Red Flag Conditions
Every patient with low back / thoracic pain should be assessed by his pain clinic doctor and undergo a diagnostic triage to ascertain which group he falls into:-
- Simple Backache OR
- Spinal Nerve Root Pain OR
- Red Flag conditions.
Red flag conditions are those types of problems which need an urgent specialist opinion, tests and investigation:-
Simple Thoracic Pain
- Age of onset less than 20 or greater than 55 years
- Violent trauma (e.g. fall from a height or road traffic accident)
- Constant progressive non-mechanical pain
- Thoracic pain
- Previous history of cancer
- Long term oral steroid use
- History of drug abuse or HIV
- Patient systemically unwell
- Recent unexplained weight loss
- Persisting severe restriction of forward trunk flexion
- Widespread neurological changes / suspected cauda equina syndrome
- Recent onset of incontinence of urine
- Loss of anal tone with incontinence of faeces
- Numbness affecting the anus, perineum and genitals
- Widespread (more than one nerve root) or progressive loss of strength in the legs or walking disturbance
- The appearance of a sensory level on pinprick testing.
- Structural deformity.
- Spinal Inflammatory Disease e.g. ankylosing spondylitis and related disorders
- Gradual onset before the age of 40 years
- Marked morning stiffness
- Persisting limitation of spinal movements in all directions
- Peripheral joint involvement
- Eye inflammation
- Urethral discharge
- Strong family history of similar problems.
- The thoracic spine extends from the round bump at the base of the neck (T1) all the way down to T12 (about 4 - 5 " below the bra-strap).
- Simple Thoracic Pain implies pain arising due to relatively minor problems with the muscles, ligaments and joints of the thoracic spine. It implies also that there is no spinal nerve root involvement (trapped or pinched nerve, slipped disc).
- The pain can come on after a minor injury or sprain. In many cases no injury can be identified, with the pain coming on say just after sleeping badly in bed at night (see Postural Thoracic Ache).
- Investigations (X-rays and MRI scans) only show age related changes, reassuring the doctor and patient that no serious damage has been done.
- 90% of all episodes of simple thoracic pain get better within 2 weeks with conservative management (analgesics - pain killers / relievers, keep it moving, avoid excessive rest).
- What is the cause of the pain ? - The sprained part is usually in the superficial part of the spine (muscle, joint or ligament). The sprained tissue becomes inflamed, causing pain signals to be sent to the spinal cord.
- If the incoming pain signals are strong enough and go on for long enough, processing centres (dorsal horn) in the spinal cord become sensitised, sending out signals to the muscles in the vicinity of the sprain to contract to produce muscle spasm. This is initially a protective reflex which may prevent further injury to the sprained part.
- If the muscles in the area are contracting quite strongly, then the tension receptors in the local muscles and joints are activated. Strong signals from the tension receptors can be interpreted in the spinal cord as pain, adding to the pain signals from the inflamed tissue. These two kinds of signal combine together to keep the spinal cord dorsal horn in a sensitised state, and also keeping the spinal muscles in a contracted state through a feedback loop. The sequence of events can be therefore summarised in the diagram below:-
- Muscle spasm is a type of cramp, and like any other cramp in the body it hurts, causing restricted painful thoracic movements. Over a variable period of time the initial sprain heals, reducing the signals to the spinal cord, and also reducing the degree of spinal cord dorsal horn sensitisation. Once this sensitisation has declined, the outward signals to the muscles in the area of the sprain also lessen, allowing the pain and muscle spasm to resolve naturally.
- Why did my thoracic pain not improve in 2 weeks ? - In about 10% of adults the thoracic pain continues despite healing of the initially sprained area. In this situation there is a perpetual loop as shown below, without there being any sprain or inflammatory process involved. This situation may leave individuals susceptible to further sprains due to the thoracic muscles being in a contracted and shortened state, and also due to there being pre-existing dorsal horn sensitisation.
Postural Thoracic Ache
- Treatment - the following treatments may be useful for simple thoracic pain:-
- Complex Thoracic Pain implies pain arising from more complicated causes in the thoracic spine. Investigations (X-rays and MRI scans) often show anatomical problems (in addition to age related changes), and may also indicate that the spinal nerve roots are being irritated, pinched or trapped.
- Why does the pain go into my chest / abdomen ?
- Muscle spasm in the thoracic region can cause referred pain to radiate into the chest or abdomen. The pain appears in there even though there isn't anything wrong with it. It occurs because of a shared nerve supply between the part of the thoracic spine affected and the part of the chest / abdomen (See Referred Pain).
- In 5% of people the chest / abdominal pain is associated with numbness, tingling and a band-like sensation all around the trunk. These symptoms are more likely to be associated with a problem affecting the spinal nerve roots in the thoracic spine, and require further investigation. (See Spinal Nerve Root Pain and MRI Scans).
Computer Seating Advice
- Postural thoracic ache usually occurs when the back is held in an abnormal posture for too long e.g. sitting for hours in an uncomfortable car/train/airplane seat or sleeping on an uncomfortable mattress or when the equilibrium of the spine is unbalanced e.g. by having one leg longer than the other.
- The muscles, joints and ligaments of the spinal column are packed full of position and stretch receptors, which are constantly monitoring and maintaining posture.
- People who suffer from postural thoracic pain usually have some ongoing problem with the equilibrium of the spine, and quite frequently have areas where the spinal cord dorsal horn shows pre-existing sensitisation. When these sensitised areas are held in abnormal positions for prolonged periods, there is stimulation of the spinal stretch and position receptors, increasing the signals going to the spinal cord.
- As the spinal cord dorsal horn is already partly sensitised, it more readily becomes fully sensitised by the extra signals coming in. The result is that there is an increase in the out-going signals to the local spinal muscles, producing muscle spasm and pain.
- The situation can normally be resolved by moving and stretching the affected parts of the spine, so that the position and stretch receptors no longer respond by firing off excessively, allowing the dorsal horn to be less sensitised. This may explain why people with postural thoracic pain become auto-manipulators, frequently clicking and stretching their backs to obtain relief.
- Sitting in front of a computer for hours with bad seating and posture frequently leads to muscular pain in the neck, shoulders and upper thoracic spine.
- Please look at the section in Neck Pain for more details.
Mechanical Imbalance due to abnormalities of lower leg function can contribute to thoracic pain in the following ways:-
Lower Limb Length Inequality (short leg) on one side causes the pelvis to tilt towards that side. This produces a series of compensatory spinal curves from the low back, to the thoracic spine, and up to the top of the neck, with associated muscle imbalance, low back, thoracic, and neck pain. The leg length difference may need to be greater than 1/2" before it causes major problems, although lesser differences can still be symptomatic. The cause may be due to:-
- Anatomical Shortening with a measurable difference between the two legs. This can be due to leg fractures, hip and knee problems in childhood OR simply being born that way.
- Correcting the shortening with a shoe heel raise of the appropriate height (start with half the difference).
- Spinal Manipulation can also be useful to re-set the dysfunctional areas of spinal muscle spasm that may occur in the compensatory curves in the lumbar, thoracic and cervical spine.
- Functional Shortening is where there is no measurable difference in leg lengths, but with functional shortening of certain leg muscles groups, or due to a fallen inside arch of the foot.
- Identifying, stretching and re-training the shortened muscle groups (iliopsoas, quadriceps, hamstrings, gastrocnemius).
- Spinal Manipulation can be useful for the thoracic pain in the short term.
- Shoe heel raises are not useful in this group as there is no true leg shortening. Arch supports may help.
Spinal Ligament Syndrome
- The upper thoracic spine may be involved in flexion / extension injuries to the neck.
- Please look at Neck Pain for more information.
Facet Joint Syndrome
- Symptoms - Chronic thoracic pain with restricted movements. Referred pain may occur in to the chest and abdomen according to the level affected. If the pain is associated with numbness and tingling in the chest / abdomen, then there may be spinal nerve root impingement due to a slipped disc, and therefore investigation with an MRI scan is advised.
Spinal Nerve Root Pain
- Mechanism - a small proportion of people have complex thoracic pain due to inflammation of one or more of the small spinal joints (facet joints , ). X-rays may show arthritic changes in the joints, but there is a poor correlation between the degree of wear and the severity of the pain. There is also a poor correlation between the part of the spine on the X-ray which shows the arthritic joints, and where the actual pain is when the back is examined clinically. An isotope bone scan may give a better correlation by showing up inflammation as increased joint blood flow .
- Groups at Risk - Facet joint syndrome is more common in the elderly where there may be associated loss of disc height at the level concerned. It is more common at the C4/5, C5/6, and C6/7 levels in the cervical spine, and L4/5, L5/S1 in the lumbar spine. It not common in the thoracic spine.
- Symptoms - thoracic ache is often worse after keeping still in one position for too long. It is usually better keeping the thoracic spine on the move. The pain may be associated with frequent cracking or clicking of the facet joints, particularly during thoracic rotation. May be a cause of referred pain to the chest and abdomen (non-nerve root).
- Treatment initially consists of injecting the facet joint diagnostically with a solution containing local anaesthetic and steroid. These injections need to be performed under X-ray screening. If there is a positive outcome to this diagnostic test, then facet joint radio-frequency denervation (rhizolysis) should be considered next (see Facet Joint Injections).These techniques are not commonly performed in the thoracic spine due to anatomical difficulties.
- See Spinal Nerve Root Pain for radicular symptoms radiating into the chest and abdomen (Thoracic Radiculopathy) caused by Annular Tears, Disc Prolapse, and Foraminal Stenosis.
Referred pain from the thoracic spine
- Any structure in the thoracic spine (discs, nerves, muscles, facet joints, spinal ligaments) can refer pain to other areas of the body.
- This occurs because the affected part of the spine shares the same nerve supply as the area that the pain is referred to, making the brain believe the source of the pain is somewhere else.
- Spinal structures with a nerve supply originating from T2 to T12 refer pain to the chest and abdomen, whilst T1 refers down the inner arm.
Referred Pain to the thoracic spine
Failed Spinal Surgery
- Spinal Causes
- Pain may appear to be coming from the interscapular area (between the shoulder blades) when the cause may be one of the following:-
- C7/T1 spinal dysfunction - interscapular pain of Dr. Maigne.
- T12/L1 spinal dysfunction - interscapular pain of Dr. Maigne.
- Cervical disc prolapse - usually associated with radicular features in the arms.
- Pancoast Tumour - cancer near the apex of the lung - 39% of these tumours present with pain here first.
- If practitioners concentrate on where the pain is referred to i.e. the thoracic region, they will miss the cause of the problem, which may be on either side.
- Visceral Causes
- Problems affecting the oesophagus (gullet), stomach, liver, gall bladder and pancreas can all cause pain to refer to the interscapular area. This is because there is a shared sympathetic nerve supply between the spinal structures and the viscus concerned.
- Those with chronic spinal and nerve root pain who did not obtain relief from surgical intervention (discectomy, fusion), are often labelled as "Failed Spinal Surgery". This group also includes those who feel that surgery may have worsened their condition.
- Where conservative treatments (Acupuncture, TENS, Exercises, Manipulation, Facet Joint Injections, Prolotherapy, Epidural Injections, Nerve Root Blocks), and maximal oral drug therapy (see Analgesic Flow Chart) have failed to improve the pain, two further options include Spinal Cord Stimulation or an implanted Intrathecal Morphine Pump.