24 hours):

• History of cancer with new or worsening back pain 1, 4
• Pain that worsens when lying down and improves when sitting up 1
• Fever, recent infection, immunosuppression, or IV drug use (suggesting infection) 4
• Neurological deficits: decreased leg strength, difficulty controlling legs, numbness/tingling radiating from chest/stomach/groin 1
• Sudden onset severe "ripping" pain with radiation to back 2, 3
• Unexplained weight loss 4
• Age >50 years with constant pain 4

Additional Red Flags Requiring Early Imaging (within 2 weeks):

• Age >65 years 4
• Chronic steroid use or known osteoporosis 4
• Midline tenderness on examination 4
• Prior spinal surgery 4
• Pain worse at night in patients under 45 years (inflammatory pattern) 1

Common Non-Life-Threatening Causes

Myofascial Pain Syndrome

• Most common cause of upper back pain in otherwise healthy individuals 5
• Characterized by localized musculoskeletal pain and tenderness with trigger points 5
• Key distinguishing feature: myofascial pain typically improves with rest and lying down, not worsens 5
• Treatment includes thermotherapy, NSAIDs, and rehabilitation exercises showing 78% improvement over 6 weeks 5

Thoracic Disc Herniation

• Occurs most commonly below T7 level, often in patients aged 30-50 years 4, 6
• One-third of cases have trauma history 4
• Presents with thoracic midback pain, may have radicular symptoms 6
• However, disc-related pain typically worsens with activity and improves with rest, making positional worsening with supine position less characteristic 6

Critical Clinical Pitfalls to Avoid

Do Not Assume Musculoskeletal Origin

• The positional pattern of pain worsening when lying supine is atypical for benign musculoskeletal causes, which generally improve with rest 1, 5
• This symptom pattern should trigger consideration of serious pathology until proven otherwise 1

Do Not Delay Imaging in High-Risk Patients

• The American College of Radiology recommends early imaging for patients with fracture risk factors or red flags 4
• MRI thoracic spine with and without contrast is the preferred modality when malignancy or infection is suspected 4
• Plain X-rays are inadequate for excluding spinal metastases, cord compression, or early inflammatory arthropathy 1

Do Not Miss Inflammatory Arthropathy in Younger Patients

• Axial spondyloarthropathy can have a very disabling long-term course, and early diagnosis is vital but often delayed 1
• Specialist rheumatology assessment and physiotherapy can prevent long-term disability 1
• Initial treatment is with NSAIDs, with early progression to anti-TNF agents often necessary 1

Recommended Diagnostic Approach

For patients with upper back pain worsening when lying supine:

1. Immediate assessment for red flags including cancer history, neurological deficits, fever, or sudden severe onset 1, 2, 4

2. Urgent MRI (within 12 hours) if neurological symptoms or suspected MESCC 1

3. Early MRI (within 2 weeks) if cancer history with local back pain only 1

4. CT angiography chest if sudden onset with ripping quality or cardiovascular risk factors 2, 3

5. MRI thoracolumbar spine with STIR sequences if young patient (<45 years) with chronic pain (>3 months), night pain, and morning stiffness suggesting inflammatory arthropathy 1

6. Consider malignancy or infection workup with MRI thoracic spine with and without contrast if age >50, weight loss, constant pain, or systemic symptoms 4