common causes of thoracic back pain include a spinal disc herniation which often may have radicular pain (wrapping around the ribs associated with numbness and burning pain), spinal tumors and rib fractures may mimic thoracic pain/radicular pain. Other possible sources of referral pain into the thoracic region include visceral organs like: lungs, gallbladder, stomach, liver duodenum, pleura and cardiac. Middle back pain has long been considered a "red flag" to alert healthcare professionals to the possibility of cancer (metastasis or spread to the spine). This is not a sensitive or specific phenomenon and can therefore not be relied upon in isolation. Risk factors Thoracic spinal pain is associated with: concurrent musculoskeletal pain; growth and physical; lifestyle and social; backpack; postural; psychological; and environmental factors. Specific risk factors identified in adolescents included age (being older) and poorer mental health. Mechanism The word "thoracic" means pertaining to the chest, and the thoracic spine comprises the upper portion of the spine that corresponds to the chest area. The upper spine includes twelve vertebrae, and each of the upper nine vertebrae in this section attach to a rib on either side of the spine. Each of the ribs then curves around the side of the body and attaches to the breastbone in front. This forms a sturdy structure (the thoracic cage) that supports and protects the internal organs — the heart, lungs and liver. Diagnosis Detailed physiologic testing proving what percentage of pain in the thoracic spine is caused by disc, facet, rib or muscle are yet to be completed so the answer to the question what is causing the pain often is left unanswered. If thoracic pain presents with weakness or numbness of the legs, bowel or bladder incontinence, and/or falling immediate MRI imaging is indicated. Management Non specific thoracic spine pain is usually treated by one or a combination of the following: Exercise/Active and passive physical therapy Deep massage or massage therapy Ice and/or heat therapy Analgesics such as non-steroidal anti-inflammatory drugs Joint manipulation, as commonly performed by physical therapists, chiropractors or osteopathic physicians (D.O.). If there is a specific tender spot, then trigger point massage or injections can be helpful. A painful vertebral compression fracture may be treated with pain medication and rest, or with vertebroplasty or kyphoplasty surgery. If the cause is thought to be osteoporosis, oral or intravenous bisphosphonates may be administered to reduce further fracture risk. See also