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Thoracic back pain is common but is not as well studied as neck pain or low back pain. Persistent 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 (Rizzello et al 2019). It is therefore vital to make a thorough assessment of this patient group.
Thoracic Back Pain (Causes, Symptoms, and Treatment) (patient.info)
Acute high velocity injury (e.g., road traffic collision) is not covered in this CRG and would be managed by the trauma team.
Insidious/low velocity osteoporotic (insufficiency) fractures
Royal Osteoporosis Society - Spinal fractures
Pathological fracture
Inflammatory Spondyloarthropathy
NICE guideline [NG65] - Chapter/recommendations
Infection (see Red Flags)
Visceral Referral
Problems affecting the lung, oesophagus, mediastinum, stomach, liver, gall bladder and pancreas can all cause referred pain in the interscapular area.
Shingles
NHS Condition - Shingles
Myelopathy: Presence of symptoms of thoracic spinal cord compression lower limb weakness or altered sensation thorax, abdomen or legs, loss balance/ coordination when walking, disturbance of bowel or bladder function. See referral section.
Infection: Discitis with vertebral osteomyelitis can present insidiously with low grade thoracic pain and pyrexia. The classic triad of pain, temperature and local tenderness may be seen. There may be a history indicating immunocompromised state. Note fever can be absent in approximately 50% of patients with spondylodiscitis so clinicians should not be reassured by its absence (Yusuf et al 2019). See referral section.
Cancer: Raised suspicion in presence of past history of cancer (see pathological fracture), weight loss (5-10% in 3-6 months more suspicious), unremitting non-mechanical or night pain, night sweats, band-like or unfamiliar pain should be considered a concern. Refer to appropriate Urgent Suspected Cancer Pathway.
No immediate investigations are required for localised non-progressive thoracic pain in the absence of red flags or any suspicion of fracture.
Thoracic X-Ray is appropriate and sensitive to check for spinal fracture. Chest x-ray if suspicious of TB.
Blood tests are appropriate in some patients to exclude differential diagnoses:
MRI - refer to spinal interface service if MRI may be required:
Many cases of thoracic pain resolve without treatment.
a) Advice and education - lifestyle changes including:
b) Pharmacological interventions:
See Formulary pages on appropriate analgesia prescribing, including:
c) Physiotherapy:
d) Safety Netting and Review:
Osteoporotic Compression Fracture
1) Refer to the Spinal Interface Service
The Spinal Interface Service will complete a comprehensive assessment, refer for diagnostic tests or refer onto pain management and spinal surgeons via the Spinal MDT where appropriate.
Urgent – patients without red flags requiring same-day assessment who have:
Routine - patients without red flags or urgent features who have:
Referrals made outside of these referral criteria will be triaged based on the information provided and managed appropriately. To facilitate this process and maintain patient safety, please ensure that the reason for referral and clinical concerns are clearly stated in the referral letter.
2) Refer to Emergency Department – patients with:
3) Refer Urgently to Rheumatology – patients with:
Refer to the Spinal Interface Service via e-RS
Specialty: Orthopaedics
Clinic Type: Spine – Back Pain (not scoliosis/deform)
Service: DRSS-Eastern-Orthopaedics-Spine- Devon ICB- 15N
Refer to Rheumatology via e-RS
Specialty: Rheumatology
Clinic Type: Musculoskeletal
Service: DRSS-Eastern and Northern-Rheumatology- Devon ICB -15N
Finucane, L., Downie, A., Mercer, C., Greenhalgh, S., Boissonnault, W., Pool-Goudzwaard, A., Beneciuk, J., Leech, R. and Selfe, J., 2020. International Framework for Red Flags for Potential Serious Spinal Pathologies. Journal of Orthopaedic & Sports Physical Therapy, 50(7), pp.350-372.
Lener S, Hartmann S, Barbagallo GM V, et al. Management of spinal infection: a review of the literature. American Society of Anaesthesiologists. 2018;487–96.
Rizzello E, Ntani G, Coggon D; Correlations between pain in the back and neck/upper limb in the European Working Conditions Survey. BMC Musculoskelet Disord. 2019 Jan 2320(1):38. doi: 10.1186/s12891-019-2404-8.
Yusuf M, Finucane L, Selfe J. Red flags for the early detection of spinal infection in back pain patients. BMC Musculoskeletal Disorders. 2019;20(1):1-10
Patient information/doctor - Thoracic back pain
UHP NHS Trust - Healthy Bones
Antony Louis Rex Michael, James Newman and Abhay Seetharam Rao. The assessment of thoracic pain. Orthopaedics and Trauma, 2010-02-01, Volume 24, Issue 1, Pages 63-73,
Patient information - Thoracic back pain
Royal Osteoporosis Society - Spinal fractures
Mr S Pritchard. Neurosurgical Spinal Extended Scope Physiotherapist (Neurosurgery Department University Hospitals NHS Trust)
Mr Himanshu Sharma. Consultant Orthopaedic Spinal Surgeon. (Neurosurgery Department University Hospitals NHS Trust)
Publication date: October 2024