Differential Diagnosis for Thoracic Back Pain at the Medial Border of the Scapula

Introduction to Thoracic Back Pain

The American College of Radiology suggests that the differential diagnosis for thoracic back pain at the medial border of the scapula must systematically distinguish between benign musculoskeletal conditions and serious underlying pathologies that require urgent intervention, with the thoracic spine being a common site for inflammatory, neoplastic, metabolic, infectious, and degenerative conditions 1

Thoracic disc herniation occurs most commonly below T7, often calcified (20%-65%), and presents with thoracic midback pain (76% of cases), typically in patients aged 30-50 years, with one-third having trauma history 2
Myofascial pain is a common benign cause in the thoracic paraspinous soft tissues 1
Spinal stenosis is caused by disc herniations, facet arthropathy, or ligamentum flavum ossification, typically below T7 3

Osteoporotic compression fractures are common in the thoracic spine, particularly in patients >65 years, those on chronic steroids, or with known osteoporosis 1, 4
Traumatic fractures should be considered in patients with significant trauma history 1
Primary or metastatic tumors are a common site for neoplastic conditions in the thoracic spine 1, 4
Spinal infection/osteomyelitis and discitis/epidural abscess should be considered with fever, recent infection history, immunosuppression, or constant pain and systemic symptoms 1
Ankylosing spondylitis should be considered in younger patients with inflammatory back pain patterns 1, 4

Intrathoracic pathology, such as cardiac ischemia or pulmonary embolism, can cause referred pain to the thoracic region 1
Gastrointestinal conditions, such as peptic ulcer disease or pancreatitis, can also cause referred pain to the thoracic region 1
Renal pathology, such as nephrolithiasis or pyelonephritis, can cause referred pain to the thoracic region 1

The American College of Radiology recommends determining acuteness, screening for red flags systematically, and assessing for neurological compromise in the initial assessment of thoracic back pain 1, 2
Imaging considerations, such as no red flags with acute presentation, midline tenderness with fracture risk factors, myelopathy or radiculopathy, suspected malignancy or infection, should be taken into account when deciding on the appropriate imaging study 1, 2, 5
The American College of Radiology suggests that MRI thoracic spine without contrast is the initial imaging of choice for myelopathy or radiculopathy 2, 5
The American College of Radiology recommends MRI with and without contrast for suspected malignancy or infection 5

Elderly patients have a lower threshold for imaging due to increased fracture and malignancy risk 1, 5
Patients with prior spinal surgery require early imaging 1