Thoracic Spine Pain & Dysfunction

Patients describe pain that is midline (spinous process, disc, ligamentous), paravertebral (facet, costovertebral, muscular), or referred anteriorly to the chest or abdominal wall. The mechanical pattern is activity-related, worse with movement, and eased with rest. Morning stiffness is typically less than 30 minutes (longer suggests inflammatory disease). Radicular pain follows a band-like dermatomal pattern around the chest. Myelopathic symptoms include progressive lower-limb weakness, spastic gait, lower-limb stiffness, urinary or bowel dysfunction, and numbness below a defined sensory level - a same-day MRI emergency.

Examination:

• •Observation: kyphosis (angular and rigid in Scheuermann; smooth and flexible if postural), scoliosis, scapular position. Adam forward bend test screens for structural scoliosis (a persistent rib hump on forward flexion is structural)
• •Active range of motion: flexion, extension, rotation (seated to isolate thoracic motion), lateral flexion
• •Palpation: spinous processes, facets (1 to 2 cm paravertebral), costovertebral and costotransverse joints, paraspinal muscles
• •Segmental mobility testing (PAIVMs) and rib spring test
• •Lower-limb neurology (essential): tone, power, reflexes, sensation (including sensory level), and plantar responses

Always consider visceral referred pain in acute thoracic pain: cardiac (MI - interscapular), aortic dissection (sudden tearing), PE, pneumonia, oesophageal, renal, pancreatic, and gallbladder pathology.

Most mechanical thoracic pain is diagnosed clinically without imaging. Investigations are red-flag driven.

Plain radiographs (AP and lateral thoracic spine) are indicated when vertebral fracture, Scheuermann disease, malignancy, or infection is suspected. Key findings: anterior wedging (compression fracture or Scheuermann), Schmorl nodes, lytic or sclerotic lesions (malignancy), disc-space narrowing with endplate erosion (infection), or flowing anterior ossification over 4 or more contiguous levels (DISH).

MRI is the investigation of choice for suspected serious pathology - same-day for myelopathy or cord compression, and routine for suspected malignancy, suspected infection, radiculopathy not responding to conservative care, and to assess fracture acuity or exclude a pathological fracture.

CT is reserved for detailed bony assessment, surgical planning, or where MRI is contraindicated. DEXA is indicated after a fragility fracture per NICE CG146.

Bloods are targeted: CRP and ESR (infection, malignancy, inflammation), FBC, bone profile, vitamin D, myeloma screen (serum protein electrophoresis, urinary Bence-Jones) when age, anaemia, raised ESR, renal impairment, or hypercalcaemia raise suspicion. HLA-B27 only as part of a spondyloarthritis workup per NICE NG65 - not diagnostic alone.

Most thoracic pain is mechanical and self-limiting. Conservative care is the mainstay; UK practice extrapolates from NICE NG59.

Mechanical pain: reassure and educate, encourage continued activity (avoid prolonged rest), and prescribe therapeutic exercise targeting thoracic extension and rotation mobility, scapular and posterior chain strengthening, postural retraining, and diaphragmatic breathing. Manual therapy may give short-term relief but only as part of a treatment package. Topical NSAIDs for localised pain; short oral NSAID courses at the lowest effective dose with gastroprotection where needed. Strong opioids are not routinely offered. For thoracic radiculopathy or post-herpetic neuralgia, consider amitriptyline, duloxetine, or gabapentinoids per NICE CG173.

Scheuermann disease is usually managed conservatively with extension-based exercise and postural correction. Bracing for skeletally immature patients with progressive kyphosis is a specialist decision; surgery is reserved for severe kyphosis (over 70 to 75 degrees) with pain or neurological compromise.

Osteoporotic vertebral compression fracture: analgesia, gentle activity, and osteoporosis treatment (bisphosphonates per NICE TA464, vitamin D, calcium, falls assessment). Percutaneous vertebroplasty or kyphoplasty per NICE TA279 may be considered case-by-case for severe ongoing pain from a recent fracture after optimal conservative management.

Urgent referral: same-day MRI and spinal referral for suspected myelopathy or conus medullaris syndrome; NICE NG12 suspected-cancer pathway for malignancy; urgent admission for suspected spinal infection. Refer to rheumatology if spondyloarthropathy is suspected (NICE NG65).

Phase 1 (pain management and activation, 0 to 4 weeks): reassurance and education, continued activity, simple analgesia, gentle thoracic mobility (foam roller extension, seated rotation, cat-cow, thread-the-needle), diaphragmatic breathing retraining, manual therapy as an adjunct, ergonomic advice for desk workers.

Phase 2 (strengthening and postural correction, 4 to 8 weeks): progressive thoracic extensor strengthening (prone extension, Superman variations), scapular stabiliser strengthening (rows, lower trapezius, serratus anterior), core stabilisation (plank variations, pallof press, anti-rotation), postural retraining (chin tucks, wall angels), and progressive rotational mobility.

Phase 3 (functional restoration and return to activity, 8+ weeks): sport-specific rehabilitation (rotational loading for golf, tennis, cricket; overhead for swimming; extension for gymnastics), return-to-work conditioning, and ongoing mobility maintenance.

Scheuermann disease rehabilitation: extension-based thoracic exercises (avoid heavy loaded flexion during active growth), core and posterior chain strengthening, pectoral stretching, scapular stabiliser strengthening, and aerobic fitness.

• •NICE NG59 (Low back pain and sciatica) - core principles extrapolated to thoracic mechanical pain: stay active, therapeutic exercise, manual therapy only as part of a treatment package, avoid routine strong opioids.
• •NICE NG12 (Suspected cancer) - referral pathway for thoracic pain with red flags for malignancy; the thoracic spine is the commonest site for spinal metastases.
• •NICE CG146 and TA464 - osteoporosis risk assessment and bisphosphonate treatment for fragility vertebral fracture.
• •NICE TA279 - percutaneous vertebroplasty or kyphoplasty may be considered for severe ongoing pain from a recent fracture after optimal conservative management.
• •NICE NG65 (Spondyloarthritis) - insidious onset under 45 with morning stiffness over 30 minutes improving with exercise warrants sacroiliac imaging and rheumatology referral.

• •Thoracic pathology causes myelopathy (UMN signs), not cauda equina.
• •Thoracic spine is the commonest site for spinal metastases - PB KTL: Prostate, Breast, Kidney, Thyroid, Lung.
• •Scheuermann disease: angular rigid kyphosis with 5 degrees or more anterior wedging at 3+ consecutive vertebrae (Sorensen), Schmorl nodes.
• •Conus medullaris syndrome (T12-L1): mixed UMN/LMN with prominent early sphincter dysfunction.
• •DISH: flowing anterior ossification over 4+ contiguous levels in older adults.
• •Sudden tearing interscapular pain is aortic dissection until proven otherwise.