Thoracic back pain is common throughout life but is not as well studied as neck pain or low back pain. Thoracic back pain is more often due to serious spinal pathology than neck or low back pain, but thoracic back pain is also prevalent among healthy individuals without any serious underlying cause.¹ For further information on causes, differential diagnosis and management of back pain, see the separate articles Low Back Pain and Sciatica and Neck Pain and Torticollis.

Epidemiology¹

• A recent review found the range of prevalence estimates of thoracic back pain in the general population to be very broad because of many factors, including the different definitions and duration of thoracic back pain included. The results of the review were as follows:
  • Prevalence data ranged from 4.0-72.0% (at any one time), 0.5-51.4% (7-day), 1.4-34.8% (1-month), 4.8-7.0% (3-month), 3.5-34.8% (1-year) and 15.6-19.5% (lifetime).
  • Studies reported a higher prevalence for thoracic back pain in children and adolescents, especially for females.
  • In children and adolescents, thoracic back pain was associated with female gender, postural changes associated with backpack use, backpack weight, other musculoskeletal symptoms, participation in specific sports, chair height at school, and difficulty with homework. Poorer mental health and age transition from early to late adolescence were also significant risk factors.
  • In adults thoracic back pain was associated with concurrent other musculoskeletal symptoms and difficulty
    in performing activities of daily living.

Causes

• Thoracic back pain can occur as a result of trauma or sudden injury, or it can occur through strain or poor posture over time.
• The most common cause of thoracic back pain appears to originate from muscular irritation or other soft tissue problems. These can arise from lack of strength, poor posture, prolonged sitting at a computer, using a backpack, overuse injuries (such as repetitive motion), or trauma (such as a whiplash injury caused by a car accident or as a result of a sports injury).
• Asymptomatic thoracic disc herniations are relatively common but symptomatic disc herniations are rare.²
• The thoracic spine is a relatively common site for inflammatory, degenerative, metabolic, infective and neoplastic conditions.¹
• Thoracic back pain and dysfunction are associated with conditions such as primary and secondary osteoporosis (especially vertebral fractures and hyperkyphosis arising from vertebral bone loss), ankylosing spondylitis, osteoarthritis and Scheuermann's disease.¹

Presentation

The presentation of thoracic back pain will depend on the underlying cause.

Red flags

Thoracic back pain is more likely than neck or low back pain to be caused by serious underlying pathology. However many patients with thoracic back pain have a benign, mechanical cause. Red flags for possible serious spinal pathology include:³

• Recent violent trauma (such as vehicle accident or fall from a height)
• Minor trauma, or even just strenuous lifting, in people with osteoporosis
• Age at onset less than 20 or over 50 years (new back pain)
• History of cancer, drug abuse, HIV, immunosuppression or prolonged use of corticosteroids
• Constitutional symptoms, e.g. fever, chills, unexplained weight loss
• Recent bacterial infection
• Pain that is:
  • Constant, severe and progressive
  • Non-mechanical without relief from bed rest or postural modification
  • Unchanged despite treatment for 2-4 weeks
  • Accompanied by severe morning stiffness (rheumatoid arthritis and ankylosing spondylitis)
• Structural deformity
• Severe or progressive neurological deficit in the lower extremities

Examination

See separate article Examination of the Spine.

Intervertebral disc prolapse²

• Pain: localised to the spine or also radicular along the relevant dermatome.
• Sensory disturbances:
  • Sensory disturbance may occur in a dermatomal distribution.
  • Wider distribution of sensory disturbance below the level of pain is consistent with myelopathy due to cord compression.
• Weakness:
  • Unlikely to be an early presenting problem.
  • Weakness in the lower extremities may indicate cord compression.
• Bladder symptoms and incontinence of faeces may indicate cord compression and myelopathy.

Differential diagnosis

• Problems affecting the lung (including a Pancoast tumour), oesophagus, stomach, liver, gall bladder and pancreas can all cause referred pain in the interscapular area.
• Interscapular pain may also be referred from disc prolapse or spinal dysfunction affecting the cervical or lumbar spine.

Investigations

• As with the lumbar spine, degenerative signs identified in imaging of the thoracic spine are not necessarily associated with pain.¹
• Investigations are mainly used to explore underlying musculoskeletal or other diseases causing the thoracic back pain.

Complications

Thoracic back pain may cause significant restrictions and exclusion of domestic, leisure, educational and employment activities.

Prognosis

• The prognosis of thoracic back pain will depend on the underling cause and specific circumstances of the individual.
• Thoracic back pain is more likely to indicate underlying pathology than neck pain or low back pain.
• Many cases of non-specific thoracic back pain resolve within a few weeks.

Document references

1. Briggs AM, Smith AJ, Straker LM, et al; Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskelet Disord. 2009 Jun 29;10:77. [abstract]
2. eMedicine, January 2009.; Thoracic Discogenic Pain Syndrome; Malanga GA
3. European guidelines for the management of acute nonspecific low back pain in primary care, COST B13 Working Group (2004)

Acknowledgements