Setting: Tertiary care academic medical center. Patient: A 74-year-old man with thoracic facet joint osteoarthritis. Case Description: The patient presented with chronic mid thoracic anterior radiating back pain, quality described as burning, aggravated by physical activity including walking, and relieved by heat, ice, and massage therapy. Physical examination revealed intact strength and sensation in all upper and lower myotomes; reflexes that were +2 and symmetric at biceps, triceps, and brachioradialis; and negative Hoffman and Spurling signs. Palpation revealed right rhomboid major and latissimus dorsi tenderness, with focal tenderness over T5-6 facet joints. Radiographs revealed facet osteoarthritis on T5-6 and T6-7 and magnetic resonance imaging showed T6-7 disk protrusion without foraminal narrowing. The patient’s initial treatments included nonsteroidal anti-inflammatory drugs, physical therapy, and thoracic facet steroid injections without any relief of the mid back pain. The patient was prescribed 5% lidocaine patches (Lidoderm), with instructions to apply them to the affected area for 12 hours on and 12 hours off. Assessment/Results: At 4 weeks, the patient reported significant pain relief with numeric pain scores before and after lidocaine patch of 7/10 and 0/10, respectively. The patient reported no unfavorable side effects and further conveyed improved function in daily activities and movement. Discussion: The U.S. Food and Drug Administration approved Lidoderm for postherpetic neuralgia. No published studies exist for thoracic facet osteoarthritis treatment with the lidocaine patch. The lidocaine patch provided more pain relief for thoracic joint osteoarthritis than analgesics and other physical interventions. Conclusions: Conservative medical management for thoracic joint osteoarthritis is limited to oral medications, physical therapy, and thoracic facet steroid injections. Lidocaine patch may provide a safe alternative for pain relief as monotherapy or in combination with other treatments.