MR KEITH GOMES

Melbourne Brain and Spinal Neurosurgeon

Thoracic (Middle Back) Pain

Spine Conditions

Thoracic (or mid-back pain) is much less common than neck or lower back pain. This is because of the limited range of motion in this area resulting from the stabilizing effect of the ribs and chest. This means the structures in this part of the spine like the discs are less prone to wear and tear.

Mid-back pain can be localized or manifest as radiating pain or pins and needles in the side of the chest. More serious symptoms include loss of strength in the legs, loss of sensation in the trunk or legs and difficulties with bladder and bowel control.

Causes of thoracic pain

Thoracic disc prolapse (herniation/bulging)
This is the most common cause for this condition.
Download patient information sheet
Thoracic spinal stenosis
Download patient information sheet
Nerve root compression (pressure on a spinal nerve)
Arthritic/rheumatological conditions

Other causes that need further investigation are the presence of infection, tumour or a history of trauma. Like other spinal regions, there are particular red flags or ‘warning signs’ outlined below.

Red flags

A red flag (or ‘warning sign’) may indicate serious but uncommon disease or condition that is causing middle back pain and make up the minority of cases (<5%). If red flags are identified, further specialist medical attention is needed.

Red flag	Intervention
Severe unremitting (non-mechanical) worsening of pain sometimes associated with a fever (at night and pain when laying down)	Consider infection or tumour. Refer urgently to a spine surgeon.
Significant trauma	Consider fractures. Check for instability and refer urgently to spinal surgeon.
Back pain with weight loss, fever, history of cancer or human immunodeficiency virus (HIV)	Consider infection or tumour. Needs magnetic resonance imaging (MRI) and urgent referral to spinal surgeon.
Use of intravenous drug or steroids	Consider infection or compression fracture. URGENT investigation required. In case of suspected infection, consider appropriate bloods (full blood count, an erythrocyte sedimentation rate or c-reactive protein). If blood work is positive proceed to MRI, if available. If compression fracture is suspected, proceed to standing anteroposterior and lateral x-rays. Refer urgently to a spine surgeon.
Age over 50 years, but particularly over 65 years of age (first ever episode of severe back pain)	If other risk factors are for malignancy are present investigate further, refer urgently as indicated.
Widespread neurological signs	Consider tumour or neurological disease – investigate further and refer urgently if indicated.

Red flag

Intervention

Severe unremitting (non-mechanical) worsening of pain sometimes associated with a fever (at night and pain when laying down)

Consider infection or tumour. Refer urgently to a spine surgeon.

Significant trauma

Consider fractures. Check for instability and refer urgently to spinal surgeon.

Back pain with weight loss, fever, history of cancer or human immunodeficiency virus (HIV)

Consider infection or tumour. Needs magnetic resonance imaging (MRI) and urgent referral to spinal surgeon.

Use of intravenous drug or steroids

Consider infection or compression fracture. URGENT investigation required. In case of suspected infection, consider appropriate bloods (full blood count, an erythrocyte sedimentation rate or c-reactive protein). If blood work is positive proceed to MRI, if available. If compression fracture is suspected, proceed to standing anteroposterior and lateral x-rays. Refer urgently to a spine surgeon.

Age over 50 years, but particularly over 65 years of age (first ever episode of severe back pain)

If other risk factors are for malignancy are present investigate further, refer urgently as indicated.

Widespread neurological signs

Consider tumour or neurological disease – investigate further and refer urgently if indicated.

What tests are needed?

Tests needed depend on the presentation but may include blood tests, x-rays, Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) scan. The MRI scan is the one radiological test that provides the most information to assist in the diagnosis and cause of thoracic pain, especially when ‘red flag’ signs are present.

When to order an MRI (this can also be ordered by Mr Gomes following consultation):

Failed conservative management
Weakness and/or sensory deficit
Worsening pain
History of cancer
Suspected infection

How is a diagnosis made?

Diagnosis of the cause of thoracic pain requires getting a good patient history, physical examination and relevant tests. Findings of the clinical examination will be correlated with relevant tests to make a diagnosis.

Treatment

In most cases, all types of back pain will improve with non-surgical treatment which should be managed by your General Practitioner (GP) and other specialists.

Non-surgical treatment

Non-surgical treatment for thoracic pain includes but is not limited to exercise, physiotherapy, clinical pilates and medication. If you have risk factors of back pain, you will be advised to make lifestyle modifications.

A comprehensive treatment plan for you must be put in place. This treatment plan will need involvement from you, your GP and other specialists such as your physiotherapist.

Medication for thoracic pain may include NSAIDs, analgesics and muscle relaxants as prescribed by your doctor. Opioid analgesic agents may be appropriate in some situations.

A referral to a Pain Physician, Neurologist or Rheumatologist may be required. This will either be for further non-surgical treatment or evaluation prior to surgery.

Surgical treatment

Only a very small number of patients with thoracic pain and/or radicular symptoms require surgical intervention. This will be assessed and discussed at your consultation with Mr Gomes.

Mr Gomes performs a number of surgical procedures which will be recommended taking into account the underlying condition and individual patient factors.

Refer to Mr Gomes for consideration of surgical treatment if:

Significant radicular pain that radiates around the chest or into lower abdominal area
Weakness
Suspected infection (patient should be assessed by a spine surgeon the same day)
Suspected/presumed tumour
Failed non-surgical treatment

For all appointments and enquiries, please phone 03 8318 4929

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Mayfair Specialist Centre
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250 Victoria Parade
East Melbourne VIC 3002

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