[hart]

#4924

40 something female, Agile 5’5″ 50kg, skier, runner, backpacker, swimmer, yoga enthusiast

“T9-T10 RIGHT SUBARTICULAR ZONE LARGE DISC EXTRUSION EXTENDING 4.7 MM POSTERIORLY AND 10 MM SUPERIORLY WITH RIGHT LATERAL RECESS STENOSIS AND MASS EFFECT ON THE EXITING RIGHT T9 NERVE”

(MRI and full report available) Can I post photos (MRI images) here?

December 2010 — 2 wk history of increasing thoracic RADICULAR PAIN and parathesia. There is no good story. No memorable trauma. The worse the pain got, the more I thought I needed to stretch :( I had NO BACK PAIN.

New to area. Didn’t know where to go. Self treated with ice, acetaminophen/hydrocodone and NSAIDS. Then prednisone (5 days, 20mg qd). Desperate, presented to the ED at an upscale LA area hospital with “T9 radicular pain” — served it right up! Consultant immediately honed in on the gallbladder. I told him 0% chance but agreed to cooperate with the U/S — I needed pain control! I could not afford to be difficult but I politely stuck to my story! The abdo work up continued and finally I was offered IV antibiotics in case the bit of bacteria in my urine (no cells in urine and WBC 3.5) was somehow associated with my pain. I refused the antibiotics and requested removal of the IV catheter and discharge (with my kidneys) from hospital.

In pain and very discouraged, I had a family member in another state order an MRI.

No relevant hx EXCEPT:

approx 5 years ago, as a medical student in Australia, I got up the nerve to tell my older wise GP that for the previous 2 months, I felt as if I had a tuning fork placed right about on the tip of my 10th rib. This annoyed me at night when I was trying to fall asleep. I thought he was going to tell me I was nuts. He had a look and very confidently said “T9 spinal nerve”. He asked if I’d like a referral to the physio next door or to a surgeon. I had no pain and I most certainly was not interested in an operation so I went to the physio. I had a few sessions of twisting maneuvers. The annoying sensation went away. At the time, I didn’t consider the etiology. I quickly forgot about the incident.

So when the radicular pain started 9 months ago, I was pretty certain of the level.

I gathered enough information to get the idea that there are spine surgeons out there who would be pretty keen to have a go at this. I also figure that they don’t get to do these too often! A spine surgeon friend in another state had a look at the MRI and told me to try to get comfortable and wait it out. A fellow skier and neuroradiologist in another state also advised against surgery. There were no obvious “red flags” in the presentation and I felt OK with this. I saw a local PM&R — I wasn’t impressed. I have a good physical therapist. I am not fully complying with the prescribed ballistic twisting maneuvers and PNF golf swing like motions with the cables — I am scared! I can run and swim now. It has been a long 9 months. Radicular symptoms have all but disappeared. My thoracic spine is sore. I continue to get better but I am frustrated with my progress and would like to consult a (conservative!) spine surgeon (in person!) with a keen interest and experience in thoracic spine herniations. I can travel to see such a doctor! However, there must be someone here in the LA area.

I have read everything I can find on thoracic disc herniations. There more I read the more puzzled I am…the patient, the presentation and the lesion itself. First disc to go?

[Donald Corenman, MD, DC]

#4925

You are one of the rarer patients with a thoracic disc hernation. I see about 10 patients a year with a thoracic disc hernations compared to 300 lumbar and 100 cervical hernations.

I try to keep most thoracic disc hernations out of the operating room as the surgery to remove the herniation is extensive. The chest has to be entered and ribs are either stretched or removed which can lead to intercostal neuralgia. The other technique is to do a transpedicular approach which can occasionally lead to incomplete removal. None the less, there are times that a surgery has to be performed due to cord compression. There are some surgeons who use endoscopy to remove thoracic herniations and those results are mixed.

Epidural steroid injections can work well for these herniations. If there is no cord compression and in your case, it sounds like there is none, injection treatment can give relief. If you can be patient, in my opinion, 80% of patients with these herniations can have moderate to significant symptom relief over time.

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.

[hart]

#4926

Thanks Dr. Corenman!

Yes, there is no reason to suspect cord compression. I suppose if you have to have a 10mmx5mm blob in there, this is a good place to have it! :)

I tried to get an epidural but my PM&R told me that 1. the correct injection was a spinal nerve block and 2. Injections were my last step before surgery, the idea being I would be getting one step closer to theatre. Ridiculous! (He was not in the injection business.) I could have doctor shopped. But I was exhausted and wasting from little sleep and little appetite. At this point, I had shingles T5-ish on the other side. (I was healthy 6 weeks previously!) I didn’t really have my wits about me! The radicular pain was improving. BTW, shingles feels much different than thoracic radicular pain!!

I am nine months out. I am improving by the month. Rehab? Are there any good resources out there? Articles. I am running and swimming and doing some agility drills and various planks and things. Balances with my eyes closed. I am making it up as I go along.

I have annoying limitations. I am sure they are subtle to the observer. I have always had a lot of definition in the core musculature — genetics I guess — I don’t work at it! Of course, there is a lot less bulk now but the surface anatomy is very clear. I am filling out under the ribs but the muscles are asymmetric. My 10th rib is clearly a floating rib on the affected side. The end is obviously free. It gets in the way. Interestingly, this rib seems to become less mobile as I get a bit stronger. I don’t care about the cosmetic aspect. My balance and quickness are affected by this asymmetry. I don’t have the same control of my body! It is very frustrating.

Can someone in this situation expect continued improvement indefinitely. I would love to ski this winter 8) I tried this past June. I had the feeling that I was one big blocking pole plant and defensive twisting maneuver away from trouble. I quit. I sense that I have the power and muscle memory to hurt my self on skis. The pool where I swim also has a full diving facility. Prior to my mysterious injury, I had been up on the platforms and seriously giving some thought to giving diving another go after a quarter century. They are trying to put together a serious masters program. It’s a fun group. My common sense is telling me…NO, not at this point!

Should I be seeking a followup MRI at 9 months? It’s not going to affect management but I am curious. I read that thoracic lesions tend to behave a bit differently than lumbar lesions. Calcification, etc.

[Donald Corenman, MD, DC]

#4927

I would disagree with your PM&R doctor regarding injections. Epidural injections are the best single treatment for thoracic disc hernations in my opinion. The steroid can be delivered through a nerve block or through the posterior route depending upon the comfort level of the injectionist.

Don’t pay too much attention to the rib or the rib muscle mass. You will lose some mass and it really won’t matter to your function too much. You still have a complete tear in the annulus of the disc (see website under lumbar disc herniation as some of it applies to the thoracic spine as well). You could develop a recurrent disc herniation but that would be very rare.

You have picked two sports that do put significant G forces on the spine, skiing and diving. You now have to think in terms of risk. I don’t think your risk is very high with either sport but these two do increase the risk of a recurrent hernation.

You are correct that thoracic disc herniations do tend to calcify but lumbar disc herniations do too. It is just that the annulus is so much bigger in the lumbar spine that the calcification does not cover as much area as the thoracic spine does.

Before you consider competing in the Master’s division in diving or hard core skiing, you need to have fluid, strong and controlled movements to the complete end range of motion in your thoracic spine. If you have an impact or fall that can carry you beyond the normal physiological limitations of the thoracic spine, you have a chance of recurrent injury.

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.

[hart]

#4928

I just figured the annulus was gone. No?

[Donald Corenman, MD, DC]

#4929

The annulus just tears but the ends retract and the annulus becomes incompetent.

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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