[CNB]

#27001

Still Need Help. Injured while paddle guiding advanced whitewater. Aggressive twisting over-rotation to the right with arms extended out and back while paddling. Hips and Head stationary while torso and shoulders hyper-rotated/extended. Sudden onset weird pain center thoracic spine nipple line and sharp excruciating pain center L thoracic spine nipple line when returning to center, rotating left or reaching up or out with arms. Immediate bilateral full hand numbness/tingling/pins/needles. Decreased strength, ability and ROM. Body felt extremely heavy slow and HURT… VERY different than the normal wear and tear as years of professional guide. Could not effectively guide or move normal.

X-rays normal. Cervical and Thoracic MRI no significant findings. Cervical EMG normal. PT discovered T4-5-6 rotated left. Relief with manual counter-rotation and traction. Rebound tenderness on release. No sustainable relief. Provocation of body wide tremor, nausea and burping upon manually applied range of motion of T4-5 and T7-8 as well as with sitting. Tremor and nausea occurred without increase in pain.

Progressively got worse. Provocation of pain when bending at waist, cutting down on cutting board, reaching above head, reaching out or to the side, rotating torso left or right, tilting head back, any use of arms, fingers or hands. Pain would radiate to under left arm to the chest/rib/sternum or radiate straight through to chest/sternum. Became difficult to walk, unsteady shaky slow, would need assistance or something to hang onto, fell several times in the night when getting up in dark to pee, legs did not seem to know where they were in space/proprioception off. At store, people would ask if I was drunk. Clumsy with legs and arms, fine motor skills decreased, hard to write zip button grasp things, went through alot of dishes, grasp was not there. Any arm hand finger movement would provoke the thoracic zone causing tremor, nausea, increased clumsiness and intense burn in the spine. Heat would exacerbate. Relief with ICE on thoracic spine/chest, constant pressure on chest where rib meets sternum pushing left and straight back, lateral recumbent position, NOT supine. Could not type or even text. Could not sit or stand without EXCRUCIATING BURN T4 zone. Zap like camera flash pain in thoracic spine when reaching/twisting/head or shoulder movement. If had to be upright, would pack self on ice, wear homemade brace that would squeeze upper torso and pull shoulders back for temp relief then would have to remove brace, HUNCH shoulders with very slight chin down and exaggerated pelvic tilt, apply pressure on sternum pushing left and retro, ice on spine/chest for any sort of relief. At one point could walk better if also extended arms at side with wrists flexed toward body and could balance better if alternated flexion/extension of right wrist then left. Could walk better after sitting if I leaned back against something and adjusted spine down or leaned chest into something to adjust spine. Stopped PT. Started Chiropractic Care Conservative.Could not sit longer than 5 minutes without onset of tremor, nausea, burping. Constant pain at T4-5 zone and increasing blunt feeling of being sliced in half at xiphoid line, being squeezed by rubberband with slight difficulty breathing. holdingMonths of inability, constant thoracic pain and extreme sympathetic response. Felt like the gas pedal was on and nothing could turn it off. Constant increase in blood pressure, pulse, heart palpitations/racing, extreme sweating esp at night, would wake up soaking wet, have to dry off change wrap myself in towels. Lost 25 pounds in six months. Now I fluctuate, gain then lose, depending on arm movements, body position and degree of provocation. ESI T4-5 at six months in. Kept pain diary. Immediate full hand numbness left side, increase in pain spine/chest/neck/jaw, increase BP pulse. ER visit 5 days later. MRI revealed inflammation and ‘mild thoracic stenosis’. Began experiencing urinary hesitancy, could not pee, body would shake terribly then when finally start to pee there would be sharp excruciating increase in thoracic pressure/pain that would radiate up to neck. Chiropractor and PT both determined “Dural Involvement” signs with motion. Conservative adjustments began to “shut off” / slow down the sympathetic response. I began to gain some weight and the ability to stand/walk, NOT sit. Returned to modified work position answering phones while standing. Began to experience INCONTINENCE, full on emptying of bladder without warning. Ongoing constipation issues that began with onset of injury. Recently referred to Neurologist, he determined thoracic outlet signs L side as well as neural deficits that indicated “neck involvement”, requesting Cervical and Brain MRI and more specific EMG. Definitely have had neck pain, headaches/migraines. R shoulder/arm pain and R hip/leg pain. Two weeks prior to the sudden twisting thoracic injury, a Raft was dropped onto the top of my head while group was carrying raft above our heads, neck crunched and onset R shoulder pain. A few days of rest ice and icy hot it seemed to resolve. Now that is the same R shoulder pain been increasing since ESI. Complex and Confusing. More than one thing going on. Definite thoracic issue, I can feel the thoracic vertebrae shift, get stuck and cause chest pain with thoracic spine pain. Pressure and Adjustment gives some relief. Chiropractor describes it as thoracic segment ‘sunken in’ again, anterior/posterior translation issue. Described sternum/rib cage as having buckled, and that ‘something’ had my sympathetic system ‘on’. PT and Chiro also suspected traumatic hiatal hernia/torn diaphragm from the traumatic twisting event and facet joints “not closing”?. Primary thinks abnormal instability thoracic vertebral segments. One of your educational videos explains there should be no white lines within the spinal cord MRI images. What would a thin long linear white line above and below a vague signal abnormality at C5-6 possibly indicate? Could the initial bilateral hand numbness possibly be from the thoracic zone or most likely only the cervical zone would cause this? Does it seem likely that the relentless thoracic pain could be from instability? Literally yearn for something to hold that zone in place! (Even getting the 1/2 gallon milk out of the fridge causes it to move)(Sitting causes it to shift) Two different PT’s and Two different chiropractors observe a direct sympathetic response to position, “not pain”, “could be mistaken for anxiety when not observed diligently over time”. Chiropractor insists on cord involvement.? Could a protrusion at T4-5 protrude more when sitting, enough to put pressure on cord? Could cervical retrolisthesis be a factor? Could Schmorls Node be a sympotmatic finding in this case? Guiding involves lots of axial loading, heavy lifting and/with abnormal torsion on the thoracic and cervical spine. I am small in stature, normally 120lbs.

Initial Radiology Report:
Cervical and Thoracic MRI findings:
C4-5 mild central disk protrusion causing mild spinal canal narrowing. Neural foramina normal.
C5-6 mild amount of disk and bone material ventrally causing mild canal narrowing.Foramina normal.
T4-5 small left paracentral disk protrusion causing canal narrowing. No evidence of cord or nerve root compression. Minimal fluid left paraspinous muscles at this level.
T7-8 mild broad disk bulge causing minimal canal narrowing.

Second Opinion Report:
C3-4 early desication. Mild circumferential disc bulging. early endplate osteophyte formation.
C4-5 mild desication. early endplate osteophyte formation. Posterior central contained disc protrusion. The herniation contacts the thecal sac which is mildly flattened.
C5-6 moderate desication. Degenerative retrolisthesis of C5. Endplate osteophyte formation as well as joint of Luschka osteophyte formation. Posterior central contained protrusion. Small region of high signal intensity.
C6-7 mild desication. shallow posterior midline contained disc protrusion.
C7-T1 and T1-2 mimimal circumferential disc bulging. less hydrated.
T4-5 mildly narrowed. Posterior disc bulging and small right paracentral disc protrusion. early endplate osteophyte formation.
T7-8 disc narrowed with Schmorl Node formation on the endplates. mild disc desication. Circumferential disc bulging.
T10 hemangioma in vertebral body.

The pain specialist who performed the ESI at T4-5 kept saying “Its tight in there, not much room, definitive stenosis, should be taking anti-inflammatory daily”. Why would the ESI have made me so significantly worse? why would it cause the left hand to go numb/tingly for days?

Is there more that could be done to assist further definitive diagnosis? If instability suspected, would more specific xray or CT imaging be helpful. Would instability be definitively revealed on MRI?

[Donald Corenman, MD, DC]

#27013

You have many symptoms that say myelopathy (See https://neckandback.com/conditions/cervical-central-stenosis-and-myelopathy/). Pain in the nipple line could be from T4 or C4 (the C4 nerve covers the anterior chest wall as well as the neck and top of the shoulders).

You do have signal change (“Small region of high signal intensity” at what I assume is the cord). Your examination is important. Do you have long-tract signs (hyperreflexia, Hoffman’s sign, clonus, Babinski’s)?

What did the brain MRI note?

You could have developed severe thoracic outlet syndrome but at least half of your symptoms don’t match that disorder.

Weight loss could be from pain and stress but metabolic disorders can also cause weight loss.

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.

[CNB]

#27109

Thank you for response Dr. Corenman. .

Chiropractor has mentioned myelopathy as well.

Could pain in chest and spine at nipple line be from both T4 AND C4.

High signal intensity ‘within the herniation’. Long tract signs present. Babinski, Hoffman’s and hyperreflexia. No clonus. No brain imaging yet.

In how to read mri video, you mention there should be no white lines within the cord. What would a thin longer linear white line possibly indicate?
In the cervical images, there is a thin linear white line that extends well above and below C5-6.

Would MRI with contrast possibly detect more miniscule signal changes within the spinal cord?

Would a cervical or *thoracic* lesion definitely be detectable with MRI?

Would CT scan with contrast and/or testing of spinal fluid be beneficial?

Is autonomic dysreflexia caused only by complete spinal cord injury?

Can a spinal cord contusion cause immediate bilateral hand numbness?

Would a cord contusion be considered a lesion and definitely show on mri?

Could spondylolisthesis cause corticospinal lesion?

Is spondylolisthesis always identifiable on imaging or is it often diagnosed by exam, symptoms, history and observation?

Do any of previously posted symptoms correlate with spondylolisthesis?

Can spondylolisthesis cause myelopathy?

Could a reported small disc bulge be larger than what most images reveal or become larger in certain positions?

Could it be fairly easy or possible to overlook or pass right over one image that may indicate a larger protrusion compressing cord?

TOS could be co-occurring? 90° left arm/hand tested positive tos: loss of pulse and pallor with increased heat numbness/tingling. Constant degree of left arm/hand sensation difference r/t T4 provocation pressure and tightness.

No doubt been in pain and experiencing stress. Convinced weight loss directly r/t joint/nerve dysfunction in tspine, chest/rib/sternum at the nipple line.

Convinced autonomic dysfunction r/t thoracic dysfunction and possibly co-occurring with cervical dysfunction and TOS. #knowthybody;) Seems when joint misaligns and/or pressure on nerve tissue occurs, the gas pedal turns on. At night when sleeping, often awakened by sudden profuse sweating that convincingly comes from dysfunctional positioning in the T4 zone. Seems to occur more often when laying on right side but happens on left side as well. I can shift position slightly and sweating subsides. Curious.

Could a spinal injury cause a metabolic disorder?

Thank you.

[Donald Corenman, MD, DC]

#27114

Holy Moly, you have given me some work here! I’ll do my best to answer but some issues might be missed.

“Could pain in chest and spine at nipple line be from both T4 AND C4”. Possible but unlikely.

“Long tract signs present”. Look to cord or brain involvement but sometimes a normal finding.

“In the cervical images, there is a thin linear white line that extends well above and below C5-6”. This could be a persistent central canal in the cord (no big deal) or a syringomyelia (See
https://neckandback.com/conditions/chiari-malformation-type-arnold-chiari-syndrome/)

“Would MRI with contrast possibly detect more minuscule signal changes within the spinal cord? Would a cervical or *thoracic* lesion definitely be detectable with MRI?” MRI with gadolinium is generally only really important in tumors and infections and I will assume there is no indication based upon previous films. Lesions are detectable.

Is autonomic dysreflexia caused only by complete spinal cord injury? No but abnormal without significant injury.

Can a spinal cord contusion cause immediate bilateral hand numbness? Yes. See central cord injury here https://neckandback.com/conditions/spinal-cord-injuries-neck/

Would a cord contusion be considered a lesion and definitely show on mri? Yes and generally yes.

Could spondylolisthesis cause corticospinal lesion? Is spondylolisthesis always identifiable on imaging or is it often diagnosed by exam, symptoms, history and observation? Do any of previously posted symptoms correlate with spondylolisthesis? Can spondylolisthesis cause myelopathy? Generally, a spondylolisthesis will show up on MRI and if unstable, will have an accompanying high signal in the cord at the slip level. You might not see the full extent of the slip unless you have flexion/extension x-rays but the slip and cord injury would be evident on MRI.

Could a reported small disc bulge be larger than what most images reveal or become larger in certain positions? I previously looked for this but have never found this to be a fact.

Could it be fairly easy or possible to overlook or pass right over one image that may indicate a larger protrusion compressing cord? Can be missed on an axial but the sagittal images would reveal this.

Could a spinal injury cause a metabolic disorder? No

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.

[CNB]

#27130

Thank you lol. Holy moly is right. Sigh. Mentally so ready to return to guiding, could be leading snowmobile trips as we speak. And I want to be ready for the summer guiding season. Seems odd to be so abnormal with no definitive diagnosis or apparently no obvious imaging results. Sigh. Do you have any suggestions? What type of specialist/who would you recommend for thorough nonsurgical spinal exam, observation and mri review? Am I able to attach mri image to the forum post? Could “some”(minor) thoracic stenosis cause myelopathy? Pain specialist kept saying “it’s tight in there” at T4-5 “stenosis”. Could that cause the myelopathy symptoms? PTx3 and Chiro observed dural tension/involvement. What’s causing the long tract signs? Central cord injury could progress or resolve? Would central cord injury cause white line? How to know if white line is no big deal or syringomyelia? Original thoracic mri report was based on “all sagittal and axial images” in which months later,I discovered axial images of levels in question were not actually there or evaluated. Some level of distrust. The thin linear white line in the cervical cord is obvious and not reported or explained. ‘Retrolisthesis’, disc protrusion and bone material effacing thecal sac is no big deal if it doesn’t cause signal change? What if I see faint signal change at that level and I see the thin wire long extend above and below that level? The “small” thoracic disc protrusion appears quite large in one sagittal image as if it could be pressing on the cord? So if mri report did not note slip or cord signal change, it is not spondylolisthesis? There is a segment of thoracic vertebrae that ‘sinks into’ chest cavity causing rib to stick out in chest all of which provokes the thoracic spine pain simultaneous with chest pain where rib/ sternum meet. Sometimes I have to lean chest into corner of solid surface and push posterior and to the left to gain relief and adjustment. Traction of cervical and thoracic zone against wall also provides adjustment and/or relief. Sitting provokes symptoms. Using arms provokes. Full bladder provokes. Full intestines provokes. Heat can provoke. Ice relieves. Certain posture relieves. Blah blah blah. Etc etc etc. Obviously so confused and At a loss. Thanks for your patience.

[CNB]

#27131

….lifting, bending at waist, reaching, sitting, laying supine, tilting head back, leaning body back, putting shoulders back all provokes. Pelvic tilt knees bent with shoulders pulled down slightly hunched forward with slight chin to chest and pressure on sternum pushing rib cage back and left relieves…..

[Author]

Posts