Midline interscapular pain

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ampaphb

Interventional Spine
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If the patient complains of midline midthoracic interscapular pain of long standing, not abated by meds and PT,

and the MRI has pathology to justify (C7/T1 midline herniation, with bilateral C7/T1 facet arthropathy) the proposed procedure

what is your next step?

1) C7/T1 ESI, directing the solution inferiorly (caudad)?
2) Bilateral C7/T1 intra-articular facet joint injections/MBBs?
3) something else?

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it is pain from the traps/peri scapular muscles as they insert on the spinous processes. basically an enthesopathy from poor posture. PT, or MAYBE inject at the spinous process itself. MBB / epidural will get you nowhere
 
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In the big picture, and short of either severe trauma or compression fractures, you will never figure out or placate spine pain from the vertebra prominens to L1. If it occurs in
a young person I'd look first for secondary gain or a centralized pain process.
 
SP bursitis exists in some. No downside to squirting it. No real upside as data lacking as to whether it is placebo vs helpful. No long term effect.
 
CBT, hypnosis, TENS, endless chiropractic---add high dose vitamins & chelation therapy...

So tell us what works for chronic thoracalgia in working aged adults with normal imaging?

The answer in most instances is nothing. So the payer goal posts move toward reducing harms and costs. None of us have magic.
 
So tell us what works for chronic thoracalgia in working aged adults with normal imaging?

The answer in most instances is nothing. So the payer goal posts move toward reducing harms and costs. None of us have magic.

Periscapular stabilization exercises...done with fidelity...seated rows with terminal "scapular pinch"...look at the shoulders; tight pecs/scalenes; "myofascial" TOS type postural issues. Sometimes a of couple judicious trigger point injections especially to the levator scapulae if you get focal "Travell-esque" radiation of pain (done with US-guidance), some times interspinous ligament injection for "bastrup syndrome." In females, ask about how well their bra's fit...serious...In men, the most common problem I see is resistance overtraining the pecs, biceps, and triceps, and completely neglecting lats, traps, and shoulders...

"Failed PT??" Call the PT and ask...9/10 you'll get, "Oh, yeah, he came in for three sessions and then stopped coming..." The patient failed PT; PT didn't fail the patient...
 
See it frequently --> C6-T2 MBB with RF if diagnostic block is positive.

Nobody else here has said they see and treat it successfully routinely except for NOSfan, so why doesn't that post get more scrutiny?
Overall I'm with drusso on the muscular imbalance/myofascial pain that would improve with resistance training and mobility. But I can say the base of my own neck and upper Tspine/periscapular region hurts pretty often and it's likely because of facet pain from chronically reading in bed in horrible neck positions. Also reading in a chair with my neck craned over like a giraffe drinking from a pond likely caused my herniated disks and probably led to spondyloarthropathy at the joints too.
Get more history...you may suspect the pain would respond very well to MBBs and off you go proving NOSfan right.
 
http://www.ncbi.nlm.nih.gov/pubmed?cmd=historysearch&querykey=9

BMC Musculoskelet Disord. 2009 Jun 29;10:77. doi: 10.1186/1471-2474-10-77.
Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review.
Briggs AM1, Smith AJ, Straker LM, Bragge P.
Author information

Abstract
BACKGROUND:
Thoracic spine pain (TSP) is experienced across the lifespan by healthy individuals and is a common presentation in primary healthcare clinical practice. However, the epidemiological characteristics of TSP are not well documented compared to neck and low back pain. A rigorous evaluation of the prevalence, incidence, correlates and risk factors needs to be undertaken in order for epidemiologic data to be meaningfully used to develop evidence-based prevention and treatment recommendations for TSP.

METHODS:
A systematic review method was followed to report the evidence describing prevalence, incidence, associated factors and risk factors for TSP among the general population. Nine electronic databases were systematically searched to identify studies that reported either prevalence, incidence, associated factors (cross-sectional study) or risk factors (prospective study) for TSP in healthy children, adolescents or adults. Studies were evaluated for level of evidence and method quality.

RESULTS:
Of the 1389 studies identified in the literature, 33 met the inclusion criteria for this systematic review. The mean (SD) quality score (out of 15) for the included studies was 10.5 (2.0). TSP prevalence data ranged from 4.0-72.0% (point), 0.5-51.4% (7-day), 1.4-34.8% (1-month), 4.8-7.0% (3-month), 3.5-34.8% (1-year) and 15.6-19.5% (lifetime). TSP prevalence varied according to the operational definition of TSP. Prevalence for any TSP ranged from 0.5-23.0%, 15.8-34.8%, 15.0-27.5% and 12.0-31.2% for 7-day, 1-month, 1-year and lifetime periods, respectively. TSP associated with backpack use varied from 6.0-72.0% and 22.9-51.4% for point and 7-day periods, respectively. TSP interfering with school or leisure ranged from 3.5-9.7% for 1-year prevalence. Generally, studies reported a higher prevalence for TSP in child and adolescent populations, and particularly for females. The 1 month, 6 month, 1 year and 25 year incidences were 0-0.9%, 10.3%, 3.8-35.3% and 9.8% respectively. TSP was significantly associated with: concurrent musculoskeletal pain; growth and physical; lifestyle and social; backpack; postural; psychological; and environmental factors. Risk factors identified for TSP in adolescents included age (being older) and poorer mental health.

CONCLUSION:
TSP is a common condition in the general population. While there is some evidence for biopsychosocial associations it is limited and further prospectively designed research is required to inform prevention and management strategies.
 
........NOSfan, so why doesn't that post get more scrutiny?

Because I'm right Pop.....jk (see below for facet referral patterns, which in reality is likely a mosaic of the group....sorry for the large pic size)

You could also consider CT SPECT.

Facet%20Referral%20Patterns.jpg
 
Last edited:
http://www.ncbi.nlm.nih.gov/pubmed?cmd=historysearch&querykey=9

BMC Musculoskelet Disord. 2009 Jun 29;10:77. doi: 10.1186/1471-2474-10-77.
Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review.
Briggs AM1, Smith AJ, Straker LM, Bragge P.
Author information

Abstract
BACKGROUND:
Thoracic spine pain (TSP) is experienced across the lifespan by healthy individuals and is a common presentation in primary healthcare clinical practice. However, the epidemiological characteristics of TSP are not well documented compared to neck and low back pain. A rigorous evaluation of the prevalence, incidence, correlates and risk factors needs to be undertaken in order for epidemiologic data to be meaningfully used to develop evidence-based prevention and treatment recommendations for TSP.

METHODS:
A systematic review method was followed to report the evidence describing prevalence, incidence, associated factors and risk factors for TSP among the general population. Nine electronic databases were systematically searched to identify studies that reported either prevalence, incidence, associated factors (cross-sectional study) or risk factors (prospective study) for TSP in healthy children, adolescents or adults. Studies were evaluated for level of evidence and method quality.

RESULTS:
Of the 1389 studies identified in the literature, 33 met the inclusion criteria for this systematic review. The mean (SD) quality score (out of 15) for the included studies was 10.5 (2.0). TSP prevalence data ranged from 4.0-72.0% (point), 0.5-51.4% (7-day), 1.4-34.8% (1-month), 4.8-7.0% (3-month), 3.5-34.8% (1-year) and 15.6-19.5% (lifetime). TSP prevalence varied according to the operational definition of TSP. Prevalence for any TSP ranged from 0.5-23.0%, 15.8-34.8%, 15.0-27.5% and 12.0-31.2% for 7-day, 1-month, 1-year and lifetime periods, respectively. TSP associated with backpack use varied from 6.0-72.0% and 22.9-51.4% for point and 7-day periods, respectively. TSP interfering with school or leisure ranged from 3.5-9.7% for 1-year prevalence. Generally, studies reported a higher prevalence for TSP in child and adolescent populations, and particularly for females. The 1 month, 6 month, 1 year and 25 year incidences were 0-0.9%, 10.3%, 3.8-35.3% and 9.8% respectively. TSP was significantly associated with: concurrent musculoskeletal pain; growth and physical; lifestyle and social; backpack; postural; psychological; and environmental factors. Risk factors identified for TSP in adolescents included age (being older) and poorer mental health.

CONCLUSION:
TSP is a common condition in the general population. While there is some evidence for biopsychosocial associations it is limited and further prospectively designed research is required to inform prevention and management strategies.

Why do journal editors approve of this crap? Big take-aways: It's a common condition. It is "associated" with biopsychosocial phenomena. It should be studied prospectively---like how? Induce thoracicalgia experimentally on people....good luck getting that through an IRB...
 
Why do journal editors approve of this crap? Big take-aways: It's a common condition. It is "associated" with biopsychosocial phenomena. It should be studied prospectively---like how? Induce thoracicalgia experimentally on people....good luck getting that through an IRB...
GIGO
 
There are also newer maps that those NOS posted: http://www.ncbi.nlm.nih.gov/pubmed/?term=bogduk cooper

The maps will continue to change through time as presumably we have a better understanding of pain referral patterns. That being said, they really are just that, a map/reference, but as we know, patient's frequently don't read the book (or look at the map).

Also, there is no evidence that SPECT provides any additional useful information: http://www.ncbi.nlm.nih.gov/pubmed/24029387

Yes, the jury is still out on SPECT/Ct.......but was just trying to make PL feel better!

http://www.ncbi.nlm.nih.gov/pubmed/23942325
 
You should note that the lead author on both facet studies is the same guy (Tim Maus). At least at ISIS last year, he didn't think they were diagnostically useful
 
May be dorsal scapular neuralgia. Can investigate by doing middle scalene block; the nerve pierces the middle scalene in most humans. Botox if needed.

MUCH more often it is C5-7 facetogenic pain.
 
Along the same lines..what is the consensus on treating patients with this same pain pattern who have thoracic scoliosis? I personally find this population to be very difficult to manage in general.
 
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