Thoracic Spine Pain & Dysfunction

Thoracic spine pain is pain between the base of the neck and the lower ribs, usually mechanical, that is common in adolescents, desk workers and athletes in rotational sports.

Most of it arises from the facet, costovertebral or costotransverse joints, discs, muscles or ligaments. Serious causes are proportionally more common than in low back pain, so every presentation needs red flag screening.

The thoracic spine has 12 vertebrae (T1 to T12). Each articulates with a rib at the costovertebral joint (rib head to vertebral body) and the costotransverse joint (rib tubercle to transverse process), forming a rigid cage that limits motion. Normal kyphosis is approximately 20° to 45° (Cobb angle).

The canal is narrow relative to the cord, and the cord runs its whole length. Small lesions can therefore cause myelopathy (upper motor neurone signs), unlike the lumbar spine.

Common mechanical sources:

• •Facet joint dysfunction: unilateral paravertebral pain, worse with extension and rotation; may refer to the chest wall and mimic cardiac or pulmonary pain
• •Costovertebral and costotransverse joints: posterior or lateral pain referring along the rib
• •Thoracic disc: uncommon, but can cause radiculopathy or myelopathy
• •Muscles (erector spinae, rhomboids, trapezius) and thoracic stiffness
• •Breathing pattern disorders: apical breathing may stiffen the cage and drive paraspinal overactivity

Scheuermann disease is the commonest cause of structural hyperkyphosis in adolescents, more often boys. The Sorensen criteria are anterior wedging of 5° or more at 3 or more consecutive vertebrae. Schmorl nodes are common, and the angular kyphosis does not correct with active extension, unlike a smooth, flexible postural kyphosis.