Compared to other regions of the spine, diagnosing upper back pain can be especially complicated because it has more potential sources of pain, including the ribs connecting at each level of the thoracic spine and several internal organs and muscle groups in close proximity.
While it is sometimes impossible to find the exact cause of a person’s upper back pain, the following three-step process is typically followed to narrow down which causes are more likely.
1. Patient History
A thorough medical history of the patient is taken, including:
- When the symptoms started. How long has the upper back pain been present?
- How current symptoms feel. Where in the upper back is the pain located? Does the pain spread anywhere else, such as into the shoulder or lower in the back? How intense is the pain? Does the pain come and go, or is it constant? Do certain activities make the pain worse or better?
- Injury history. Did the pain start relatively soon after an accident, such as a bike crash or ladder fall? If not, was there an accident or fall from years earlier that was particularly bad?
- Lifestyle and habits. Does the patient live an active or sedentary lifestyle? Does he or she have a job that involves a lot of heavy lifting, or perhaps most of the day is spent sitting?
- Family health history. Did a parent, grandparent, or other relative have problems with upper back pain? What about other hereditary health conditions that could be relevant to the current symptoms?
For upper back pain, a patient history is likely to provide the strongest clues as to the underlying cause.
2. Physical Exam
After the patient’s medical history is collected, a physical examination helps to further narrow down what might be causing the upper back pain. This process typically includes:
- Observation. The back and posture are observed for anything that seems unusual, such as head and shoulders abnormally hunched forward or lesions on the skin.
- Palpation. The doctor presses against the thoracic spine, going up and down the back while feeling for any tenderness, rib instability, or abnormality.
- Clinical tests. Sometimes one or more tests is performed in the exam room to see if certain movements exacerbate symptoms. For example, the slump test involves having the patient purposely slump forward while a qualified medical professional gently puts the head and knee (on the side that hurts) in various positions to test if any of the patient’s complaints of radiating pain or tingling can be reproduced.
Based on information collected from the patient history and physical exam, the doctor might decide to collect more information by way of diagnostic tests.
3. Diagnostic Tests
When trying to diagnose upper back pain, or in some cases to confirm a diagnosis, one or more of the following diagnostic tests might be performed:
- X-ray. An x-ray (radiograph) uses electromagnetic radiation to create an image of the bones. This imaging may show spinal degeneration, fractures, or possibly tumors.
- MRI. Magnetic resonance imaging (MRI) uses radio waves and a strong magnet to create cross-section images of soft tissues and bones. In particular, an MRI can be good at detecting compression of spinal nerves or the spinal cord, infections, tumors, or damage to ligaments, muscles, or other soft tissues.
- Medial branch nerve block. Using x-ray guidance (fluoroscopy), an anesthetic is injected near the medial nerves that exit a facet joint. If numbing the nerves of that joint causes the pain to go away, the source of the pain has been found and can guide future treatments.
- Bone mineral density exam. This test uses x-rays to measure bone density (based on how much of the x-rays are absorbed into the bones) and is commonly performed to check for osteoporosis, which can occur in the thoracic spine and cause upper back pain.
Several other diagnostic tests could be used, such as electrodiagnostic testing to check nerve and muscle function, CT scan with myelography (typically for patients who cannot have an MRI), or blood tests.
It should be noted that most diagnostic tests for upper back pain are performed to confirm a suspected cause, not to make a diagnosis itself. For example, it is possible for an MRI to show spinal degeneration that is completely unrelated to a patient’s symptoms. An official diagnosis of upper back pain must take into account the patient’s reported symptoms.