What causes upper back pain in a patient with cervicogenic dizziness and a history of neck pain?

Upper Back Pain in Cervicogenic Dizziness

Upper back pain in patients with cervicogenic dizziness and neck pain most commonly results from mechanical dysfunction of the cervical spine and its supporting structures, particularly involving the upper cervical segments, facet joints, and paraspinal musculature that refer pain caudally through shared biomechanical and neurological pathways. 1

Primary Mechanical Causes

The pain originates from nociceptive sources in the upper cervical spine that extend into the upper thoracic region:

• Cervical facet joint dysfunction causes localized mechanical pain that frequently radiates into the upper back, particularly from C2-C7 levels 1, 2
• Paraspinal and suboccipital muscle hypertonicity extends from the cervical region into the upper thoracic musculature, creating referred pain patterns 3, 4, 5
• Intervertebral disc degeneration in the cervical spine can produce pain that radiates into the upper back through mechanical stress on adjacent structures 1
• Cervical strain often coexists with cervicogenic headache and dizziness due to shared injury mechanisms, producing tenderness and limitation of motion that extends into the upper thoracic region 3, 4

Neuroanatomical Pain Referral Pattern

The convergence of upper cervical nerve fibers creates characteristic pain distribution:

• Pain typically starts in the neck and can refer both cranially (to the oculo-fronto-temporal area) and caudally (to the upper back) through convergence of cervical nerve pathways 4
• The upper cervical segments (C1-C3) have extensive proprioceptive connections that, when disrupted, contribute to both dizziness and referred pain patterns extending into the upper thoracic region 6, 7, 8
• Cervical spine tenderness, paraspinal muscle tenderness, and limitation of cervical motion produce compensatory biomechanical stress on upper thoracic structures 3, 4

Clinical Examination Findings

Key physical findings that confirm cervical origin of upper back pain:

• Cervical spine tenderness with palpation extending into the upper thoracic paraspinal muscles 3, 4
• Restricted cervical range of motion with pain provoked by neck movements 3, 4, 5
• Muscle hypertonicity in both cervical and upper thoracic regions 5
• Pain with sustained awkward head positions that stresses both cervical and upper thoracic musculature 4

Critical Red Flags to Exclude

Before attributing upper back pain to mechanical cervicogenic causes, systematically screen for serious pathology:

• Constitutional symptoms (fever, unexplained weight loss, night sweats) suggesting infection or malignancy 1, 2
• Elevated inflammatory markers (ESR, CRP, WBC) indicating inflammatory arthritis, infection, or autoimmune disease 1, 2
• History of malignancy, immunosuppression, or IV drug use raising concern for metastatic disease or vertebral osteomyelitis 1, 2
• Intractable pain despite appropriate conservative therapy suggesting serious underlying pathology 1, 2
• Progressive neurological deficits or myelopathic signs requiring urgent evaluation for spinal cord compression 1, 2
• Vertebral body tenderness on palpation indicating possible metastatic disease or infection 1, 2

Diagnostic Approach

For patients without red flags:

• Acute symptoms (<6 weeks) typically resolve with conservative management without requiring imaging 1, 2
• Persistent symptoms beyond 6-8 weeks warrant MRI cervical spine without contrast to evaluate for structural pathology 2
• MRI is superior to other modalities for identifying degenerative cervical disorders, nerve root impingement, and soft tissue abnormalities that may contribute to upper back pain 2

For patients with red flags:

• Immediately obtain MRI cervical spine without contrast to exclude infection, malignancy, inflammatory processes, or vascular pathology 2
• Consider laboratory evaluation including ESR, CRP, and WBC count if inflammatory or infectious etiology suspected 1, 2

Common Pitfall to Avoid

Do not over-interpret degenerative changes on imaging: Cervical spondylotic changes are present in 85% of asymptomatic individuals over 30 years, and these findings correlate poorly with clinical symptoms 2. The diagnosis of cervicogenic dizziness and associated upper back pain remains primarily clinical, requiring correlation of imaging findings with the patient's specific symptom pattern and physical examination 3, 6, 7.