THORACIC PAIN

This presentation provides a concise, evidence-based clinical review of thoracic pain for pain medicine practitioners, anaesthesiologists, and healthcare professionals engaged in spinal and interventional pain management. Thoracic pain is the second to third most common spinal pain condition, affecting 15–35% of the general population across the lifetime, yet it remains significantly underdiagnosed and undertreated in primary care settings. This presentation addresses the full clinical spectrum — from anatomy and pathophysiology to red flag screening, evidence-based diagnosis, pharmacological management, and interventional procedures. Scope and Content The presentation covers 24 slides structured as follows: Epidemiology and disease burden, including the prevalence of thoracic facet-mediated pain (34–48% of chronic mid-back pain based on controlled diagnostic blocks) Clinical anatomy of the thoracic three-joint complex, costovertebral and costotransverse joints, and the critical innervation differences at T4–T8 Classification of pain mechanisms: nociceptive, neuropathic, visceral/referred, and nociplastic (IASP 2019 taxonomy) Red flag screening and systematic differential diagnosis Evidence-based clinical assessment using validated tools (DN4, Oswestry Disability Index, PHQ-9, FABQ, Pain Catastrophizing Scale) Diagnostic imaging: X-ray, MRI, CT, SPECT-CT, and the role of dual comparative medial branch blocks as the reference standard for facetogenic pain Pharmacological management: NSAIDs, paracetamol, muscle relaxants, gabapentinoids, SNRIs, TCAs, topical lidocaine 5%, capsaicin 8%, and opioid prescribing principles with the WHO analgesic ladder Interventional procedures: thoracic medial branch blocks, radiofrequency ablation (conventional and pulsed), thoracic epidural steroid injection (safety considerations including particulate steroid contraindication at transforaminal level), intercostal nerve block, spinal cord stimulation, and vertebral augmentation Non-pharmacological therapies: physiotherapy, manual therapy, CBT, pain neuroscience education, and multidisciplinary pain programmes Special conditions: post-herpetic neuralgia (PHN) including Shingrix vaccine evidence, and post-thoracotomy pain syndrome (PTPS) with perioperative prevention strategies A stepwise treatment algorithm and six take-home clinical messages Evidence Base All content is grounded in peer-reviewed literature. Key references include Finnerup NB et al. (Lancet Neurology, 2015) for neuropathic pharmacotherapy, Kumar K et al. PROCESS trial (Pain, 2007) for spinal cord stimulation, Klazen CA et al. VERTOS II (Lancet, 2010) for vertebroplasty, Atluri S et al. (Pain Physician, 2008) and Manchikanti L et al. (Pain Physician, 2013) for thoracic facet interventions, and Briggs AM et al. (BMC Musculoskeletal Disorders, 2009) for epidemiology. Guidelines from IASP, NeuPSIG, ASIPP, NICE NG59, and ACR Appropriateness Criteria 2021 are incorporated throughout. Intended Audience Pain medicine fellows and specialists, anaesthesiologists, orthopaedic and neurosurgical practitioners, physiotherapists, and general practitioners managing spinal pain conditions. Author Dr. Bindiya Devi, MD Anaesthesiologist | Pain Medicine Fellow, Daradia Pain Clinic, Kolkata, India | IAPM Certification (ISSP)