Referred Pain From The Thoracic Spine

Pain is the body’s way of signalling distress or injury. But what if your body manifests pain in a certain area of your body and yet the actual source of the discomfort is a completely different part of your body? 

In this article, we will explore the intricacies of referred pain, specifically referred pain from the thoracic spine. We’ll explore what this typically feels like, what conditions commonly cause referred pain, and the treatment options available to treat the root cause of this symptom.

What Is Referred Pain?

Referred pain is pain that is perceived or felt in a location that is different from the actual site of tissue damage/injury. The classic example is that of a patient who is having a heart attack. The tissue injury is occurring in the heart, but a patient may only feel pain or discomfort in their arm or jaw. In this example, the pain and tissue injury of a heart attack is referred to the arm or jaw.

What Does It Feel Like?

Referred pain can vary widely, depending upon the individual, the source of the pain, and past medical history, including the presence or absence of central sensitization. Common examples include: 

• Dull ache or throbbing
• Radiating or traveling sensation
• Deep discomfort
• Widely distributed pain
• Triggered by movement or pressure
• Absence of tenderness in the referred area

Common Conditions Associated With Referred Thoracic Pain

The thoracic spine is composed of many different structures that are susceptible to degeneration and injury. These include the facet joints, intervertebral discs, vertebral bodies, ligaments, nerves and spinal cord. 

Injury to any of these structures can cause pain that is localized to the involved structure or that is perceived in an area different from that of the tissue injury (referred pain). 

For example, a herniated disc may cause debilitating pain at the level of the disc or can elicit pain in an area that is away from the actual site of tissue injury such as the abdomen. This is known as referred pain.

Thoracic Facet Joint Pain

A facet joint is a small, paired joint in the back of the spine that provides stability and limits excessive movement. There is a facet joint at each level of the spine, one on the right and one on the left. They are labeled according to their level in the spine. For example, the first thoracic facet joint occurs at the T1/2 level.

Like the knee and hip joints, a facet joint is lined with cartilage and enveloped by a fibrous capsule. Facet joints are susceptible to degeneration and injury. Thoracic facet joints have distinct referral patterns, as seen in the figure below.

Unfortunately, there is a significant overlap between some of the thoracic facet joints.¹

Thoracic Costotransverse Joint Pain

The costotransverse joint is a unique joint, as it occurs only in the thoracic spine. It is formed by the union of the rib and the transverse process of the spine. Like the facet joints, it is lined with cartilage and surrounded by a thick capsule. The costotransverse joint allows for gliding and rotation of the rib head during breathing.

These joints are susceptible to degeneration and injury. The costotransverse joints have distinctive referral patterns.²

Thoracic Interspinous Ligaments

Ligaments are thick pieces of connective tissue that provide support and stability. Think of them as duct tape for the human body. The spinous processes are the large protruding bones on the backside of the spine. 

With my children, I refer to them as the dinosaur bones. There is a spinous process at each level of the spine.

A series of ligaments span between each spinous process. The most important ligaments are the supra and interspinous ligaments.

The interspinous ligaments are susceptible to injury and degeneration. Like thoracic facets and costotransverse joints, the thoracic interspinous ligaments have known referral patterns.

Thoracic Degenerative Disc Disease

Thoracic discs are important shock absorbers that are sandwiched between the boney building blocks in the spine. They are labeled according to the two building blocks they are sandwiched between. For example, the first disc in the thoracic spine is the T1/2 disc as it is situated between the T1 and T2 vertebral bones.

Thoracic discs are susceptible to injury and degeneration. Common examples include a disc protrusion, disc herniation, annular tear or extrusion. These injuries can produce localized pain or pain that is referred.

Thoracic Radiculopathy

Thoracic radiculopathy is a medical condition that occurs due to irritation or compression of one or more thoracic nerves as they exit the spine. The compression can lead to pain, tingling, numbness or weakness that radiates along the path of the affected nerve. For example, compression of the T1 nerve can be referred to the inside aspect of the forearm.

Nerve irritation or compression can occur due to disc injury, facet overgrowth, bone spurs, thickening of ligaments or slippage of the vertebral body.

How Is Referred Pain In The Thoracic Spine Diagnosed?

Diagnosis of referred pain in the thoracic spine requires multiple steps. An accurate diagnosis is essential for best clinical outcomes. Treating symptoms without understanding and identifying the underlying cause of the pain can be frustrating, with mediocre results at best. 

• Medical history: A detailed medical history will include onset of symptoms, aggravating and alleviating factors, location, severity of pain, type of pain, treatment to date, past medical and surgical history, current medications and allergies. 

• Physical examination: A physical exam will include inspection, palpation and a sensory examination and an evaluation of range of motion, muscle strength, reflexes and neurologic strength. 

• Imaging tests: Radiographic studies are an integral part of the evaluation and diagnosis of referred pain. X-rays are useful for identifying disc locations, fractures and bony abnormalities. 
  
  MRI is a powerful modality that uses strong magnetic fields and radio waves to create detailed 3D images of the body. Unlike X-rays, MRIs provide detailed images of both bone and soft tissue such as thoracic discs, facet joints, nerves, tendons, ligaments, muscles and the spinal cord. 
  
  MRI is the preferred radiographic study for evaluation of thoracic pain. 

What Are The Conventional Treatments For The Pain?

When appropriate, conservative care should always be the first line of treatment. This would include the following:

• Dietary supplements: Studies have shown that seven dietary supplements can help reduce pain from arthritis, namely collagen hydrolysate, passion fruit peel extract, Curcuma longa extract, Boswellia serrata extract, curcumin, pycnogenol, and L-carnitine.¹ 

• NSAIDs: NSAIDs are powerful anti-inflammatory agents. Common examples include ibuprofen, naproxen, Voltaren and Celebrex. They are available in both tablets and topical creams. They have significant side effects, which have been previously discussed, and should be avoided.

• Oral narcotics: Narcotics are powerful medications to reduce pain and increase function. They have significant side effects, which include dependence, and therefore should be avoided. Furthermore, they do NOT address the underlying problem or tissue injury. Rather, they simply mask the pain. 

• Corticosteroids: Corticosteroids are a type of medication that reduce inflammation and immune responses. They do so by inhibiting transcription factors that control the synthesis of pro-inflammatory mediators such as macrophages, eosinophils, lymphocytes, mast cells, and dendritic cells. 
  
  They also inhibit phospholipase A2, which produces numerous inflammatory mediators. 
  
  Common examples include prednisone, betamethasone, dexamethasone and “oral dose pack”. Corticosteroids can be taken orally or injected into muscle or directly into a targeted joint. Corticosteroids do NOT treat the underlying injury but rather treat the symptoms. 

• Surgery: Thoracic surgery should be the option of last resort as there are no guarantees that the pain will improve. Surgery is associated with a significant number of complications that include bleeding, infection, failure, escalation in pain, nerve damage, spinal cord injury and death.

Common surgeries in the thoracic spine include:

• Laminectomy: removal of a section of bone on the backside of the spine to decompress a narrowed spinal canal. Oftentimes the stability of the thoracic spine is compromised due to the removal of the lamina, ligaments and tendons.
• Discectomy: removal of a section of the disc that is damaged or causing pain. 
• Fusion: removal of one or more discs, replaced with spacers, bone graft and supported by rods and screws.

The Centeno-Schultz Regenerative Treatment Approach

At the Centeno-Schultz Clinic we are committed to providing an accurate diagnosis so that the best treatment plan can be designed and implemented. That means taking the time to secure a detailed medical and surgical history and performing a comprehensive physical examination and review of radiographic studies. 

This does not mean simply reading the radiologist’s report. Rather, it means reviewing the actual study, scanning for abnormalities or injuries that could be responsible for the pain. Specific treatment options will depend upon the location of the injury, its size and whether adjacent tissue is irritated or injured. Treatment options include:

Why Timely Diagnosis Is Important

Referred pain is pain that is perceived or felt in a location that is different from the actual site of tissue injury or damage. The pain can be dull, aching, throbbing, or deep in character. Referred pain from the thoracic spine can arise from the facet joints, costotransverse joints, interspinous ligaments, discs or nerves. 

The diagnosis of referred pain from the thoracic spine involves a complete medical history, thorough physical examination and review of radiographic imaging. Conservative treatment options include medication, heat, physical therapy and chiropractic care. Surgery should be the last resort, given the significant risks.

Persistent thoracic pain that does not respond to rest and conservative care is a warning signal that there is an underlying problem and that further evaluation is required. If left untreated, the underlying injury can – and most likely will – progress in severity.

References

1. Liu X, Machado GC, Eyles JP, Ravi V, Hunter DJ. Dietary supplements for treating osteoarthritis: a systematic review and meta-analysis. Br J Sports Med. 2018;52(3):167-175. doi:10.1136/bjsports-2016-097333.
2. Young BA, Gill HE, Wainner RS, Flynn TW. Thoracic costotransverse joint pain patterns: a study in normal volunteers. BMC Musculoskelet Disord. 2008 Oct 15;9:140. doi: 10.1186/1471-2474-9-140. PMID: 18922181; PMCID: PMC2587465.