What Is the Upper Back?
The upper back starts where the neck meets the shoulders and ends at the bottom of the ribcage. Doctors call this area of the body the thoracic spine. It’s composed of bones, muscles, ligaments, tendons, and nerves. Injury to any one of these structures can result in thoracic pain after a car accident.
The twelve bones within the thoracic spine are called vertebrae. The vertebrae are numbered T1 at the top all the way to T12 at the bottom. Each vertebra is connected to each other by protruding bones called facets. The facets of the thoracic vertebrae come together to form facet joints. The facet joints have cartilage that holds the joints together.
In between each thoracic vertebra are soft cushiony material called discs. The discs are mini shock absorbers that help prevent middle back injury to the spinal cord during normal movement and extreme impact. The outer surface of the disc is called annulus fibrosus and the inner core of the disc is called the nucleus pulposus.
Thick ligaments attach to each thoracic vertebra to hold the discs in place. Muscles and tendons are also part of the middle back. The vertebrae, facet joints, discs, ligaments, muscles, and tendons all work together to create the movement of the upper and middle back.
Whiplash Is the Main Cause of Middle Back Pain After a Car Accident
Middle back pain after a car accident can be caused by injury to any of the structures of the upper back. Most often, the cause is whiplash.
Whiplash happens because the car stops moving instantly in a crash, but the body continues to move inside the car until it comes into contact with something. Most of the time, it’s the seat belt that stops the person from moving forward. Once the body hits the seatbelt, then it whips backward into the seat. This extremely fast movement backward and forward is called whiplash. It is named after the movement of a whip through the air because of how similar the motion is.
Whiplash in the upper back can cause ligaments, tendons, or muscles in the upper back to stretch or even tear. When ligaments stretch or tear, doctors call it a sprain. When this happens to muscle or tendon, doctors call it a strain.
How Long Do Thoracic Sprain and Strain Injuries Continue to Cause Pain?
The overwhelming majority of thoracic sprains and strains go away in eight to 12 weeks. This is called the acute phase of the injury. If a sprain strain lasts longer than this, it is called chronic. For some people, their middle back pain never goes away.
Medical doctors hired by the insurance industry get paid a tremendous amount of money to tell juries that chronic sprains or strains are impossible. Doctors that actually treat car crash patients know this is not true. These doctors believe their patients. They will testify that sometimes muscles, tendons, and ligaments can overstretch so much that they never completely heal.
Diagnosing Thoracic Sprains or Strains
Unfortunately, you cannot see a sprain or strain on an X-ray, CT Scan, or MRI. In fact, there is no way to actually see a sprain or strain. Instead, doctors rely on their clinical evaluation. After taking a medical history, the doctor performs a physical evaluation. If the doctor rules out all other causes for mid back pain, the doctor will come up with the diagnosis of thoracic sprain strain.
Middle Back Sprain/Strain Treatment
Treatment for thoracic sprain or strain begins with rest and ice. If the pain continues past a couple of days, chiropractic adjustments, massage, and physical therapy may be ordered. These treatments often help the body heal itself.
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Degenerative Thoracic Spine Disease and Car Accidents
As the body ages, the thoracic spine begins to show signs of wear and tear. The fluid content inside thoracic discs starts to disappear. As a result, the disc can start to bulge or even herniate. Movement can cause the thoracic vertebrae to bang into each other. As a result, bone spurs can develop over time. The movement can also cause the facet joint cartilage to wear down. All these things together are known as thoracic degenerative spine disease.
Some people experience pain from degenerative spine disease. Many people have absolutely no pain in their middle back, even though they have a substantial amount of middle back degenerative spine disease. For these people, mid-back whiplash from a car accident can cause thoracic degenerative spine disease to become painful.
Aging thoracic spine ligaments can stretch too far during whiplash. Degenerative thoracic discs that are already bulging can become painful or even herniate. An already herniated disc can progress and begin to touch against the spinal cord or nerves within the spine. Worn facet joints of the thoracic spine can bang together during a whiplash or overstretch to the point of pain.
Discogenic Middle Back Pain from a Car Accident
Normal healthy discs in the thoracic spine are not painful. As the disc degenerates, it can bulge or herniate. Even still the disc may not be painful. But the degenerative process can cause nerve fibers within the disc to grow.
When a degenerated disc experiences whiplash trauma in a car accident, the nerves within the disc can become inflamed and irritated. The inflammation and irritation can cause the disc itself to become painful. Because the pain is coming from the thoracic disc itself, doctors that treat car accident patients call this pain discogenic middle back pain.
Fortunately, discogenic thoracic back pain is rare. Because it is rare, doctors hired by insurance companies routinely testify that it does not exist at all. These defense doctors are paid substantial amounts of money to try and convince juries that people cannot get a middle back injury after a car accident. An effective cross-examination from an experienced auto accident lawyer can demonstrate the obvious bias of these hired expert witnesses.
Diagnosing and Treating Middle Back Discogenic Pain
An MRI can show a bulging or herniated disc without identifying if it is painful. As a result, it can be very hard to diagnose and treat discogenic middle back pain.
Doctors start by taking a complete history and performing a complete physical. If all other causes are ruled out, then the doctor will assume you have discogenic middle back pain.
To treat middle back discogenic pain, doctors often order anti-inflammatory medication, massage, physical therapy and/or chiropractic care. If the middle back pain does not go away, the next step is often an epidural injection. If the middle back pain goes away after the injection, the pain was probably middle back discogenic pain.
Unfortunately, pain relief from an epidural injection into the thoracic spine often does not last more than 6 months. For these patients, there are really no good treatment options. While it is certainly possible to perform surgery for middle back discogenic pain, the overwhelming number of surgeons will not do so because it is a complicated procedure with poor outcomes.
Herniated Disc Touching the Spinal Cord in the Middle Back
A herniated disc touching the spinal cord in the middle back can be a medically urgent condition. In order to understand treatment options, you must first understand what a herniated disc actually is.
What Is a Herniated Disc in the Thoracic Spine?
Normal discs are soft inside and are surrounded by a thick outer lining. As we age, the water content inside the disc can decrease and the outer lining can begin to wear. This degenerative process can cause a disc to bulge or even herniate. The trauma from a car accident can also cause the disc to herniate. This simply means the disc pushes beyond the space it normally occupies. Think of how a ball that expands when it is flattened.
When a herniation does not push through its outer lining, it is called a protrusion. When a herniation does push through the outer lining, it is called an extrusion. Either way, if a bulge or a herniation pushes far enough in the thoracic spine, it can touch the spinal cord. Symptoms from a herniated disc touching the spinal cord in the thoracic spine include:
- Weakness in the muscles of the middle back
- Tingling into one or both legs
- Spastic movement in one or both legs
- Changes in bowel or bladder function
- Paralysis from the waist down
Diagnosing a Herniated Disc in the Middle Back
The first step to any diagnosis of the mid-back is getting a complete medical history and performing a physical examination. The next step is taking x-rays. Although x-rays cannot show if a disc is herniated, the images let the doctor know how much wear and tear there is in the spine.
The main way to diagnose a herniated disc is through MRI imaging. Because MRI is very good at showing soft tissue, it can not only show whether a disc is herniated, it can also show whether the disc is touching the cord.
Treatment for Thoracic Herniated Discs Touching the Spinal Cord
Unfortunately, there are very limited treatment options for a herniated disc in the thoracic spine. Initial treatment often includes an epidural steroid injection. The shot delivers medication directly to the inflamed area. The hope is that the medication will reduce the inflammation and the disc will stop pushing on the spinal cord. For some people, the epidural can eliminate the pain. Others are pain-free for 8 months before the pain returns and they get another shot.
Surgery for Thoracic Herniated Discs
If an epidural provides temporary relief, surgery is sometimes an option. However, middle back surgery is much more difficult than neck or lower back surgery. The difficulty arises because the ribs and sternum make it much harder to get to the thoracic spine.
In addition, the surgery takes place near vital organs such as the heart and lungs. Potential complications include damage to these organs and/or irreversible spinal cord damage. For these reasons, many surgeons won’t perform thoracic spine surgery. Others require a heart surgeon to be present in the operating room.
There are some very skilled surgeons that have good results with thoracic spine surgery. Common middle back surgeries include:
- Laminotomy and Discectomy: Many doctors have stopped doing this procedure in the thoracic spine because of the high complication rates.
- Transthoracic Decompression: This new technique involves operating from the patient’s side. The doctor makes a small hole in the ribs and operates on the spine through the chest cavity.
- Costotransversectomy: The surgeon operates from the back of the spine. With this technique, the surgeon must remove part of the rib that meets the spine.
- Video-Assisted Thoracoscopy Surgery (VATS): This newer procedure only requires a small opening. A thoracoscope with a small video camera at the end is passed through a small hole in the chest cavity. The surgeon operates by watching the surgery live on a video monitor.
- Minimally Invasive Lateral Thoracic Discectomy: This procedure is performed on the side and may include video. The small surgical requires much less recovery time.
- Thoracic Spine Surgery: With this technique, the disc is removed and the vertebrae are fused together. This procedure is often performed at the same time as some of the other procedures.
Upper and Middle Back Facet Joint Injuries After a Car Accident
In the upper back, the facets help connect the vertebra together and come together to form a facet joint. There are very tiny nerves that run across the surface of the facet joints. In a car crash, the facet joints can bang together during whiplash. This movement can irritate the nerves running across the facet joints and can cause the facet joints themselves to be painful. This is often referred to as thoracic facet joint syndrome.
Diagnosing Upper Back Facet Joint Injury
Although an MRI can show wear and tear to the facet joints, an MRI cannot tell whether this is the cause of pain. An MRI also cannot identify whether the tiny nerves of the facet joints are damaged.
The best way to diagnose facet joint syndrome starts with the physical exam. If the joints are tender, it may be the source of the problem. To find out, some doctors perform facet joint blocks, which involves injecting a mixture of local anesthetic and steroid into the facet joint itself. If the pain goes away or is reduced by at least 75% for at least 30 minutes, then the pain is probably coming from the facet joints.
Upper Back Facet Joint Surgery
For people that experience temporary relief from facet joint blocks, there is a surgical option available. The procedure is called thoracic radiofrequency ablation.
With this procedure, the surgeon touches the tiny nerves of the facet joints with an electrode. This burns the nerve and stops the pain sensation from traveling from the joint to the brain. Unfortunately, the nerves grow back within six to eight months. This means the procedure may need to be performed up to twice per year.