Thoracic spine pain Flashcards
acute pain is often from?
compression fractures or muscle spasm
what are the reasons for pain or deformity in young patients?
scoliosis and hyperkyphosis (scheueremann’s)
what are the reasons for pain or deformity in adults?
chronic postural problems, long term scoliosis problems
what are the reasons for pain or deformity in seniors?
compression fractures
how do you tell between a T1 and a T2 weighted image?
T1: dark CSF
T2: white CSF
red flags for thoracics
trauma, history of cancer, corticosteroid use, history of infection, drug or alcohol abuse
older: weight loss, history of cancer, night pain or fever
when examining the thoracic spine, what should you look for?
deformity skin lesions AROM, PROM, Resisted ROM prone extension test Adam's test palpate and percuss area of complaint radiography if needed specialized imaging if needed labratory investigation if needed
how do you tell the difference between osteoporosis, lytic mets or multiple myeloma?
old films, if not helpful, go to labs (CBC, ESR, C-RP, BCP, UA)
if the labs look like they have lytic mets, what is going to happen next?
bone scan
if there are hot spots, do MRI, then biopsy
if the labs look like they have multple myeloma, what is going to happen next?
PEP (protein electrophoresis), if there is an M spike, then they get a skeletal survey, then they get an MRI, then biopsy
what is the most likely reason for pathological fracture in a child?
eosinophilic granuloma
what cells are involved with eosinophilic granuloma?
langerhans cell histiocytosis (LCH)
describe EG
proliferation of langerhans cells with an abundance of eosinophils, lymphocytes and neutrophils (produce prostaglandins, cause medullary bone resorption)
lesions may be ansymptomatic
what are symptoms of EG if there are symptoms?
pain, swelling, tenderness around lesion
malaise, occasionally fever with leukocytosis
describe osteoid osteoma demographic, pain and general location.
young male (10-25)
localized mid back pain
pain worse at night relievedby salicylates
metaphyseal region of long bones
what are the signs and symptoms that can be in the thoracic spine?
postural problems stiffness deformity scapular winging Sprengel's deformity buffalo hump dowager's hump acute angle kyphosis hyperkyphosis
lower costovertebral pain can be referred pain from?
kidney
mid thoracic/scapular pain can be referred pain from?
gallbladder
thoracic sprain/strain ortho neuro AROM PROM radiography recommendations
ortho: none
neuro: none
AROM: pain that contracts involved muscle
PROM: pain at end range of involved muscle or ligament
radiography: not required unless significan trauma
recommendations; myofascial therapy, limited orthotic support, ergonomic advice, preventative exercises and stretches
neuritis or radiculitis signs and symptoms, ortho, neuro, aROM, PROM, recommendations
radiation along rib
pain radiate with valsalva
ortho: valsalva may increase pain
neuro: deficit in corresponding dermatome or myotome
AROM: variable weakness
PROM: variable
recommendations: MRI if no progression, limited orthotic support, myofascial therapy
facet syndrome signs and symptoms, ortho, neuro, AROM, PROM, recommendations
signs and symptoms: may radiate along rib, but not usually, hyperextension increases local or radiating pain
ortho: Kemp’s or hyperextension
neuro: none
AROM: variable
PROM: variable
recommendations: myofascial therapy, limited orthotic support, ergonomic advice, preventative exercises and stretches, avoid hyperextension
describe Scheuermann’s disease
13-17 years, slight male predominance
mid back pain and fatigue
increased kyphosis
vertebral growth plate trauma
anterior wedging greater than 5 degrees in 3 consecutive vertebra
decreased disc height and end plate irregularity
what is the most likely place for scheuremann’s? second most common?
mid thoracic region (75%) thoracolumbar region (25%)
prone extension test
pt prone, place hands behind back, bring head up as far as you can
prone extension test findings
persistence of kyphosis indicates structural kyphosis
if it improves, it is a functional kyphosis
describe what to do with someone with scheuermann’s
<60 degree curve- conservative, stretching, postural changes, hamstring stretching
60-80 degrees- brace
>80 degrees- surgery
when is an orthopedic consultation needed for scheuermann’s?
when the patient is skeletally immature
when can older patients get a compression fracture? Young patients?
older- could be a minor event (sneezing, stepping off curb, etc.)
younger- fall on butt or hyperflexion injury)
what are signs/symptoms of compression fracture?
sharp kyphotic angle
pain on percussion and deep pressure
anterior step defect and zone of impaction
when is a fracture unstable?
when more than 1 column has decreased in height or iif the middle segment has flattened.
radiographic features of osteoid osteoma
acute angle scoliosis
lesion usually on concave side
small density that surrounds a central radiolucent nidus
bone scans or CT may be needed
what needs to happen after an osteoid osteoma is confirmed?
complete surgical excision of the nidus little chance of recurrence vertebral body lesions may be irradiated percutaneous radiofrequency ablation is the preferred treatment option resolve spontaneously in ~33months
what are the different possibilities of a missing pedicle?
congenital
destructive
surgical
what are the different possibilities if the missing pedicle is destructive?
bone tumor (lytic mets, primary (ABC, osteoblastoma))
soft tissue tumor (neurofibroma)
infection
possible radiographic changes with infection
osteopenia soft tissue swelling decreased joint space lytic destructive changes periosteal reaction involucrum cloaca with potential draining sinus sequestrum sclerosis debris ankylosis
herpes zoster
shingles
acute, painful dermatomal dermatitis (blistering skin eruption)
presence of immunosupression
describe how herpes zoster occurs
virus travels from skin and mucosal surfaces to the sensory ganglia, lies dormant
only reactivates with immunosupression, emotional stress, trauma, irradiation, surgical manipulation of spine
signs and symptoms of herpes zoster
pain, blistering skin eruption with a dermatomal distribution
nerve pain
rash typically resolves in 2-4 weeks, nerve pain may continue for months to eyars after lesions have healed
definition of a scoliosis
lateral deviation of >15 degrees and rotation of the spine, often associated with thoracic hypokyphosis
severe disease distorts chest wall enough to restrict pulmonary and cardiovascular function
cosmetic deformity may also be serious
functional scoliosis
postural, compensatory reversible curve due to another condition (limb length, painful muscle spasm)
structural scoliosis
nost postural, characterized by structural skeletal changes such as vertebral rotation and wedging and rib deformation
idiopathic scoliosis
70-80% AKA familial scoliosis
not associated with dysmorphic features, skin lesions, bone fragility or neuromuscular disease
congenital scoliosis
10%, errors of formation (hemivertebra) or errors of segmentation(unilateral bar, worsens gradually), commonly associated with genitourinary anomalies, curves present at birth, up to 75% require treatment
neuromuscular scoliosis
15%
associated with any disease that causes weakness of spastic imbalance of paraspinal muscles in growth child, including cerbral palsy, muscular dystrophy, spinal muscular atrophy, spinal cord injury; may develop at any age in growing child but doesn’t occur after skeletal maturity
dysmorphic syndrome (scoliosis)
neurofibromatosis, Marfan syndrome, Ehlers-Danlos syndrome, osteogenesis imperfecta, homocystinuria
infantile scoliosis
by age 3, more common in boys and Europeans, usually resolves spontaneously
juvenile scoliosis
4-10 years
adolescent scoliosis
age 10 years until skeletal maturity, most significant and prevalent form, can become worse during growth spurt
when do you send someone with a scoliosis to an orthopedist
if they have changed 5 degrees or more in a 3 month time period
nash moe method
determines the rotational component of the vertebrae
risser sign
risser 1- 1/4 of bone risser 2- 1/2 of bone risser 3- 3/4 of bone risser 4- all bone, not fused risser 5- all bone, fused
when is someone considered a good surgical candidtate for scoliosis?
> 50 degrees
when do you send someone with scheuermann’s to an orthopedist?
if they are still growing
how do you determine osteoporosis from lytic mets from multiple myeloma?
history, clinical presentation, old films
if films are not helpful, do labs
if the labs look like osteoporosis, what do you do?
adjust
if the labs look like lytic mets, what do youdo?
bone scan
MRI
biopsy
if the labs look lke multiple myeloma, what do you do?
PEP (urine and blood)
skeletal survey
MRI
biopsy
PET scan
positron emission tomography
radiotracer such as fluorodeoxyglucose (FDG), which contains both sugar and radioactive elements
what happens physiologically if someone has eosinophilic granuloma?
proliferation of Langerhans cells with an abuncance of eosinophils, lymphocytes and neutrophils. the cells produce prostaglandins which result in medullary bone resorption
what are some symptoms of eosinophilic granuloma
pain, swelling and tenderness around lesion
malaise, fever, leukocytosis
what are the ddx for decreased disc height?
joint disease
developmental
infection
what is the ddx of ivory vertebra?
blastic mets
lymphoma
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