Management of Burning Thoracic Pain Below Scapula with History of Scoliosis

Initial Clinical Assessment

The American College of Radiology recommends checking for neurologic deficits, including focal weakness, abnormal reflexes, muscle weakness, sensory changes, or pes cavus, in patients with burning thoracic pain below the scapula and scoliosis history 1
The American College of Radiology suggests evaluating for myelopathy signs, such as spasticity, hyperreflexia, positive Babinski sign, or bladder dysfunction, in patients with burning thoracic pain below the scapula and scoliosis history 2
The American College of Radiology recommends documenting rapid progression indicators, such as functionally disruptive pain or new neurologic symptoms, in patients with burning thoracic pain below the scapula and scoliosis history 1, 3
The American College of Radiology suggests identifying atypical curve patterns, such as left thoracic curves or short segment curves, which may suggest secondary causes requiring different workup 1

The American College of Radiology recommends no initial advanced imaging for chronic thoracic back pain without red flags 2
The American College of Radiology suggests plain radiographs of the thoracic spine to document current scoliosis severity and assess for progression if prior films are available 1, 3
The American College of Radiology notes that thoracic spine radiographs have limited diagnostic utility for scoliosis assessment due to overlying structures but can identify other pathology 4
The American College of Radiology recommends MRI thoracic spine without contrast as the initial imaging of choice if neurologic symptoms develop 2
The American College of Radiology suggests CT myelography as complementary imaging for presurgical planning or when MRI is contraindicated 2

The American College of Radiology recommends serial radiographic monitoring every 12-18 months for stable curves in adults 5
The American College of Radiology suggests surgical intervention typically reserved for curves >50° with documented progression or intractable pain 3
The American College of Radiology recommends immediate orthopedic/spine referral if patient develops new neurologic symptoms, functionally disruptive pain not responding to conservative measures, or rapid progression 3

The American College of Radiology warns against assuming pain is solely from scoliosis, as thoracic disc herniations can present with burning pain and are often calcified 2
The American College of Radiology advises against ordering MRI routinely without red flags or neurologic deficits, as advanced imaging is not supported and unlikely to change management 2
The American College of Radiology recommends not delaying evaluation of new symptoms, as development of myelopathic signs requires urgent imaging and potential surgical evaluation 2, 3