[Future Spine Surgeon]

#9364

Hello Dr. Corenman,

I am a 20-year-old female and I have had horrible thoracic spine pain that radiates bilaterally around my ribs since an orthopedic surgeon forcefully palpated along my spine during a physical exam on 4/28/2011. I fell off a horse over 10 yrs ago and had some achy thoracic pain from my fall. This pain was always easily controlled with rest, ice/heat, and OTC analgesics and rarely interfered with normal activities. My pain since the exam is sharp, burning, and stabbing and has been so severe I am unable to function or even breathe normally. I have undergone every imaging scan my doctors can possibly order and the only abnormality that has been detected is an HNP at T7-8 that does touch my spinal cord. One surgeon thought I might have Scheuermann’s Kyphosis but the others have disagreed with that diagnosis. I have seen more than a dozen ortho/neuro spine surgeons and most have agreed that surgery would only worsen my pain and quality of life. But they have also admitted they have never seen anything similar to my case. I have been under the care of an amazing pain management specialist but my pain has failed to respond to the treatments I’ve listed below. I was wondering if there were any other treatments you recommend for your patients with severe thoracic spine pain with intercostal radiculopathy (especially those patients who you believe are not good surgical candidates)? In your experience, have you found thoracic discograms helpful in diagnosing the etiology of thoracic pain?

Pain Rating:
-Constant 10/10

Imaging:
-Full Spine MRI (5/02/2011)
-Nuclear Bone Scan (6/03/2011)
-Thoracic Spine/Chest CT (12/19/2011)
-Thoracic Spine CT Myelogram (5/15/2012)
-Portable Chest X-Ray (7/13/2012)
-Thoracic Spine MRI (7/23/2012)
-Thoracic Spine X-Rays (8/10/2012)
-Thoracic/Lumbar Spine MRI (2/19/2013)

Medications:
-Naproxen
-Ibuprofen
-Acetaminophen
-Flexeril (10 mg)
-Indocin (75 mg)
-Prednisone (10 mg tab—50×2, 40×2, 30×2, 20×2, 10×2)
-Lyrica (50 mg & 75 mg)
-Neurontin (600 mg)
-Tylenol #3
-Norco (7.5-325 mg)
-Vicodin (5-500 mg)
-Dilaudid (2 mg & 4 mg)
-Oxycontin (10 mg)
-Diazepam (5 mg)
-Celebrex (200 & 400 mg)
-Savella (100 mg)
-Cymbalta (50 mg)
-Nortriptyline (10 mg)
-Ultram (50 mg)
-Flector Patches (1.3% Diclofenac)
-Lidoderm Patches (5% Lidocane)
-Fentanyl Patches (12 mcg)
-Zophran (8 mg)
-Phenergan (12.5 mg & 25 mg)

Injections:
-Epidural Steroid Injections (3)
-Facet Joint Injections (1)
-Medial Branch Block (1)
-Intercostal Nerve Blocks (4)

*Intercostal Nerve Block performed in August 2011 provided significant pain relief for 2 weeks. When the pain returned, it was more intense than before the block*

Radio-Frequency Ablations:
-Right Sided T7-8 Intercostal Nerve

Conservative Treatments:
-Rest
-Ice/Heat
-TENS Unit
-Long Term Use of NSAID’s (Naproxen, Ibuprofen, Indocin & Celebrex)
-Medication Therapy
-Physical Therapy (1 Session)
-Spinal Cord Stimulator Trial (2)
-Bilateral On-Q Pump Trial- .2% Ropivacaine
-Peripheral Nerve Stimulator Trial
-Acupuncture Therapy
-Psychological Evaluation performed on 2/28/2012

My pain management physician has put his heart and soul into easing my pain and he is becoming extremely frustrated that I don’t respond well to treatment. If he gives up on me, I have no one left to fight for me and I’m afraid I’ll be trapped in this nightmare for the rest of my life. My doctor and I would greatly appreciate any ideas you may have on this very complicated situation. Thank you so much for your time.

[Donald Corenman, MD, DC]

#9380

I can tell you that your pain physician is unsurpassed and obviously cares for you very well.

The palpation that this orthopedist performed was unlikely to have caused permanent injury but unfortunately he was there when the pain became unbearable. Don’t place too much blame on him.

What is the degree number for your kyphosis in the thoracic spine and especially in the few segments that surround this painful region? What do the discs and vertebra look like? Are the endplates of the vertebra very irregular and are the vertebra trapezoidal in shape instead of being rectangular? What do the discs look like on the MRI in this region (including the herniated level)? Are there Schmorl’s nodes (endplate fractures) present?

Do you have more or less pain with flexion (bending forward). Conversely, do you find some relief with bending backwards?

Have you had epidurals and kept a pain diary (see website)? If no pain diary was kept, the information will have been lost as to the diagnostic value of these injections.

Dr. Corenman

PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
 
Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.

[Future Spine Surgeon]

#9419

Hello Dr.
I reviewed the dictation from the surgeon who dx’d me with Scheuermann’s and he doesn’t note the degree of angulation he measured and the radiology reports don’t state it either. This is what the spine surgeon did have to say:
“Physical Examination:
The patient is alert, oriented, and appropriate to person, place, and time. She is in moderate distress due to pain. She has difficulty holding still due to pain, and she vocalizes her pain during the examination.
Musculoskeletal/Neurologic:
Flexion and extension of the thoracic and lumbar spine cause pain. They cause pain with equal motions. Does have pain to light palpation of the thoracic spine. There are no scars or ulcerations, cervical, thoracic, or lumbar spine. Has 5/5 strength, bilateral lower extremities. Sensation is symmetric, bilateral lower extremities. There are no sensation deficits in a dermatomal distribution across the thoracic spine.

Diagnostic Imaging:
Radiographs, thoracic spine, obtained August 10, 2012, demonstrate multilevel Schmorl nodes, most pronounced at T7-8, T8-9, T9-10, T10-11. Does have wedge shaped vertebrae at T7, T8, and T9. There is no evidence of focal kyphosis. There is no evidence of posterior ligamentous disruption.
MRI scan, thoracic spine, obtained July 23, 2012 demonstrates what appears to be a central disc protrusion at T7-8 that is best appreciated on the axial view. However, the hash marks on the axial view and the saggital views do not line up with the disc herniation. The patient possibly has a small central syrinx in the upper thoracic spine. However, this may also be signal flow voids. The patient does have multiple Schmorls nodes in the thoracic spine. There is no increased signal in the vertebral bodies. No evidence of tumor in the thoracic spine.

Impression:
1: Complex pain syndrome
2: Scheuermann changes in the thoracic spine, including Schmorl nodes, as well as wedge shaped vertebrae
3: Disk herniation, T7-8, with central disc protrusion”

Like I said before, he was the only surgeon (out of 9) that indicated these findings. The radiology reports briefly discussed the schmorl nodes but failed to discuss wedge shaped vertebrae or kyphosis. The only other mention of a wedge shaped vertebrae was by a neurosurgeon who thought I had a healed compression fracture at that level (T7-8). The thoracic vertebral height and alignment are preserved. The only abnormality is the small protrusion at T7-8. The disc is slightly darker on the MRI than those around it, one surgeon told me that was a sign of disc degeneration.

I have had 3 epidural steroid injections. Each time my pain management physician has had me keep a pain diary. All 3 injections failed to provide any relief. I didn’t even feel pain relief from the local anesthetic in all 3 cases. In fact, the ESI’s caused a dramatic increase in my pain for 3-4 weeks after each injection. This was one reason no surgeon believed my pain would benefit from a discetomy/fusion.

One issue my pain MD and I have run into is that no one can agree what’s wrong with me.

I’d be more than happy to send you a copy of my imaging scans/med records if you’d be interested in looking at them. I’ve considered making an appointment with you numerous times (I live in Denver, CO) but a lot of surgeons seem to think I’m wasting their time so I’ve sort of given up.

[Donald Corenman, MD, DC]

#9420

It does appear from the information you provided that you do have a neuropathic pain problem and not a mechanical pain problem. According to the report, you do have some Schmorl’s nodes and possibly one or a few wedged vertebra but your symptoms do not fit with a mechanical Scheuermann’s disorder.

These mechanical Scheuermann’s disorder patients have multiple degenerative discs, an angular wedging on X-ray (of more than one level), pain with flexion (bending forward) which is relieved with extension (bending backwards or pulling the shoulders backwards). This subset of patients also will have temporary relief from epidurals.

I think you need to stick with your pain doctor and possibly consider a consultation with a specialist who uses spinal cord or peripheral stimulation (see website).

Dr. Corenman

PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
 
Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.

[Future Spine Surgeon]

#9427

Do you think a thoracic discogram would be helpful in my case? I’ve had some docs highly recommend it and others tell me it wouldn’t tell us anything and be unnecessarily painful for me.

[Donald Corenman, MD, DC]

#9428

Thoracic discograms are a potential prelude to surgery. Surgery would work if you had a mechanical problem but you describe a neuropathic pain problem. I would expect the discogram to be positive and you would be lead down a surgical path. Although you have to remember that I have never examined you, by your description and my limited understanding of your pain, surgery would probably not be in your best interest.

Dr. Corenman

PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
 
Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.

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