Prefer to watch? 4-minute lesson13 slides · same content, shorter

1 · SNAPSHOT

Thoracic Discogenic Pain body chart — Illustrative, not diagnostic. Canva body chart for Thoracic Discogenic Pain.

Who: Any age. Often someone who has just had an MRI for something else.
What: Symptomatic thoracic disc pathology. Not the same thing as a thoracic disc seen on a scan.
How it behaves: Thoracic pain, possibly radiating around the chest or abdomen in a band. Aggs: flexion, loading, coughing, sneezing. Eases: unloading. ± paraesthesia or weakness in the trunk or legs if the cord is involved.

The one thing to take from this page:

Thoracic disc herniation is usually taught as rare. The more useful version of that fact is its mirror image: incidental thoracic disc herniation is common on imaging. So a disc on the scan is usually a finding, not the diagnosis — and what actually decides your management is the neurological examination, because the failure mode here is myelopathy.

Three levels of concern

Level	What you're seeing	What it means
Thoracic pain ± band-like referral	Mechanical behaviour, no neurology	Treat, and reassess
Radicular	Dermatomal band, sensory change	Medical review, imaging considered
Myelopathy	Bilateral leg symptoms, gait change, hyperreflexia, clonus, upgoing plantars, bladder or bowel change	URGENT; EMERGENCY with rapid decline or bladder or bowel change

Your neurological examination is what moves a patient between those bands. Nothing else does.

2 · SE — THE SUBJECTIVE PATTERN (the 70%)

Five stages, in your course's order.

MAIN PROBLEM

"There's a deep ache in my mid-back and it goes round the front."
"It's like a band across my chest."
"My legs have felt heavy and I've been a bit unsteady."

That third sentence changes the consultation. Listen for it.

BODY CHART

Thoracic, ± a band around the trunk. Draw the band and note where it ends.
Mark both legs. Bilateral leg symptoms in a patient with thoracic pain is myelopathy until proven otherwise.
Mark the abdomen. Clinical pearl: thoracic radicular pain is often misdiagnosed as visceral pain. Its inverse — visceral pain treated as thoracic — is the more dangerous error.

BEHAVIOUR

Aggs: flexion, loading, coughing and sneezing. Sitting, lifting, sustained flexed postures.
Eases: unloading, lying, changing position.
24-hr pattern: follows the load — sitting, lifting, sustained flexion — and eases with unloading and lying.
Night: lying is in the Eases. Night pain and rest pain are §4 flags.
Severity: VAS 0–10 at best / at worst / right now.
Coding: M / In / P / Is.
Irritability: resting symptoms + vigour of the provoking activity + time to settle.
Ask specifically about coughing and sneezing. It's a cheap question and it points at load transfer through the disc.

HISTORY

Onset — sudden with loading, or insidious?
Any recent imaging, and what were they told? This is where "you've got a disc" usually comes from.
Progression of any neurological symptom — this is the one that decides urgency.
Previous spinal history, including the cervical spine. Read further: coexisting cervical stenosis with progressive thoracic myelopathy [1].
Systemic and cancer history.

SPECIAL / SCREENING QUESTIONS — the ones that decide the page

Any change in walking, balance, or how your legs feel?
Any bladder or bowel change? Any numbness in the saddle area?
Any clumsiness, dropping things, or change in the hands? — that's a cervical question, and you ask it here.
Any band of numbness or altered sensation around your trunk?
Night pain, rest pain, fever, weight loss?

Assessing this region? Download the Thoracic Spine assessment template →

3 · HYPOTHESIS RANKING

Competing pattern	The one discriminating feature
Thoracic facet (PIV) joint	Extension- and rotation-provoked, segmental, reproduced by unilateral PA. Flexion-loading is the disc pattern.
Costovertebral / costotransverse	Reproduced by rib springing, sharp and catching with breath.
Scheuermann's	A structural curve with the radiographic criteria, in an adolescent.
Costochondritis	Anterior, at the junctions, tender to palpation.
Non-specific thoracic pain	No band, no neurology, no flexion-loading dominance. The most likely diagnosis on most days.
An incidental disc on someone's scan	The scan finding without a matching clinical pattern. This is the commonest trap on this page.

The ones that outrank the table

Thoracic myelopathy. This is the failure mode. Read further: thoracic myelopathy for physiotherapists [2].
Degenerative thoracic myelopathy from causes other than disc. Read further: degenerative thoracic myelopathy [3], ossified ligamentum flavum [4]. "Thoracic disc" is not the only thing that compresses a thoracic cord.
Coexisting cervical stenosis. Read further: cervical stenosis alongside progressive thoracic myelopathy (Dowlati et al. 2022). Check the neck.
Visceral pathology. Visceral pain treated as thoracic — the more dangerous direction.
Malignancy or infection. Night pain, rest pain, systemic features.

4 · RED FLAGS — DON'T MISS THIS

This section is free, on every pattern, forever. Safety is never gated.

Finding	What it suggests	What you do
Bilateral leg symptoms, heaviness, weakness	Myelopathy	URGENT medical review
Gait change, unsteadiness, falls	Myelopathy	URGENT
Hyperreflexia, clonus, upgoing plantars	Upper motor neurone signs	URGENT
Bladder or bowel change, saddle anaesthesia	Cord compromise	EMERGENCY
A band of altered sensation around the trunk	A cord level	URGENT
Progressive neurological deterioration of any kind	Whatever the cause	URGENT; EMERGENCY if the decline is rapid
Hand clumsiness or dropping things alongside it	Coexisting cervical involvement	Urgent medical review
Night pain, rest pain, fever, weight loss, cancer history	Malignancy, infection	Urgent medical review
Chest or abdominal pain not behaving mechanically	Visceral	Medical review — see the cross-link

The rule: this is the pattern where the neurological examination is the assessment. Power, reflexes, sensation, plantars, gait and tandem gait, every time. Always screen for myelopathy, bowel and bladder change, and bilateral neurology — and the reason a physiotherapy journal published a paper called Acute Thoracic Myelopathy is that we are the ones who see it first.

Cross-links: Thoracic facet (PIV) joint dysfunction · Cardiac / pulmonary referred pain · Costovertebral / costotransverse dysfunction · Scheuermann's disease

Members

The 4-minute lesson is for members

Twelve slides on this pattern: what you'll hear, what to examine, what to do. Free with an account.

Guideline anchor

No Australian guideline for this presentation.

Anchored to the diagnosis and management review of thoracic myelopathy (Lockey et al. 2024, PMID 38739870) and the scoping review of degenerative thoracic myelopathy (Rujeedawa et al. 2024, PMID 38146739), with the diagnostic approach and surgical indications review (Bonomo et al. 2022, PMID 35396636). The physiotherapy-facing anchor is Acute Thoracic Myelopathy in Journal of Orthopaedic & Sports Physical Therapy (Zimmerman et al. 2020, PMID 33256518) — read that one.

PubMed Source

There is no clinical practice guideline for thoracic discogenic pain. The literature that exists is overwhelmingly surgical and is about the myelopathic end of the spectrum, not about the sore mid-back you will actually see. This page keeps those two things apart deliberately.

Members

The evidence summary is for members

Verified diagnostic accuracy, where the evidence stands and what it doesn't settle. Free with an account.

Sources · 20

Show

Every source on this page resolves and title-verifies against PubMed. Newest first.

2022Dowlati et al. (2022). Should asymptomatic cervical stenosis be treated in the setting of progressive thoracic myelopathy? A systematic review of the literature. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society, 31(2), 275-287. https://doi.org/10.1007/s00586-021-07046-1
2020Zimmerman & Allen (2020). Acute Thoracic Myelopathy. The Journal of orthopaedic and sports physical therapy, 50(12), 723. https://doi.org/10.2519/jospt.2020.9262
2024Rujeedawa et al. (2024). Degenerative Thoracic Myelopathy: A Scoping Review of Epidemiology, Genetics, and Pathogenesis. Global spine journal, 14(5), 1664-1677. https://doi.org/10.1177/21925682231224768
2015Feng et al. (2015). A diagnostic study of thoracic myelopathy due to ossification of ligamentum flavum. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society, 24(5), 947-54. https://doi.org/10.1007/s00586-015-3818-0
2018Han & Jang (2018). Prevalence and Distribution of Incidental Thoracic Disc Herniation, and Thoracic Hypertrophied Ligamentum Flavum in Patients with Back or Leg Pain: A Magnetic Resonance Imaging-Based Cross-Sectional Study. World neurosurgery, 120, e517-e524. https://doi.org/10.1016/j.wneu.2018.08.118
2021Cornips & Peuskens (2021). Letter to the Editor Regarding "Prevalence and Distribution of Incidental Thoracic Disc Herniation, and Thoracic Hypertrophied Ligamentum Flavum in Patients with Back or Leg Pain: A Magnetic Resonance Imaging-Based Cross-Sectional Study". World neurosurgery, 156, 154-157. https://doi.org/10.1016/j.wneu.2021.08.101
2021Yan et al. (2021). The clinical value of three-dimensional measurement in the diagnosis of thoracic myelopathy caused by ossification of the ligamentum flavum. Quantitative imaging in medicine and surgery, 11(5), 2040-2051. https://doi.org/10.21037/qims-20-713
2021Ahi & Goktan (2021). Incidence of Neuropathic Pain in Patients with Thoracic Disc Pathologies Presenting with Chronic Upper Back Pain and Correlation of Herniation Grade with Pain Severity. Turkish neurosurgery, 31(6), 918-923. https://doi.org/10.5137/1019-5149.JTN.32899-20.3
2018Court et al. (2018). Thoracic disc herniation: Surgical treatment. Orthopaedics & traumatology, surgery & research : OTSR, 104(1S), S31-S40. https://doi.org/10.1016/j.otsr.2017.04.022
2019Bouthors et al. (2019). Surgical treatment of thoracic disc herniation: an overview. International orthopaedics, 43(4), 807-816. https://doi.org/10.1007/s00264-018-4224-0
2020Zhu et al. (2020). A systematic review of surgical procedures on thoracic myelopathy. Journal of orthopaedic surgery and research, 15(1), 595. https://doi.org/10.1186/s13018-020-02081-y
2025Yurtluk et al. (2025). Thoracic disc herniations: diagnosis, surgical techniques, and complication insights. Turkish journal of medical sciences, 55(1), 17-23. https://doi.org/10.55730/1300-0144.5939
2023Silva et al. (2023). Full-endoscopic discectomy for thoracic disc herniations: a single-arm meta-analysis of safety and efficacy outcomes. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society, 32(4), 1254-1264. https://doi.org/10.1007/s00586-023-07595-7
2019Brotis et al. (2019). Complications Associated with Surgery for Thoracic Disc Herniation: A Systematic Review and Network Meta-Analysis. World neurosurgery, 132, 334-342. https://doi.org/10.1016/j.wneu.2019.08.202
2021Yuan et al. (2021). Risk factors associated with post-operative neurological deterioration in patients with thoracic disc disorders with myelopathy. International orthopaedics, 45(6), 1539-1547. https://doi.org/10.1007/s00264-021-04999-2
2025Gerstmeyer et al. (2025). Incidence and predictors of readmission following hospitalization for thoracic disc herniation. Clinical neurology and neurosurgery, 249, 108698. https://doi.org/10.1016/j.clineuro.2024.108698
2024Ito et al. (2024). Patient-Reported Outcomes and Patient Satisfaction Following Surgery for Thoracic Myelopathy. Spine surgery and related research, 8(4), 409-414. https://doi.org/10.22603/ssrr.2023-0279
2022Kohei (2022). Postoperative Rehabilitation for Thoracic Disc Herniation in a Professional Rugby Player: A Case Report. Cureus, 14(10), e30423. https://doi.org/10.7759/cureus.30423
2022Bonomo et al. (2022). Diagnostic approach, therapeutic strategies, and surgical indications in intradural thoracic disc herniation associated with CSF leak, intracranial hypotension, and CNS superficial siderosis. Neurological sciences : official journal of the Italian Neurological Society and of the Italian Society of Clinical Neurophysiology, 43(7), 4167-4173. https://doi.org/10.1007/s10072-022-06059-y
2024Lockey et al. (2024). Diagnosis and Management of Thoracic Myelopathy. The Journal of the American Academy of Orthopaedic Surgeons, 32(18), 815-822. https://doi.org/10.5435/JAAOS-D-23-00984

Generic measures that also apply

Did this page do its job?

CliniStudy is in beta. One tap is enough — it decides what gets fixed first.