57 yo withThoracic pain

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.

NJPAIN

Full Member
10+ Year Member
Joined
Nov 28, 2011
Messages
2,664
Reaction score
1,683
upload_2017-9-11_19-58-14.png
57 year old factory production line worker with 1 year of insidious onset midline thoracic pain at the level of the shoulder blades. No radicular symptoms. Worse with standing. Relieved when seated. Pain worse with flexion >> extension. No pain to palpation over the thoracic spine. No relief with PT. Modest decrease in pain with OTC NSAID. ESR and CRP - wnl.

MRI read as "mild degenerative changes at T7-8 possibly consistent with old hyperflexion injury" No known injury.
STIR image attached.

Any ideas?

Members don't see this ad.
 

Attachments

  • 2017-09-11_19-31-52.pdf
    357.9 KB · Views: 37
  • 2017-09-11_19-32-44.pdf
    369.5 KB · Views: 36
Members don't see this ad :)
Any markers of infection or malignancy? ESR/CRP/Procalcitonin/LDH/Alk Phos?

It's rather oddly symmetric and his other discs look rather good.

I would be concerned for infection/malignancy/etc due to the insidious nature of it.
 
Any markers of infection or malignancy? ESR/CRP/Procalcitonin/LDH/Alk Phos?

It's rather oddly symmetric and his other discs look rather good.

I would be concerned for infection/malignancy/etc due to the insidious nature of it.

ESR and CRP normal


Sent from my iPhone using SDN mobile app
 
This plus trial of manual manipulation.


Sent from my iPhone using SDN mobile app

I wasn't planning any injections as I couldn't see how they would be of any value. Of note, I'll bet I'm the ONLY guy in town who wouldn't tee her up for a series of thoracic ESI.

Taus - I like the manipulation idea. Are you personally doing that in your practice?


Sent from my iPhone using SDN mobile app
 
I wasn't planning any injections as I couldn't see how they would be of any value. Of note, I'll bet I'm the ONLY guy in town who wouldn't tee her up for a series of thoracic ESI.

Taus - I like the manipulation idea. Are you personally doing that in your practice?


Sent from my iPhone using SDN mobile app

I don't personally anymore- out of practice. But refer for OMT or DC for chronic axial pain occasionally.


Sent from my iPhone using SDN mobile app
 
  • Like
Reactions: 1 user
Similar guy today. 6-8 mo low T-spine pain, no aggravating or insult. 49 y/o. No PMH.
Xrays unrevealing. Getting MRI today. Heavy labor driver, equipment operator.
 
Repeat MRI with and without contrast
 
I wasn't planning any injections as I couldn't see how they would be of any value. Of note, I'll bet I'm the ONLY guy in town who wouldn't tee her up for a series of thoracic ESI.

Taus - I like the manipulation idea. Are you personally doing that in your practice?


Sent from my iPhone using SDN mobile app
Call his PT - he may have already had a trial of thoracic HVLA.
 
Members don't see this ad :)
Worth trying a few injections. What you got to lose? Start with an epidural
 
What are you treating with an epidural?

Depends how you look at it. Steroids act as a local pain reliever as well. I mean, you put steroids in places like shoulders for chronic tendinopathy? Most people do, despite not an inflammatory process. Why? because shoot, it's worth trying. Some people respond. But hey, feel free to throw them on opiates, if you feel that's the more benign option.
 
Depends how you look at it. Steroids act as a local pain reliever as well. I mean, you put steroids in places like shoulders for chronic tendinopathy? Most people do, despite not an inflammatory process. Why? because shoot, it's worth trying. Some people respond. But hey, feel free to throw them on opiates, if you feel that's the more benign option.
This is why interventional pain reimbursement keeps getting slashed, needles are not always the answer
 
  • Like
Reactions: 2 users
Depends how you look at it. Steroids act as a local pain reliever as well. I mean, you put steroids in places like shoulders for chronic tendinopathy? Most people do, despite not an inflammatory process. Why? because shoot, it's worth trying. Some people respond. But hey, feel free to throw them on opiates, if you feel that's the more benign option.

Both appear equally stupid based on education, experience, and training.

Got any studies backing you up.

BTW, like your username. license to kill.
 
Both appear equally stupid based on education, experience, and training.

Got any studies backing you up.

BTW, like your username. license to kill.

Wait, do you really not do steroid injections for chronic tendinopathy pain? You're noble. You can call me a chararan, but I do. Fairly certain >90% of pain doctors do too.
 
Had a patient like that with a very similar thoracic MRI with several levels showing strange anterior modic changes. The radiologist of course hedged and said cancer could not be ruled out if there is a high clinical index of suspicion. This sent me on a wild goose chase getting inflammatory markers and an MRI w/w/o. Everything turned out unremarkable with modic changes being the final diagnosis. Crazy how bad some of these vets spines can look. I tried an epidural...don't shoot me :shrug:
 
Last edited:
Had a patient like that with a very similar thoracic MRI with several levels showing strange anterior modic changes. The radiologist of course hedged and said cancer could not be ruled out if there is a high clinical index of suspicion. This sent me on a while goose chase getting inflammatory markers and an MRI w/w/o. Everything turned out unremarkable with modic changes being the final diagnosis. Crazy how bad some of these vets spines can look. I tried an epidural...don't shoot me :shrug:

Did it do anything?


Sent from my iPhone using SDN mobile app
 
Cervical/thoracic MBB?
 
Unless there is some kind of goober in there I haven't seen an anterior column thoracic pain generator in 13 years. Facet pain in that part of the spine.
 
Top