Although rarer than its sister conditions of low back pain and neck pain, thoracic or upper back pain still causes many people to seek help from pain management doctors. At Louisiana Pain Specialists, we aim to accurately diagnose and successfully treat the source of your upper back pain, bringing you back to full functionality and good health as quickly as possible.
The Thoracic Spine
In most people, the spine or vertebral column is comprised of 33 interlocking bones, or vertebrae, which are connected by fibrous bands called ligaments and divided into five regions: cervical, thoracic, lumbar, sacral and coccygeal. The vertebral column provides support for the upper body as well as protection for the spinal cord, and furnishes attachment points for the ribs and muscles of the back. Between the vertebrae are elastic intervertebral discs, which provide cushioning for the bones of the spine and promote flexibility. Deterioration and deformity of these discs can lead to impaired movement as well as severe pain.
The thoracic region of the spine begins at the base of the neck and extends to the top of the low back, which is located approximately six inches below the bottom of the shoulder blades. It includes 12 vertebrae that are medium in size in comparison to the fine vertebrae of the neck and the thick vertebrae of the low back. The vertebrae of the thoracic spine connect to ribs on both sides at every level, and the ribs meet in the front and attach to the breastbone. This creates a protective bony cage (the thoracic cage) that surrounds vital organs including the heart, lungs and liver.
While the main function of the neck and low back is to provide mobility, the key purpose of the thoracic spine is to provide strength and stability that permit upright standing, and protect important internal organs housed in the thoracic cavity. Because the upper back is highly stable, it does not tend to develop as wide a variety of common painful back disorders as more mobile spinal regions. Nonetheless, the upper back has its own set of pain-producing pathologies.
Spinal Ligaments and Muscles
The most common cause of thoracic back pain is myofascial injury, or muscle and ligament damage sustained from exercise, physical accidents, lifting of heavy objects, poor posture, and other causes. When thoracic muscles and ligaments become strained, irritation may occur in local nerves that exit the spine.
Typically, back pain from myofascial injury resolves in a few weeks. If your upper back pain persists, consult with the doctors at Louisiana Pain Specialists. We offer a variety of treatments for persistent back pain. Your pain doctor will choose the most appropriate treatment plan based upon the underlying cause of your pain and your medical history.
Spinal Bones
The vertebrae of the spine provide a mobile, supportive framework for the spinal cord and back. These bones interconnect, or articulate, smoothly with each other at special joints called facets. Each facet joint is comprised of articular and transverse processes. The articular processes of a vertebra include two superior (upwardly pointing) processes that are linked to two inferior (downwardly pointing) processes from the preceding vertebral body. These processes project outward and can be felt through the skin. The transverse processes are located on either side of each vertebra and serve as attachment points for muscles and ligaments.
Each vertebra contains a central opening to permit passage of the spinal cord, as well as apertures on either side to accommodate spinal nerves and vessels. Degeneration of the bone from aging and overuse can lead to painful friction between facet joints and compression of nerves that exit the vertebral column. Degenerating thoracic facet joints can cause upper back pain that is aggravated by prolonged standing, and hyperextension and rotation of the thoracic spinal column (Van Kleef, 2010).
Sometimes thoracic facet joint pain is arthritic in nature. In this condition, facet arthritis, harmful friction between the processes of the facet joints results from breakdown of the cartilaginous tissues between each joint. In healthy joints, these tissues provide a smooth cartilage surface and a lubricating fluid that facilitate smooth movement. When these tissues degrade, the bony surfaces grind upon each other, inhibiting movement and causing pain and stiffness.
Vertebral Discs
Located between neighboring vertebrae are pliable intervertebral discs filled with a soft, gelatinous substance. These discs provide cushioning and promote smooth, flexible movement of the vertebral column. When excess pressure is put on a disc, it may bulge out of place, producing local nerve irritation and compression of the spinal cord, and you may be diagnosed with a bulging disc. Sometimes a tear or softening in the outer fibrous layer of an intervertebral disc forces the pliable inner material through the weakened part of the disc. This phenomenon is known as a herniated disc. As in the case of a bulging disc, a herniated disc causes local nerve irritation and compresses the spinal cord, producing pain.
When spinal nerve roots are compressed from disc problems or other reasons, pain often radiates down the length of the nerve. Termed radiculitis, this pain is frequently described as “shooting” since it travels from the spine outward. For example, pain from a compressed nerve may shoot down an arm or leg.
When radiculitis goes untreated, complications such as muscle atrophy, reflex changes and sensory loss may occur over time. In addition, a patient may begin to favor their unaffected side, causing overdevelopment of unaffected muscles. This more severe nerve root condition is known as radiculopathy and underscores the importance of seeking help for your radiating nerve pain.
Other Causes
Although found less commonly in the upper back than in the neck and low back, spinal stenosis is a painful condition that can be responsible for thoracic back pain. In spinal stenosis, pathological narrowing of the spinal canal puts painful pressure on the spinal cord. The condition may result from a variety of causes including arthritis of the spine, herniated discs, congenital defects (abnormalities present at birth) and Paget’s disease, a bone disorder involving abnormal breakdown and regrowth of bone tissue. If your doctor diagnoses you with central spinal stenosis, the narrowing is occurring around the central region of the spinal canal directly surrounding the spinal cord and cauda equina, or the downward-extending bundle of nerve fibers at the bottom of the spinal cord. If your spinal stenosis is “neural foraminal” or “neuroforaminal stenosis,” the narrowing is affecting spinal nerves where they exit through the foramen, which are openings in the vertebrae.
Another pain-producing ailment of the upper back is osteoporosis, an age-related disorder where bones become weaker and more brittle due to loss of bone mass. This weakening heightens the risk for painful vertebral compression fractures and irritated nerves. Osteoporosis can be diagnosed following a bone fracture using imaging and bone density tests. Treating osteoporosis early can prevent deformity, back pain, broken vertebrae and other fractures.
Chronic upper back pain from any long-term condition like osteoporosis, facet arthritis and spinal stenosis may lead to central sensitization. In central sensitization, chronic injury and inflammation in peripheral tissues eventually prompt pain receptors in the central nervous system to overreact to normal physical sensations. Low-threshold sensory fibers activated by light touch of the skin trigger neurons in the spinal cord that normally respond only to painful stimuli. As a result, harmless stimuli eventually provoke feelings of pain. To avoid central sensitization, do not delay seeking help for your upper back pain.
Rarer mechanisms of upper back pain include cancer and infection. In the case of cancer, tumors or metastases to the spine weaken or expand bone in the vertebral column, often leading to fracture, nerve compression, or spinal instability. And any source of infection (e.g., dental abscess, pneumonia) can seed the spine; urinary tract infection is the most common (Siemienow et al, 2008).
Referred Pain
Another typical cause of upper back pain is referred pain. Although this type of pain originates from organs located in the thoracic cavity, it may be interpreted by the brain as pain felt in the upper back. For example, problems with the heart, lungs, appendix and gall bladder can be perceived as upper back pain. In cases of referred pain, treating the underlying cause helps eradicate discomfort felt in the upper back.
One common cause of referred pain in the back is shingles, or reactivation of the varicella zoster virus that causes chicken pox. Back pain with shingles occurs when the dormant chicken pox virus becomes active within one or more spinal nerves, causing flu-like illness, back pain, and a distinctive localized rash. A complication of shingles is postherpetic neuralgia, or nerve damage that manifests as chronic pain, sensitivity to touch, itching, and weakness or paralysis.
Acute Thoracic Pain
Since the thoracic cavity contains vital structures like the lungs, esophagus, heart and great blood vessels (e.g., the aorta and vena cavae), acute (sudden) thoracic pain can be an emergency situation. For example, life-threatening conditions such as aortic dissection (tear in the aorta), pneumothorax (collapsed lung), and heart attack may be felt as upper back pain. Therefore, it is important to seek medical attention if you experience acute thoracic pain.
Chronic Thoracic Pain
The counterpart of acute thoracic pain is chronic thoracic pain, or long-term pain that occurs anywhere in the thorax. Chronic conditions like cardiomyopathy (deterioration of the heart muscle), GERD (gastroesophageal reflux disease), esophageal and lung cancers, and COPD (chronic obstructive pulmonary disease) can cause chronic thoracic pain. Your doctor will conduct a physical examination, take your medical history, and may order certain tests to help determine the cause and optimal treatment for your chronic thoracic pain.
Diagnostics
To better understand the particulars of your thoracic pain, the specialists at our New Orleans pain center often order tests to help diagnose your condition accurately. These tests may include:
- Imaging studies – MRI, CT scan and X-ray are used to help our practitioners visualize structures that may be causing your pain.
- Medial Branch Blocks (MBBs) – Medial Branch Blocks are a minimally invasive non-surgical treatment used for arthritis-related neck and back pain. Diagnostically, MBBs are used to test whether your pain-producing medial branch nerves will respond to more permanent interruption by a radio-frequency procedure. They also have a therapeutic effect in that they reduce inflammation and irritation in the facet joints of the spine.
- Selective Nerve Blocks – These are used to help your practitioner identify which nerves are causing your pain. By selectively numbing each nerve, pain-causing nerves can be identified and treated. Since the injected medication includes a steroid as well as an anesthetic, it reduces inflammation and irritation.
- Discography – Discography involves the use of contrast dyes to obtain a detailed image of intervertebral discs. It is used to evaluate patients whose back pain has not improved with comprehensive conservative care regimens. It provides the doctor with detailed information on the pain potential of the affected area, and is commonly used for surgical planning prior to a lumbar fusion.
Treatment Options
Louisiana Pain Specialists offers a wide variety of pain management therapies for individuals who suffer from thoracic pain. If your thoracic pain is from cancer, heart disease, lung ailments, or other diseases involving thoracic organs, we may in certain cases refer you to a different specialist who we feel can best treat your disease, or arrange rapid transport to an emergency room in the case of urgent conditions.
Since so many cases of thoracic pain involve the muscles, ligaments, nerves and bones of the upper back, we offer a comprehensive range of treatments to help resolve these conditions. These may include:
- Pharmacotherapy – Administration of non-steroidal anti-inflammatory drugs (NSAIDs, or Ibuprofen-like drugs), Acetaminophen (Tylenol), muscle relaxants, and membrane stabilizing medications is often effective in treating upper back pain. Our doctors are highly trained in pain medication management.
- Epidural Steroid Injections – Epidural injections are often used for degenerative disc disease and other pain syndromes. The doctor injects a steroid into the epidural space of the spinal cord, where the irritated nerve roots are located. The medicine then spreads to other levels and portions of the spine, reducing inflammation and irritation.
- Facet injections – These minimally invasive injections can temporarily relieve neck or back pain caused by inflamed facet joints. This treatment is thought to be highly effective.
- Spinal Cord Stimulation (SCS) – An implanted electrical device decreases the perception of pain by confusing the spinal cord and brain pain processing centers. Initially a trial is conducted to determine whether this device will help the patient on a long-term basis.
- Peripheral Nerve Stimulation – This method involves placement of tiny electrodes near the affected nerves. The electrodes release a small electrical current that inhibits pain transmission and provides pain relief.
- Kyphoplasty and Vertebroplasty – These minimally invasive procedures can treat osteoporotic fractures. Crushed vertebrae are stabilized by injecting acrylic cement into the fractured vertebra.
- Intrathecal Pump Implants – Implanted pain pumps are also available which can be extremely helpful in providing long-term pain control. A study examining the efficacy of intrathecal therapy in people suffering pain due to cancer showed a pain reduction in 66.7% of patients (Becker, Jakob, Uhle, Riegel, & Bertalanffy, 2000).
- Percutaneous Discectomy – A needle is inserted through the skin into the affected disc, material is suctioned out of the bulging disc and pressure is relieved within the disc.
- Radiofrequency Ablation – Nerves branching away from the spinal cord (peripheral nerves) can be blocked with local anesthetic, after which nerve ablation or destruction can be initiated.
- Trigger Point Injections – These injections can extremely successful in alleviating musculoskeletal pain. A local anesthetic and steroid are injected into a “Trigger Point.”
- Transcutaneous Electrical Nerve Stimulation (TENS) – This is a pain relief technique performed by applying mild electric current to the skin at the site of the pain. The electric impulses interfere with normal pain sensations and alter perceptions that were previously painful. The efficacy of this treatment is well-known; for example, a recent study examining the impact of long-term TENS therapy in patients with degenerative disc disease found TENS therapy contributed to pain relief and improvement of function and mobility of the lumbosacral spine and concluded TENS is an appropriate and effective treatment technique. In addition, 100% of patients given the treatment reported pain relief as well as improved spinal function and mobility (Pop et al, 2010).
- Biofeedback – This therapy teaches awareness of processes normally thought to be involuntary inside of the body such as blood pressure, temperature and heart rate, enabling some degree of conscious control of these processes. Biofeedback can influence and improve level of pain and promotes relaxation.
- Nutrition and Exercise – Exercise can help manage upper back pain by increasing flexibility and range of motion. Another benefit of exercise is the release of pain-relieving hormones called endorphins. In conjunction with a reasonable exercise regimen, good nutrition helps combat nutritional deficits that may hamper the body’s functionality and healing processes.
- Massage – Gentle focal rubbing of tender areas may help relieve muscle spasms or contractions and improve the discomfort associated with these. Massage may also promote relaxation, decreasing stress and tension.
- Chiropractic Manipulations – Targeted physical “adjustments” may significantly reduce back pain, especially when combined with other modalities. Specialized manipulations intended to correct nerve transmission are delivered by a knowledgeable, experienced practitioner.
- Prolotherapy – Also known as Regenerative Injection Therapy, this technique involves injection of irritating substances into painful ligaments and tendons. The procedure is used to initiate the body’s natural healing processes.
- Surgery – Surgical procedures are a last resort when conservative treatments are unsuccessful in reducing upper back pain or when the spinal cord or exiting nerves are being severely compressed. Serious compressions are characterized by bladder and/or bowel incontinence, lower extremity weakness, spasticity, and/or loss of sensation. Invasive surgical procedures include discectomy, laminectomy, spinal fusion and spinal instrumentation. Since surgery carries the risk of complications, it is used only when less invasive procedures have failed to restore functionality and provide relief.
Louisiana Pain Specialists cares about your quality of life and understands the burden of living with pain. Our caring practitioners will listen to your concerns and work with you to develop a pain management program that will help you regain good health and happiness.
Sources
Becker, R, Jakob, D, Uhle, L, Riegel, T, & Bertalanffy , L. (2000). The significance of intrathecal opioid therapy for the treatment of neuropathic cancer pain conditions. Stereotact Funct Neurosurg, 75(1), Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/11416261
Lu, W, Li, YH, & He, XF. (2010). Treatment of large lumbar disc herniation with percutaneous ozone injection via the posterior-lateral route and inner margin of the facet joint. World J Radiol, 28(2), Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/21160944
Siemienow et al (2008). Identifying serious causes of back pain: cancer, infection, fracture. Cleveland Clinic Journal of Medicine, 75(8) 557-566 http://www.ccjm.org/content/75/8/557.full.pdf+html
Van Kleef, M. (2010). Thoracic pain. Pain Pract, 10(4), Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/20492577
