Thoracic Back Pain Red Flags

This article or area is currently under construction and may only be partially complete. Please come back soon to see the finished work! (16/05/2020)

Original Editor - User Name

Top Contributors - Lucinda hampton, Nupur Smit Shah, Kim Jackson and Aminat Abolade  

Introduction

Thoracic back pain is more likely than neck or low back pain to be caused by serious underlying pathology.

• Thoracic spine pain and visceral pain can mimic the other due to the shared afferent innervation of the ANS sympathetics, which originate from T1-L2 afferents from the spinal cord.
• Segments T4-T7 have the potential to cause pseudoanginal pain as well as symptoms generated by a cough, sneeze, deep breath, movement of the trunk, palpation, and compression (Heart surgery, image on R)
• However, many patients with thoracic back pain have a benign, mechanical cause.

Red flags for possible serious spinal pathology

Include

• Recent violent trauma (such as a vehicle accident or fall from a height).
• Minor trauma, or even just strenuous lifting, in people with osteoporosis.
• Age at onset less than 20 or over 50 years (new back pain).
• 
  History of cancer, drug abuse, HIV, immunosuppression or prolonged use of corticosteroids.
• Constitutional symptoms - eg, fever, chills, unexplained weight loss.
• Recent bacterial infection.
• Pain that is:
• Constant, severe and progressive; Non-mechanical without relief from bed rest or postural modification; Unchanged despite treatment for 2-4 weeks; Accompanied by severe morning stiffness (rheumatoid arthritis and ankylosing spondylitis).
• Structural deformity.
• Severe or progressive neurological deficit in the lower extremities.

Other Potential Red Flags associated with thoracic spine pain

Listed in the following charts:

Cardiac Ischemia	Dissecting thoracic aneurysm	Peptic Ulcer	Cholecystitis	Renal Infection and Kidney Stones
- History of risk factors for CAD, MI - Angina - Nausea	- Sudden, severe and unrelenting chest pain that can radiate to the upper back. - Unrelieved with laying down.	- Boring pain from epigastric area to middle thoracic spine. Triggered or relived with meals. - History of NSAID use. - Perforated ulcer can refer pain to shoulder with irritation of the diaphragm.	- Right upper quadrant and scapular pain. Fever, nausea and vomiting. 1-2 hours after a fatty meal.	- Renal colic/flank pain. - Fever, nausea, and vomiting. - Increased risk for kidney infection with ongoing UTI.

Fracture	Neoplastic Conditions	Inflammatory Disorders	Inflammatory or Systemic Disease
- Traumatic: blunt trauma or injury. - Compression Fractures: Caucasian race, history of smoking, early menopause, thin body build, sedentary lifestyle, steroid treatment, and excessive consumption of caffeine or alcohol. - Acute thoracic pain from trivial strain or trauma in males or females > 60 years.	- Age over 50 years. - Previous history of cancer. - Unexplained weight loss. - Constant pain, no relief with bed rest. - Night pain.	- Ankylosing Spondylitis:limited chest expansion, less <2.5 cm measured at nipple line. - Sacroilitis. - Morning pain and stiffness. - Peripheral joint involvemnt. - HLA-B27	- Temperature > 100° - Blood Pressure >160/95mmHg - Resting Pulse > 100 bpm. - Resting Respiration > 25 bpm. - Fatigue. - Osteomyelitis, diskitis, epidural infection, pericarditis.

Resources

• bulleted list
• x

or

1. numbered list
2. x