How to approach a patient with chronic upper back, neck, and chest wall pain?

Approach to Chronic Upper Back, Neck, and Chest Wall Pain

Begin with a focused history and physical examination to exclude cardiac causes and identify red flags, then categorize the pain as musculoskeletal chest wall syndrome, cervical radiculopathy, or a serious underlying condition requiring urgent imaging. 1

Step 1: Immediate Risk Stratification and Red Flag Assessment

First, distinguish visceral (cardiac) from musculoskeletal pain, as acute cardiovascular processes must be excluded before attributing symptoms to musculoskeletal causes. 1 This is critical because approximately 20-40% of patients with chest pain have musculoskeletal etiologies, but life-threatening cardiac conditions must be ruled out first. 1

Red Flags Requiring Urgent Evaluation:

• History of cancer (particularly breast, lung, kidney, thyroid, or prostate with potential spinal metastases) 1, 2
• Constitutional symptoms: fever, unexplained weight loss, night sweats suggesting infection or malignancy 1, 2
• Progressive neurologic deficits: motor weakness, sensory loss, or myelopathy signs 1
• Trauma history or risk factors for vertebral compression fracture (osteoporosis, corticosteroid use, postmenopausal status) 1, 2
• History of intravenous drug use or suspected spinal infection 1
• Inflammatory conditions: ankylosing spondylitis or inflammatory arthritis (anterior chest wall pain affects 30-60% of axial spondyloarthritis patients) 1

If any red flags are present, obtain urgent MRI of the cervical and thoracic spine and arrange specialist consultation immediately. 1, 2

Step 2: Detailed Pain Characterization

History Components to Elicit:

• Pain location and distribution: Determine if pain is retrosternal (52% of chest wall pain), left-sided (69%), or involves specific cervical/thoracic regions 1
• Pain quality: Stinging (53%), pressing (35%), or electric-like sensations suggesting radiculopathy 1
• Temporal pattern: Frequency (>once daily in 63% of chronic cases), duration (>6 months in 55% of chronic chest wall pain), and aggravating/relieving factors 1
• Functional impact: Difficulty with activities of daily living, work limitations, sleep disturbance 1, 3
• Psychosocial factors: Depression, passive coping strategies, job dissatisfaction, catastrophizing, and fear-avoidance beliefs—these are stronger predictors of chronicity than physical findings 1, 4, 5

Physical Examination Focus:

• Chest wall palpation: Costochondritis (42% of nontraumatic musculoskeletal chest wall pain) is diagnosed by reproducible tenderness over costochondral junctions 1, 6
• Sternoclavicular and manubriosternal joints: Involved in up to 50% of spondyloarthritis patients 1
• Cervical spine examination: Range of motion, paraspinal tenderness, Spurling's test for radiculopathy 1, 7
• Neurologic assessment: Motor strength, sensory testing, reflexes, straight leg raise (adapted for upper extremity), and evaluation for myelopathy (spasticity, hyperreflexia, Hoffmann's sign) 1, 7
• Thoracic spine evaluation: Kyphosis, scoliosis, vertebral body tenderness 1, 2

Step 3: Diagnostic Imaging Strategy

Do not routinely obtain imaging for nonspecific musculoskeletal chest wall or neck pain without red flags. 1 Most cases (42%) are costochondritis diagnosed clinically without imaging. 1

Imaging Indications:

• Plain radiography: Consider for suspected vertebral compression fracture in high-risk patients or if symptoms persist >4-6 weeks despite conservative therapy 1, 4
• MRI (preferred) or CT: Obtain when severe or progressive neurologic deficits are present, serious underlying conditions suspected, or persistent radiculopathy symptoms in surgical candidates 1, 4
• Avoid routine imaging: High prevalence of abnormal findings in asymptomatic individuals makes MRI interpretation challenging without clinical correlation 8, 7

Common pitfall: Ordering routine imaging for nonspecific pain exposes patients to unnecessary radiation and may lead to unnecessary interventions based on incidental findings. 1, 4, 5

Step 4: Initial Management Algorithm

For Musculoskeletal Chest Wall Pain (No Red Flags):

• Reassurance and education: Provide evidence-based information about favorable prognosis and expected course 1, 4
• Activity modification: Advise remaining active within pain limits; avoid prolonged bed rest 1, 4, 5
• First-line pharmacologic therapy: NSAIDs or acetaminophen for pain control 1, 4
• Nonpharmacologic options: Superficial heat application, manual therapy, or exercises for specific conditions 4, 5, 6

For Cervical Neck Pain (No Red Flags):

• Maintain activity: Evidence supports exercise therapy as beneficial 1, 3, 8
• Pharmacologic management: NSAIDs as first-line; muscle relaxants may be considered for acute neck pain with muscle spasm 1, 8
• Physical therapy: Consider referral if symptoms persist beyond 2-4 weeks 1, 3

For Chronic Pain (>3 months):

Implement multimodal strategy prioritizing nonpharmacologic interventions: 1, 4, 5

• Exercise therapy (moderate-quality evidence) 4, 5
• Cognitive behavioral therapy for patients with psychosocial risk factors 1, 4, 5
• Acupuncture, massage therapy, or spinal manipulation (low-to-moderate quality evidence) 1, 4, 5
• Pharmacologic escalation: Continue NSAIDs; consider anticonvulsants (gabapentin, pregabalin) or antidepressants (tricyclics, SNRIs) for neuropathic pain components 1
• Avoid long-term opioids: Weak evidence for efficacy and significant risks 1, 4

Step 5: Monitoring and Reassessment

Reevaluate patients with persistent, unimproved symptoms after 1 month. 1, 4, 2 Consider earlier reassessment (2-4 weeks) for:

• Older patients (>65 years) with higher risk of serious pathology 2
• Signs of radiculopathy or neurologic progression 1
• Severe functional deficits or worsening symptoms 4, 2

If Symptoms Persist Beyond 4-6 Weeks:

• Reconsider imaging if not previously performed and symptoms remain unexplained 1, 4, 5
• Intensify nonpharmacologic therapies: Refer for physical therapy, intensive interdisciplinary rehabilitation, or psychological interventions 1, 4, 5
• Specialist referral: Consider when no response to standard noninvasive therapies after 3 months or progressive neurologic deficits develop 5

Critical Nuances and Pitfalls

Psychosocial factors are stronger predictors of chronicity than physical findings. 1, 4, 5 Failing to assess depression, catastrophizing, and fear-avoidance beliefs leads to suboptimal outcomes and unnecessary interventions.

Costochondritis diagnosis is clinical—most cases do not require imaging. 1, 6 However, maintain vigilance for spondyloarthritis in younger patients with chronic anterior chest wall pain, as this may be the first manifestation in 4-6% of cases. 1

Neck pain is the fourth leading cause of disability, with 50% of patients experiencing recurrent or persistent symptoms. 3, 8 Early physical medicine and rehabilitation consultation (within 48 hours for acute pain, 10 days for all patients) may decrease surgical interventions and increase satisfaction. 3

Avoid assuming elderly patients experience less pain—they experience the same intensity as younger patients but are frequently undertreated. 2 Lower threshold for imaging in elderly patients given higher prevalence of serious pathology (cancer, fracture, infection). 2