Not all pain in the middle or upper back originates from the spinal discs or nerves. The ribs, costovertebral joints, costotransverse joints, muscles, and other structures of the chest wall can also produce significant pain.
These conditions are particularly relevant in the thoracic spine because each thoracic vertebra is connected to the rib cage. Problems involving these joints can cause localized back pain as well as pain that travels around the chest wall.
Although these disorders can sometimes produce symptoms that resemble a thoracic disc herniation or pinched nerve, they usually do not involve compression of the spinal cord.
Understanding the Thoracic Spine and Rib Cage
The thoracic spine consists of 12 vertebrae, labeled T1 through T12. Most of these vertebrae connect directly to the ribs.
Each rib forms joints with the spine near the back of the chest.
These include the:
Costovertebral joint – where the head of the rib connects with the vertebral body.
Costotransverse joint – where another portion of the rib connects with the transverse process extending from the vertebra.
These small joints allow controlled movement of the ribs during breathing and movement of the trunk.
Like other joints in the body, they can become irritated, inflamed, injured, or arthritic.
Minor Diagnosis Types
These terms are often encountered, but are either infrequently treated in our clinic.
Costovertebral Arthritis
Costovertebral arthritis occurs when degenerative changes develop in the joints connecting the ribs to the vertebral bodies.
The cartilage within these joints can gradually deteriorate, producing inflammation, stiffness, and sometimes bone spur formation.
Costovertebral arthritis may cause:
- Localized mid-back pain
- Pain near the spine and ribs
- Pain that wraps partially around the chest
- Pain with twisting
- Pain with deep breathing
- Pain with coughing or sneezing
- Tenderness near the rib-spine junction
- Stiffness in the thoracic spine
Symptoms may sometimes resemble thoracic radiculopathy or pain from a thoracic disc.
Most patients are initially treated without surgery.
Treatment may include:
- Activity modification
- Anti-inflammatory medications
- Physical therapy
- Postural exercises
- Heat or ice
- Targeted injections
Image-guided injection of the affected costovertebral joint can sometimes help determine whether the joint is actually responsible for the patient’s pain while also providing temporary relief.
Surgery is rarely necessary for isolated costovertebral arthritis.
Costotransverse Arthritis
The costotransverse joints connect the ribs to the transverse processes of the thoracic vertebrae.
These joints undergo small amounts of movement during breathing, rotation, and other movements of the chest and spine.
Degeneration or inflammation of these joints is called costotransverse arthritis.
Symptoms may include:
- Localized pain beside the thoracic spine
- Pain between the shoulder blades
- Pain near the rib-spine junction
- Pain with rotation of the torso
- Pain with deep breathing
- Tenderness over the affected joint
The pain may occasionally spread along the rib but typically remains more localized than pain caused by a compressed thoracic nerve root.
Diagnosis is based on the combination of:
- Symptoms
- Physical examination
- Imaging findings
- Response to targeted injections when necessary
CT imaging can provide detailed views of arthritic changes involving these small joints.
However, arthritis seen on imaging does not necessarily mean that the joint is causing pain.
Treatment may include:
- Physical therapy
- Activity modification
- Anti-inflammatory medications
- Postural and mobility exercises
- Image-guided injections
Surgical treatment is rarely required.
Thoracic Outlet Syndrome
Thoracic outlet syndrome is different from most other conditions in this category.
Rather than involving the joints between the ribs and thoracic spine, thoracic outlet syndrome results from compression of nerves or blood vessels as they travel from the neck toward the arm through a confined region known as the thoracic outlet.
The thoracic outlet is located near the lower neck, first rib, clavicle, and upper chest.
Types of Thoracic Outlet Syndrome
- Neurogenic thoracic outlet syndrome
- Most common
- involves compression or irritation of the brachial plexus, the network of nerves traveling into the arm.
- Venous thoracic outlet syndrome involves compression of a major vein.
- Arterial thoracic outlet syndrome involves compression of an artery.
Symptoms vary depending on the structure being compressed, but may include:
- Neck or shoulder pain
- Arm pain
- Numbness or tingling
- Hand weakness
- Arm fatigue
- Symptoms that worsen when the arm is elevated
Venous compression may cause:
- Arm swelling
- Heaviness
- Bluish discoloration
- Prominent veins
Arterial compression may cause:
- Hand or arm pain
- Coldness
- Pale coloration
- Reduced blood flow to the hand
Vascular symptoms require appropriate medical evaluation because blood clots or impaired circulation may occasionally occur.
Is Thoracic Outlet Syndrome a Spine Disorder?
Not exactly.
Despite its name, thoracic outlet syndrome does not usually originate from the thoracic spinal canal.
The compression occurs near the junction of the:
- Neck
- First rib
- Clavicle
- Upper chest
However, thoracic outlet syndrome can produce symptoms similar to cervical radiculopathy and other nerve disorders.
Determining the actual source of symptoms is therefore important before treatment.