Thoracic back pain (upper back pain)

• What is Thoracic Back Pain (Upper Vertebral Fractures/Pain)
• Statistics on Thoracic Back Pain (Upper Vertebral Fractures/Pain)
• Risk Factors for Thoracic Back Pain (Upper Vertebral Fractures/Pain)
• Progression of Thoracic Back Pain (Upper Vertebral Fractures/Pain)
• Symptoms of Thoracic Back Pain (Upper Vertebral Fractures/Pain)
• Clinical Examination of Thoracic Back Pain (Upper Vertebral Fractures/Pain)
• How is Thoracic Back Pain (Upper Vertebral Fractures/Pain) Diagnosed?
• Prognosis of Thoracic Back Pain (Upper Vertebral Fractures/Pain)
• How is Thoracic Back Pain (Upper Vertebral Fractures/Pain) Treated?
• Thoracic Back Pain (Upper Vertebral Fractures/Pain) References

What is Thoracic Back Pain (Upper Vertebral Fractures/Pain)

Thoracic back pain occurs within the backbone. The backbone (or vertebral column) is composed of 32 vertebrae – 7 cervical (neck), 12 thoracic, 5 lumbar, 5 sacral, and 3 coccygeal. The 12 thoracic vertebrae are considered the upper back while the lumbar region the lower back. The thoracic vertebrae differ from the others in that the 12 ribs are attached to the 12 vertebrae respectively. The costovertebral joints (between the ribs and the vertebrae) hence provide another source of pain. On the other hand, the thoracic vertebrae, being higher up than the lumbar, do not support as much weight, hence prolapsed discs do not happen very often at all. In addition, the thorax contains the lungs, heart, and great vessels – which can be a cause of referred pain to the back.

Statistics on Thoracic Back Pain (Upper Vertebral Fractures/Pain)

Thoracic back pain is common in people of all ages, mostly due to poor posture or heavy lifting affecting the joints between the vertebrae and ribs. The other conditions affecting the thoracic spine tend to be different from the ones affecting the lumbar spine.

Risk Factors for Thoracic Back Pain (Upper Vertebral Fractures/Pain)

The most common cause is

• muscular and ligamentous strains (mainly postural).
• Vertebral dysfunction

Other conditions are less common:

• Conditions in youger people: Scheuermann’s disorder, Idiopathic adolescent scoliosis.
• Gastrointestinal disorders – oesophageal dysfunction (spasm), Peptic ulcer, or acute pancreatitis, gallstones or cholecystitis;
• Fibromyalgia
• Polymyalgia rheumatica (inflammatory condition causing symmetrical shoulder girdle pain and stiffness – easily treated with corticosteroids)
• Herpes zoster
• Spondyloarthropathies (not common in the upper back); Certain serious heart/lung disorders should not be missed:
• Myocardial infarction (heart attack)
• Dissecting aneurysm (the wall of the aorta splits into two layers)
• Malignancies: multiple myeloma, lung cancers, metastases to the spine;
• Severe infections: osteomyelitis, pleurisy, tuberculosis
• Osteoporosis with crush fracture
• Pneumothorax (see lung disorders)

Progression of Thoracic Back Pain (Upper Vertebral Fractures/Pain)

• Vertebral dysfunction – this occurs commonly in 20-40 year olds, and is related to poor posture. It causes dull, aching ,and occasionally sharp pain usually felt posteriourly behind the scapulae. It is made worse with activity and poor posture, or sleeping on beds that are too hard or too soft.
• Scheuermann’s disorder – typically begins ages 11-17, causing increasing thoracic kyphosis over 1-2 months, with wedging of the vertebrae, and pain, especially on bending.
• AIS – the vast majority of curves occurring are mild and of no consequence. The scoliotic deformity develops at 10 years of age, usually coinciding with the growth spurt. Only 10% of scoliotic deformities will progress and require medical intervention.
• The serious heart and lung conditions or infections have varying natural histories – but all require early diagnosis and immediate management or they can be fatal.
• A ‘pathological’ crush fracture (e.g. due to osteoporosis or a malignancy) may occur spontaneously when the bone is weak enough to collapse – causing wedging. In osteoporosis this may occur without the patient knowing they had osteoporosis, since the condition is asymptomatic until a fracture occurs.

How is Thoracic Back Pain (Upper Vertebral Fractures/Pain) Diagnosed?

Screening tests are indicated in chronic back pain longer than 3 months.

• Plain x-rays AP and lateral – will help diagnose kyphosis, pathological fractures, scoliosis;
• Urinalysis
• ESR – elevated in multiple myeloma, polymyalgia rheumatica, other inflammatory or infective conditions.
• Consider specific investigations for cardiac, respiratory, and gastro-intestinal disorders if suspected (ECG, CXR, grastroscopy).

Prognosis of Thoracic Back Pain (Upper Vertebral Fractures/Pain)

Prognosis is highly variable depending on the cause. For some of the conditions:

• Vertebral dysfunction can cause repeated episodes of back pain, usually in response to poor posture or activity. It usually responds dramatically to simple manipulation.
• Scheuermann’s disorder can cause progressive kyphosis in a skeletally immature adolescent (where bones have not stopped growing), although this is usually halted with appropriate management. Surgery can be corrective if there is severe kyphosis.
• Scoliosis: the greater the curve and the growth potential – the higher the likelihood of progression. Curves in girls are more likely to progress. A recent study showed that bracing had a 74 percent success rate at halting curve progression (but not correcting the deformity). Spinal surgery with instrumentation corrects a significant part of the deformity and hopefully stops further progression of the scoliotic curve. Current consensus is that surgery should be performed for curves greater than 40 to 45 degrees when there is growth remaining.
• Osteoporosis

How is Thoracic Back Pain (Upper Vertebral Fractures/Pain) Treated?

• Vertebral dysfunction is treated with simple analgesics for painful episodes, appropriate exercises (after consultation with physiotherapist) and spinal mobilisation.
• Treatment for Scheuermann’s disorder involves extension exercises, postural correction, and consideration for bracing or surgery if serious deformity.
• Treatment for scoliosis may involve bracing until skeletal maturity is reached (this will only halt the process), or surgical correction for more severe curvatures.
• Osteoporosis- can be treated with general measures (alter diet, stop smoking, alcohol), calcium supplementation, and medications such as Vitamin D, bisphosphonates, and oestrogen replacement) see topic under ‘bone’ medical centre for more detail.

Thoracic Back Pain (Upper Vertebral Fractures/Pain) References

1. BRIAN V. REAMY, JOSEPH B. SLAKEY. Adolescent Idiopathic Scoliosis: Review and Current Concepts. American Family Physiciam July 2001.
2. Kumar and Clark 4th Edition 2002
3. Murtagh, J. General Practice. Second Ed. McGraw-Hill, 1998.