Thoracic and lumbar spinal disorders: Nonsurgical management strategies

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What etiologies are included in the differential diagnosis of patients who present for initial assessment and management of symptoms attributed to the thoracic spine in an outpatient setting?

Diagnosis of patients referred for evaluation of thoracic spine conditions is not always straightforward. Thoracic spine pain may arise from a variety of sources including thoracic and cervical spinal structures, chest wall structures, as well as referral from cardiopulmonary, gastrointestinal, and miscellaneous causes. Although musculoskeletal thoracic and chest wall pain are the most common etiologies presented at outpatient spine consultations, less common etiologies must also be considered to avoid delayed diagnosis of serious or life-threatening conditions. Etiologies to consider in the differential diagnosis of patients referred for evaluation include:

Thoracic pain of spinal origin

• Musculoskeletal thoracic spine pain (sprain, strain)

• Thoracic spine degeneration and (disc degeneration, disc herniation, stenosis, facet joint degeneration)

• Scheuermann disease

• Ankylosing spondylitis

• Diffuse idiopathic skeletal hyperostosis (DISH)

• Spinal deformities

• Spinal neoplasm

• Spinal infection

• Spinal fractures (osteoporotic, pathologic, traumatic)

• Referred pain from the cervical spinal region

• Postural disorders

Thoracic pain of chest wall origin

• Referred pain from costovertebral, sternocostal, or costochondral joints or thoracic cage musculature

Thoracic pain referred from nonspinal structures

• Cardiovascular-related pain: myocardial ischemia, myocardial infarction, aortic aneurysm, valvular disease

• Pulmonary-related pain: bronchitis, lung diseases, pneumothorax, pulmonary embolism, Pancoast tumor

• Gastrointestinal-related pain: esophageal disorders, peptic ulcer disease, reflux, pancreatitis

• Breast-related pain: macromastia

Postsurgical or iatrogenic thoracic pain

• Postthoracotomy pain

• Poststernotomy pain

• Miscellaneous postprocedural pain (i.e., thoracostomy tube placement)

Miscellaneous causes of thoracic pain

• Fibromyalgia

• Diabetic thoracic radiculopathy

• Postherpetic neuralgia

• Thoracic outlet syndrome

• Thoracic pain in association with motor vehicle accidents

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What nonoperative treatments are recommended for musculoskeletal thoracic pain?

Musculoskeletal thoracic pain occurs in the absence of significant pathologies such as infection, neoplasm, metastatic disease, osteoporosis, inflammatory arthropathies, fracture, or pain referred from abdominal or pelvic viscera. Thoracic strain or sprain refers to acute or subacute pain caused by injury to soft tissue structures including muscles, ligaments, tendons, and fascia, in an otherwise normal spine. Sprain is defined as an injury to ligament fibers without total rupture. Strain is defined as an injury that affects muscles or tendons. Evidence guiding nonoperative treatment of musculoskeletal thoracic pain is limited. Active interventions, including stretching, postural, strengthening, and stabilization exercises, are the most commonly recommended treatments. Passive interventions, including mobilization, soft tissue massage, acupuncture, and electrotherapy, are commonly prescribed, but supporting evidence is limited. A multimodal program of care with manual therapy, soft tissue therapy, exercises, heat/ice, and education is recommended by many providers. A limited course of nonsteroidal antiinflammatory medication (NSAIDs) or acetaminophen may provide benefit.

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What are some important considerations in the evaluation and treatment of thoracic pain in patients with radicular symptoms?

Thoracic radiculopathy is an uncommon spinal disorder. The most common etiologies of thoracic radiculopathy are diabetes and thoracic disc pathology. Other less common causes include primary spine tumors, metastatic spine tumors, scoliosis, and herpes zoster. Patients typically present with band-like chest or abdominal wall pain. A T1 radiculopathy is challenging to distinguish from a C8 radiculopathy, and characteristics include diminished axillary sensation, motor deficits of the intrinsic muscles of the hand, and Horner syndrome. Electrodiagnostic testing can aid in the diagnosis of radiculopathy.

Thoracic disc herniation are documented on MRI in up to 40% of asymptomatic individuals. The number of patients with objective neurologic findings due to thoracic disc herniation is estimated as 1 per million annually. Thoracic disc herniations occur most commonly in the lower third of the thoracic spine (T9–T10 through T12–L1), less commonly in the middle third (T5–T6 through T8–T9), and least commonly in the upper thoracic region (T1–T2 through T4–T5).

Thoracic disc herniations may present with axial spine pain, thoracic radiculopathy, thoracic myelopathy, or with a mixed presentation. Patients with thoracic axial pain, radiculopathy, or mild myelopathy are appropriate for initial nonoperative treatment. Nonsurgical treatment options include postural, strengthening, and stabilization exercises, medication (NSAIDs, gabapentinoids), transcutaneous electrical nerve stimulation (TENS) and other modalities, and transforaminal injections. Recognition of patients with myelopathy is important; severe or progressive myelopathy requires prompt evaluation for surgical treatment.

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What etiologies are included in the differential diagnosis of patients who present for initial assessment and management of symptoms attributed to the lumbar spine in an outpatient setting?

The most common reason for referral for outpatient evaluation of the lumbar spine is axial low back pain. Conditions to consider in the differential diagnosis include:

• Lumbar strain or lumbar sprain

• Discogenic low back pain

• Zygapophyseal joint pain

• Radiculopathy due to a herniated lumbar disc

• Lumbar spinal stenosis

• Lumbar spondylolysis

• Lumbar spondylolisthesis

• Osteoporotic compression fracture

• Scoliosis

• Spine infections: discitis, osteomyelitis

• Spine tumors: metastatic, primary

• Disorders involving the hip joint

• Sacroiliac joint pain

• Rheumatologic disorders: rheumatoid arthritis, ankylosing spondylitis, fibromyalgia

• Visceral disorders presenting with referred pain: pyelonephritis, pancreatitis, renal stones

• Vascular disorders: peripheral vascular disease, aortic aneurysm

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For patients who present with a complaint attributed to the lumbar spine, what are some important areas to investigate in relation to the patient’s history?

• Is this the first episode or a recurrent problem?

• Was there a specific injury (i.e., motor vehicle injury, work-related injury, sport-related injury, or fall from a height)?

• What factors increase and decrease symptoms?

• What is the pattern of pain over a 24-hour period? Is pain intermittent or constant?

• Is the most intense and bothersome pain localized to the low back and surrounding areas or to one or both legs?

• Is there focal weakness or numbness in the lower extremities?

• Are there new bowel or bladder symptoms?

• Is morning stiffness present?

• Are any red-flag symptoms present?

• Are any yellow-flag symptoms present?

• Consider use of a self-assessment questionnaire to evaluate pain (i.e., Visual Analog Pain Scale [VAS], Numerical Rating Scale [NRS])

• Consider use of a validated scale to measure level of disability and function (Oswestry Disability Index [ODI], Roland-Morris Disability Questionnaire [RMDQ], or Patient Reported Outcomes Measurement Information System [PROMIS])

• Consider use of a screening tool to identify patients with acute low back pain at risk of poor outcomes and to stratify patients for appropriate level and intensity of future treatment (i.e., Keele Subgrouping for Targeted Treatment [STarT] Screening Tool)

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What is the difference between red flags and yellow flags in the context of evaluation of low back pain symptoms?

Red flags are risk factors that suggest significant or potentially life-threatening pathologies associated with low back pain. Examples of red flag conditions are spine fractures, neurologic emergencies such as cauda equina syndrome (CES), spinal infections, and spinal tumors. Red flag conditions are rare and are estimated to occur in less than 5% of patients. Yellow flags are factors that are used to identify psychosocial barriers, which place patients at risk of developing chronicity, disability, and poor outcomes. Examples include fear and avoidance of activity or movement, a belief that lumbar pain is harmful or disabling, depression, and an expectation that passive treatment without active participation in treatment will resolve back pain. Patients who are identified as high risk can potentially benefit from more intensive nonsurgical management, with a greater emphasis on return to activity and focus on functional recovery.

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What are the key elements to include in the physical examination of a patient referred for initial evaluation for lumbar pain with or without leg pain?

• Observation: assess gait, balance, lumbar posture, waistline or trunk asymmetry

• Palpation: assess for lumbar tender points

• Range of motion: lumbar flexion, extension, rotation, side bending

• Neurologic examination

  • Sensory, motor, reflex function

  • Provocative maneuvers to assess for radiculopathy when pain involves the lower extremities (straight-leg raise tests, femoral nerve stretch test)

  • Screen for myelopathy: plantar reflex (Babinski sign), tandem gait

• Evaluation of related areas (e.g., hip joints, sacroiliac joints)

• Peripheral vascular exam (assess dorsalis pedis and posterior tibial pulses)

• Waddell signs (superficial tenderness, simulation, distraction, regionalization, and overreaction)

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