Introduction

Notalgia paresthetica (NP) is a neurological condition that causes chronic discomfort, which can include itching, burning, or a tingling sensation on the mid to upper back region (specifically between the shoulder blades), with no signs of any marks on the skin, such as discolouration in the affected area.¹ It is underdiagnosed as it can often be misdiagnosed for epidermal problems such as eczema; however, this condition goes deeper than that (physically and metaphorically). NP primarily affects middle-aged and older women, though it can occur in adults of any age and is rare in children.² 

Understanding notalgia paresthetica

NP is a nerve-related condition causing symptoms like intense burning, numbness, itching, and tingling. The symptoms result from compression or irritation of the dorsal rami—nerves from the thoracic spine that transmit signals to the back and skin. These nerves play a crucial role in sending signals between the skin, the back muscles, and the spinal cord. Age-related spinal degeneration, tight muscles, and poor posture can irritate the nerves, causing incorrect sensory signals to be transmitted. This can lead to chronic itchiness, irritation, and other symptoms that may be confused with a skin condition.^1,2

The connection becomes clear when we understand that ageing increases the chances of spinal wear and tear, such as disc herniation and bone overgrowths, which in turn increases the risk of nerve compression affecting the dorsal rami. 

How the spine changes with age

NP has been associated with spinal degeneration, where the cervical spine experiences changes such as herniated discs, spinal stenosis, or osteophytes, which lead to nerve entrapment.

• Herniated discs - A herniated disc occurs when the soft, gel-like nucleus pulposus within an intervertebral disc bulges or protrudes through its outer, fibrous layer, known as the annulus fibrosus.⁴ This herniation can compress or irritate nearby spinal nerves, leading to symptoms like pain, numbness, or weakness in the limbs⁵
• Spinal stenosis - Spinal stenosis is the narrowing of spaces within your spine, which can press on the spinal cord and nerves, causing symptoms like numbness, weakness, and pain. It most commonly affects the neck and lower back, but can also occur in the thoracic spine⁶
• Osteophytes - Osteophytes, or bone spurs, are bony overgrowths that form on bones, particularly the spine, neck, and lower back, as the body attempts to repair damaged tissues, often due to ageing or arthritis⁷

These degenerative spinal changes become more common in older adults. As people age, the intervertebral disc undergoes a reduction in water content, which leads to a decrease in its ability to absorb axial loads (a force that pushes or pulls along the length of a bone or a beam, causing either compression or tension).⁸ This leads to disc herniation and degeneration of the endplates, placing pressure on the spinal cord and nerves.⁹ This process can result in a condition known as thoracic discogenic syndrome, which is a trauma to the thoracic spine caused by these degenerative disc changes. 

This spinal trauma may also impact the dorsal rami, leading to the sensory symptoms typical of NP, such as burning and itching between the shoulder blades. 

Risk factors in older adults

Risk factors for spinal degeneration and nerve issues in older adults include impaired mobility and posture, muscle weakness, arthritis, and pre-existing health conditions. It has been showed women over 65 are particularly at risk for kyphosis, a worsening spinal curvature, and that inactivity leads to posture changes, increasing risk of nerve injury. Other factors like diabetes, smoking, and certain vitamin deficiencies have been linked to neuropathy.¹⁰

NP and spinal degeneration

The relationship between NP and spinal pathology has not been investigated yet, even though patients with NP often have spinal lesions. Musculoskeletal nerve compression causes muscle fibres to also compress, which has been believed to be involved in how NP is developed. The nerve branches at the T2-T6 from the spinae muscle are more susceptible to compression and injury compared to other areas of the back. A study was conducted with 117 patients suffering from NP who had dermatomes (spots of the skin that connect to specific nerve roots to the spine), and in this case, T3 was the most common dermatome. Although no investigation involves a solo study, it has been shown that strengthening and stretching exercises targeting the mid to upper back (where NP affects) can relieve NP symptoms because the nerves are less compressed or stretched out of place.^11,12

FAQs

Why is NP more common in older adults?

As we age, our spine changes, including disc herniation, stenosis, and bone overgrowths that can compress nerves, particularly the dorsal rami. This compression leads to NP symptoms.

Who is most likely to get NP?

Middle-aged and older women, particularly between the ages of 50 and 60, are more commonly affected. However, it can affect anyone, though it is rare in children.

How does posture affect NP?

Poor posture, especially shoulder protraction (shoulders pulled forward), can reduce nerve movement and increase the risk of nerve irritation. While a slouched posture does not directly cause NP, it contributes to the mechanical issues behind it.

Can NP be mistaken for other conditions?

Yes, NP is often misdiagnosed as eczema or psoriasis due to its skin-related symptoms. However, NP originates from nerve issues rather than the skin itself.

Can anything be done to reduce the risk?

Staying active, maintaining good posture, and strengthening your back and shoulder muscles may reduce the risk. If symptoms arise, early recognition and medical advice are key.

Summary 

NP is a nerve-related condition that causes chronic itching, burning, or tingling on the upper back, particularly between the shoulder blades. Although it may seem like a skin condition, it stems from issues in the spine and nervous system, often going unrecognised or misdiagnosed as eczema or other dermatological issues.

As we age, our spine naturally goes through wear and tear. This includes disc herniation, spinal narrowing (stenosis), and bony overgrowths (osteophytes), which can compress small spinal nerve branches called the dorsal rami. These nerves are responsible for sending signals between your back muscles, spinal cord, and skin. When they become irritated or compressed, they can trigger the unusual sensations associated with NP.

Older and middle-aged women (especially between 50 and 60 years old) are most commonly affected. Factors such as poor posture, loss of muscle strength, reduced mobility, and spinal degeneration increase the risk. Even though slumped shoulders alone may not cause nerve damage, a forward-leaning posture and shoulder protraction (where shoulders move away from the spine) can reduce nerve movement, increasing the likelihood of symptoms.