In a patient with scoliosis who has tingling over the breast and epigastric region, what is the likely cause and how should it be evaluated and managed?

Thoracic and Epigastric Tingling in Scoliosis: Likely Nerve Irritation

The tingling at the breast and epigastric level in your scoliosis patient is most likely due to intercostal nerve irritation from the spinal deformity, and you should evaluate for both structural nerve compression and referred pain from chest wall abnormalities before attributing symptoms solely to the curve. 1, 2

Understanding the Mechanism

The nerve supply to the breast and epigastric region comes from the anterolateral and anteromedial branches of intercostal nerves T3-T5, and irritation anywhere along their course—including at the spinal level from scoliotic deformity—can produce tingling or pain in these distributions. 1

Structural Contributors in Scoliosis

• Thoracic deformity in scoliosis alters the lateral chest wall anatomy, with restriction located predominantly in the lateral thorax, which can mechanically irritate intercostal nerves as they traverse the deformed rib cage. 1

• Up to 60% of scoliosis patients have significant chest wall deformities including rib crowding, pectus carinatum, and more horizontal rib positioning from vertebral collapse, all of which can entrap or compress intercostal nerve branches. 1

• The kinematics of the trunk are altered in scoliosis, with patients shifting respiratory expansion to the abdomen to compensate for thoracic restriction, potentially creating chronic traction on intercostal nerves. 1

Evaluation Algorithm

Step 1: Rule Out Red Flags Requiring Immediate Advanced Imaging

Obtain MRI of the complete spine without contrast if any of these features are present: 2

• Left thoracic curve pattern 2
• Short segment curve 2
• Functionally disruptive pain (not just tingling) 2
• Focal neurological findings beyond sensory changes 2
• Rapid curve progression (>1° per month) 3
• Male sex with presumed idiopathic scoliosis 2

Step 2: Assess for Intraspinal Pathology

• Neural axis abnormalities occur in 2-4% of adolescent idiopathic scoliosis and up to 21-43% in congenital scoliosis, including syringomyelia, Chiari malformations, and tethered cord—all of which can cause dermatomal sensory symptoms. 2, 4

• A normal neurological examination does NOT rule out intraspinal anomalies, with physical exam accuracy only 62% for detecting these conditions. 2

• If the patient has congenital scoliosis or early onset scoliosis (age 0-9 years), MRI is mandatory before any treatment decision. 2

Step 3: Evaluate for Extramammary Causes

Check specifically for: 1

• Costochondritis (Tietze syndrome): Palpate costochondral junctions for tenderness 1
• Pectoral muscle strain or spasm: Common in scoliosis due to asymmetric muscle loading 1
• Entrapment of lateral cutaneous branch of third intercostal nerve: Can occur at sites of rib deformity 1
• Cervical or thoracic nerve root syndrome: Assess neck range of motion and perform Spurling's test 1

Step 4: Consider Breast-Specific Pathology (If Female)

• Noncyclical breast pain can be the initial presentation of underlying breast lesions in up to 10-15% of cases, though tingling is less typical than pain. 1

• If the patient is female and symptoms are unilateral or focal, consider mammography to exclude duct ectasia or other structural breast pathology, especially if there is any palpable abnormality. 1

Management Approach

Conservative Management (First-Line)

• Physical therapy focusing on intercostal nerve mobilization and chest wall flexibility exercises 1

• Postural awareness training to reduce asymmetric loading on the thorax 3

• Trial of NSAIDs if there is an inflammatory component (costochondritis) 1

• Nerve blocks (intercostal or epidural) can be both diagnostic and therapeutic if symptoms are severe 5

When to Escalate

• If curve magnitude exceeds 50° in a skeletally mature patient, surgical correction may be indicated to prevent continued progression and worsening nerve irritation, as these curves progress at approximately 1° per year even after skeletal maturity. 2, 4

• If MRI reveals intraspinal pathology (syrinx, tethered cord, tumor), neurosurgical consultation is mandatory before addressing the scoliosis. 2

• If symptoms progress to motor weakness or bowel/bladder dysfunction, this represents cauda equina syndrome and requires emergency MRI and surgical evaluation. 2

Critical Pitfalls to Avoid

• Do not assume tingling is "just from the scoliosis" without imaging if red flags are present—up to 21-43% of congenital scoliosis patients have intraspinal anomalies that alter management. 2

• Do not overlook chest wall deformities as the primary source of nerve irritation rather than the spinal curve itself, as rib crowding and pectus deformities are present in 60% of scoliosis patients. 1

• Do not order MRI with contrast routinely—contrast is not needed for detecting syringomyelia, Chiari malformations, or tethered cord, and should be reserved only for suspected tumor or infection. 2

• Do not ignore progression risk—if the patient is skeletally immature with a curve >20°, progression likelihood exceeds 70%, and worsening deformity will worsen nerve irritation. 2