Thoracic Back Pain Red Flags

Original Editor - Lucinda hampton

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

Introduction

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

• Thoracic spine pain often has a musculoskeletal origin related to poor posture or overuse injuries.

Generally these conditions are self-limiting, but a small number of patients present with thoracic spine pain as the initial manifestation of more serious pathological conditions and differential diagnosis should be performed to exclude other pain sources and, most importantly, emergent situations

• 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)

What Are Red Flags?

Red flags are clinical indicators that should raise the issue that there may be a more serious underlying medical issue presenting as common, non-serious, musculoskeletal conditions, are commonly described as red flags.

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.
• Spontaneous spleen rupture
• Pulmonary embolism
• Neuroblastoma (mimicking as thoracic back pain)

Other Potential Red Flags

Other Potential Red Flags associated with thoracic spine pain are listed in the following charts (9 conditions listed):

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.

Concluding Remarks

Pathologic processes that can cause thoracic spine pain include degenerative disc disease, congenital connective tissue or skeletal disorders, traumatic and spontaneous vertebral fractures, vascular malformations, infections, spinal or meningeal tumors and metastases.

A small number of patients present with thoracic spine pain as the initial manifestation of more serious pathological conditions and differential diagnosis should be performed to exclude other pain sources and, most importantly, emerging conditions.

The majority of those presenting to orthopaedic spinal clinic with thoracic spine pain alone with no other red flag signs have no pathological cause, and although thoracic pain is a widely accepted indicator (red flag) of potential serious spinal pathology recent findings do not support thoracic pain alone as an indicator of Serious Spinal Pathology.