Can back radiculopathy cause chest pain?

Can Thoracic Radiculopathy Cause Chest Pain?

Yes, thoracic radiculopathy can definitively cause chest pain, including pain that mimics cardiac angina ("pseudoangina pectoris"), and this diagnosis should be actively considered when evaluating chest pain of unclear etiology. 1, 2

Clinical Presentation of Thoracic Radiculopathy

Thoracic radiculopathy presents with pain radiating in a dermatomal distribution, often accompanied by neuropathic characteristics such as burning or electric sensations. 3 The pain pattern differs from plexopathy in that it follows a specific spinal nerve root distribution rather than multiple peripheral nerve territories. 3

Chest pain from thoracic radiculopathy can manifest as:

• Anterior thoracic pain that closely imitates angina pectoris, termed "pseudoangina pectoris" or "cervicogenic angina" when originating from lower cervical/upper thoracic nerve roots 2
• Thoracoabdominal pain radiating from the back toward the umbilicus in a band-like dermatomal pattern 4, 5
• Pain that may be accompanied by ECG changes (nonspecific ST-T segment abnormalities) and cardiac rhythm disturbances, further complicating differentiation from true cardiac disease 2

Common Etiologies

The most frequent causes of thoracic radiculopathy producing chest pain include:

• Degenerative disc disease with disc herniation (particularly below T7) or dorsal osteophytes compressing nerve roots 3, 2, 6
• Diabetes mellitus causing thoracic nerve root dysfunction 4, 6
• Segmental spinal dysfunction at lower cervical and upper-middle thoracic levels 2
• Facet arthropathy and ligamentum flavum ossification causing spinal stenosis 3
• Osteoarthritis of the spine 4

Diagnostic Approach

When thoracic radiculopathy is suspected as the cause of chest pain, the following evaluation is indicated:

Initial Assessment

• Identify dermatomal pain distribution with or without sensory loss or motor weakness reflecting spinal nerve root innervation 3
• Examine for motor/sensory deficits (61% of symptomatic cases), spasticity/hyperreflexia (58%), positive Babinski sign (55%), or bladder dysfunction (24%) 3
• Confirm clinical diagnosis with electrodiagnostic studies showing changes consistent with acute radiculopathy 4, 6

Imaging Strategy

MRI thoracic spine without IV contrast is the initial imaging modality of choice when thoracic radiculopathy is clinically suspected. 3, 7 This modality identifies mechanical nerve root compression from degenerative, metabolic, infectious, or neoplastic causes. 3

• Imaging should be performed urgently (within 12 hours) if there is clinical suspicion of cord or cauda equina compression, particularly with positional symptoms 7
• CT myelography may be complementary to MRI for identifying specific compressive pathology and presurgical planning 3

Critical Differential Diagnosis Consideration

A major clinical pitfall is failing to recognize that thoracic radiculopathy can coexist with true angina pectoris. 2 In patients with known coronary disease, superimposed vertebrogenic pain can substantially alter pain manifestations, potentially being misinterpreted as unstable angina. 2 This is therapeutically critical because changing cardiac medications will not eliminate vertebrogenic pain attacks. 2

Key distinguishing features to differentiate vertebrogenic from anginal chest pain:

• Vertebrogenic pain follows dermatomal patterns and may be provoked by spinal movement or positioning 3, 7
• True angina typically relates to exertion and responds to nitrates 2
• Thoracic radiculopathy is often chronic and intermittent with back pain origin 4

Treatment Implications

Once thoracic radiculopathy is confirmed as the cause of chest pain, treatment options include:

• Anti-inflammatory therapy combined with neuropathic pain medications (phenytoin, carbamazepine, amitriptyline) or local nerve blocks 4
• Corticosteroids for acute radicular pain (dexamethasone or methylprednisolone tapers) 5
• Surgical intervention reserved for progressive myelopathy, severe neurologic compromise, or intractable pain 3, 6

Red Flags Requiring Urgent Evaluation

Immediate MRI is mandatory if any of the following are present with thoracic back pain and chest symptoms:

• Progressive neurological deficits or myelopathic signs 3, 7
• Age >50 years with history of cancer or unexplained weight loss 7
• Fever, immunosuppression, or IV drug use suggesting infection 7
• Age >65 years, chronic steroid use, or known osteoporosis suggesting fracture risk 7