In talking about upper back pain, it’s important to talk about the anatomy of the complaints. So, when people complain about upper back pain, they’re usually referring to the thoracic spine. Even though there is a lot of overlap from lower neck symptoms and upper back, as in thoracic spine, most people refer to thoracic spine as upper back. So, we’ll talk about the thoracic spine.
In the thoracic spine, unlike the lumbar or cervical spine, the anatomy is somewhat different, and that changes the way the mechanics of the spine are responsible for the injury or the pain that comes from that region. So, the thoracic spine is different because it has the rib cage. The rib cage provides rigidity and reduces motion. Now, because of that, the injury to that region is quite different than it is for higher-mobile regions, such as cervical spine or the lumbar spine. That’s why the disc herniations that are common in the lumbar and cervical spine are not as common. In fact, they are very uncommon in thoracic spine.
So, the more common causes of upper back pain is caused by either a joint dysfunction or the muscle and connective tissue irritation. Now, that can come from a variety of sources. Part of it can be a deconditioning—or, essentially the muscles not being ready to take on the stress that is applied to them—or overuse, where there is more force applied to the muscle that is normally fit but is not fit enough to really respond to the additional stress.
So, in talking about that, we can’t, of course, forget about the possibility of trauma causing an injury and, thereby, causing the pain, or a nerve injury that can cause pain directly or cause inappropriate mobility of the muscle that it supplies and, therefore, going back into muscular pain.
So, one of the things that we need to be concerned about with the thoracic pain specifically is posture. Posture is very important in creating the thoracic spine disorders and muscular pain that comes with it. When I say posture, posture ideal posture is neutral, which means that it allows the forces of the gravity to travel through the spine in its optimal condition. The problem with maintaining posture is that it’s habitual. So when we form habits, it’s very difficult to really re-learn the habits, and even though we can be conscious of starting in the right posture, what tends to happen, inevitably, is that our posture changes as we dive into the subject. And I use the word “dive” because, physically, it actually seems that way. So, as you are starting, you can start by reading a book or working on the computer in appropriate, very appropriate ergonomic posture. As you are starting to work on it and as you are starting to read, you dive into your subject and end up almost physically diving into it and that obviously changes the posture.
Once the posture is changed, that puts a lot of the strain on the muscles to control the forces that they shouldn’t really be controlling because everything should be balanced by appropriate distribution of weight due to gravity. So posture becomes very, very important for the thoracic spine.
When we talk about thoracic spine, we also have to remember that scapula—or shoulder blades—really travel on the thoracic cage. They are controlled by a variety of muscles. I’d like to point out that scapula and the shoulder, the whole shoulder girdle, is really supported mainly by the muscles. So there is a pivotal point here at the clavicle—or the collarbone—and everything else, the whole motion of the scapula and its stability really depends on the muscular support and synchrony of the contraction of those muscles. Which goes back to what I said about nerve injury—if there is a nerve injury, for instance, the long thoracic nerve that supplies a muscle here that’s very important in keeping the scapula or shoulder blade in contact and stabilized against the ribcage, allows the scapula to wobble and places a lot of tension on the other scapula stabilizers. It now places undue stress on the other muscles that are not meant to control this. So that can cause pain in those muscles and, of course, dysfunction of the actual motion, which further causes additional other pains and everything that follows that mechanical change.
So, there are many reasons for upper back pain: overuse injury, injury that comes from muscle that is deconditioned, nerve injury, and mechanical changes due to posture. It’s very important to diagnose this correctly and eliminate a nerve injury from the equation, eliminate any kind of trauma and traumatic causes for the injury.
Treatment of upper back pain really is aimed at strengthening the supporting the muscles of the upper back, and that includes scapula stabilizers. It also includes the muscles that are really supporting the spine itself. It also must include stretching the opposing muscles—in other words, really balancing the forces around the spine and around the scapula in order to recreate that balance. Also, at times, it’s necessary to treat the muscle itself so that if there are any what’s called trigger points—or in other words, very tender points in the muscle that, at times, spread the pain along the path of the muscle—those can be eliminated through manipulations or, at times, through very specific trigger point injections. This will recover normal movement and normal function of the muscle back to the physiologic state. Also, it’s important to treat underlying nerve problems if those exist. And, of course, as I said before, correcting postural habits is also very, very important.
Upper back pain caused by intrinsic spine problems is not as common as other causes of upper back pain, but they do occur and they are important to consider in treatment and diagnosis of the upper back pain. Some of those are spinal fracture, degenerative disc disease, herniated disc, spondylolisthesis, or even spondylosis. In order to diagnose those, history is very, very important, of course, as always. Physical examination really aims to elicit the pain by provoking pain through different maneuvers—even percussion over the spine can elicit pain from spinal fractures. Although none of these maneuvers are really, truly diagnostic, they can raise our suspicion in order to suspect one source of the pain as opposed to another.
Spinal fracture usually occurs from one of two sources. It is either an osteoporotic fracture—in other words, the density of the bone is decreased, and it’s not as strong, and it just collapses onto itself, and that can be spontaneous or due to a small trauma—or normal vertebrae can actually fracture due to trauma or excessive force on that vertebrae. When the fracture occurs, it is thought that the actual micromotion of that fractured segment is what causes the pain.
Degenerative disc disease is also not very common in the upper back or in thoracic spine because the motion in the upper, the thoracic spine is limited by the ribcage. So although it’s not common, degenerative disc disease does occur. And we need radiographic studies really to determine whether that is the case.
Along the same lines, herniated discs. Once again, herniated discs are pretty uncommon in the thoracic spine for the same reason as the degenerative disc disease. But we do need to be concerned about that as a possibility.
Spondylolisthesis goes along the same reasoning. Spondylolisthesis in itself is slippage of one vertebra on top of the other. So, forces that usually keep that vertebra from slipping are no longer there or there is another force that was in excess of what can support one vertebra and another and the vertebra ends up slipping on top of the vertebra right below it. Now, once again because of the ribcage, that is very uncommon in the thoracic spine, but severe trauma can certainly cause spondylolisthesis.
Spondylosis or just general arthritic changes of the spinal segments and those little facet joints—that hinge-like joints of the spine—can also cause pain and that’s more like arthritic pain just like any other joint. And that can be provoked with some movement and also needs to be looked at on radiographs. Usually x-rays are sufficient to take a look at the condition of those joints. Because there is no way of knowing if spondylosis or facet-mediated pain is causing it, sometimes we have to come to the aid of diagnostic blocks, where we put a little anesthetic to the source of the pain and see if that eliminates the pain. If that does eliminate the pain, then that gives us the diagnosis of the source of the pain.