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  • Casper
    Participant
    Post count: 10

    Hello!I have allready wrote you last month about my thoracic spine issue. I will repeat shortly.I am 29 year old medical doctor from Croatia, sports medicine and reumatolog. I had injured my t spine a year ago at a ballet class, it was like a whiplash injury. My MRI showed bone marrow edema at t11 and t12 costovertebral joints (it was also in my T10 cv joint but the report didn’t say that) only right side and my pain is only right side just at that level and I have radiculopathy symptoms, my pain wraps around my ribs I have paresthesia, shooting pain. My CT scan showed subluxation of 11th rib on the right. I have done prp treatment of that joints (11 and 12) and was better for 3 months. My new MRI clearly showed a foraminal cyst which compresses the spinal nerve T11 on the right, but the problem is that is hyperintense on both T1 and T2 which is not usual, it is really hyperintense on T1 and is hypointense on STIR, radiologist said it is only fat, but my neurosurgeon is not sure, and even if it is fat it is still compressing the nerve. I have done a lot of research by myself and think it is maybe hemorrhagic or proteinaceous cyst (because this tissue has a short T1 relaxation time so is also suppresed on STIR), and also fat is not so hyperintense on T2. What do you think, is there any other way to confirm, maybe MRI with contrast? Also my new CT showed 10th rib subluxation with rib head necrosis near joint, and is kind of rotated.Also I am sure that my 10th and 11th ribs are rubbing each other when walking and laying down. Due to all this findings I went to foraminal diagnostic block and facet t11 which helpped for a few hours as the anesthetic wore of. Also one spot above was still painfull, probbably T10 cv joint so my neurosurgeon want to test it but these blocks nade my symptoms worse so I am affraid. After that blocks I have severe pain when moving my right arm, it was two weeks ago. Did he hit the cyst maybe. What do you think I should do? Especcialy I am confused about that MRI cyst and atypical signals. Other than that I don’t have any degenerative changes on my spine, my discs are great signal, other joints also, normal thoracic curvature, no Kyphosis. I am really tired of this, have pain every day all the time and even night pain. Thank you.

    Donald Corenman, MD, DC
    Moderator
    Post count: 8660

    Your symptoms seem to be from both bone degeneration which will cause local pain and radiculopathy from compression of the T11 nerve which will cause pain to radiate down the dermatome (along the diaphragm to the umbilicus). The cyst in the canal Which sounds to be in the foramen which could of course compress the T11 nerve.

    However, hyper intense on both T1 and T2 with a loss of signal on STIR is typically fat.

    Your arm should not be affected from a T11 block. Your relief from the block for 2-3 hours is diagnostic.

    The T11 rib is a floating rib so I cannot understand why you would have costovertebral joint damage unless you had a direct blow to the T11 rib jamming it into the vertebral body.

    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.
    Casper
    Participant
    Post count: 10

    Thank you for your answer. Yes it is clearly in the foramen and it is a round cystic formation, and really is visible that the spinal nerve t11 right is stuck in that foramen, and I have pain in the t11 dermatome with paresthesia and tingling, also allodynia, radiologist said just fat, nothing, ok, but why fat only in one foramen of all only dat side at that level that I have pain, my neurosurgeon thinks it can be fat from that facet joint (fat pads), but also thinks it maybe synovial cyst, for me is more likely the synovial because it is really round like all the facet cysts and think it could be hemmorhagic, thus hemosiderin not visible on STIR (also because when it was accute in my first MRI they just did T1 and T2), also my age, I am young, other facet joints are not degenerated and I had acute start of symptoms which this hemorrhagic cyst tend to. I don’t have pain in my arm, it is my arm movement above head like washing hair that triggers the pain paravertebral T10-t11, and this happens when I am in severe spasm, so it also puts tension on that area. I am thinking this because of facet joint pain due to secondary osteoarthritis and that cyst, am I right, is the facet joint itself making this spasms? So this facet diagnostic block applied more pressure on it? (I am aware this was only diagnostic that is why I ask is it normal to make symptoms worse?).The edema in cv joint t11 is what I think only extension od edema from facet joint, don’t think it is fracture anymore or it could also be due to secondary OA edema(overuse in ballet). But I don’t know about my CT scan which showed 10th rib subluxation on the right (it is visible on 3d reconstruction with osteopenia of rib head, like a hole in rib head and 10th pedicle, probbably from rubbing), I know it is rear, a lot doctors don’t believe it can happens, but 10 th rib can slipp in slipping rib syndrome, but mine looks a lot rotated and atacched to both 10th and 9th vertebra, not on the left only that right. Could you think it can happen or it can be maybe minor subluxation which appers to be more on CT because of that severe muscle spasm above this facet joint? Because if it is because of spasm, doing some medial branch block and removing the cyst endoscopic could help that level about? He suggested blocking also this 10th cv joint (terapheutic with steroid), but I am affraid of doing more damage because on osteopenia, making the bone damage worse, or maybe doing it but thinking of taking some biphosponates like Alendronat because od it’s affect on bone lesions, regional osteopenia and bone pain not only for osteoporosis. Do you have any experience With this drugs and bone pain? I am dessperate, so I am willing to try anything, also it my help a little with facet pain because it is also used for osteoarthritis pain, reducing bone marrow edema, at least it could not make more damage. Thank you and sorry for such a long report, just want the pain to stop.

    Donald Corenman, MD, DC
    Moderator
    Post count: 8660

    This round structure would not be a synovial cyst as these cysts are full of fluid (water) which would be bright on T2, dark on T1 and bright on STIR images. Hemoglobin breakdown products change in their specific image intensity from bright to dull depending upon what stage the breakdown product is (hemosiderin, bilirubin, biliverdin).

    Facet injections, if performed in the facet joint (and not medial branch blocks), can cause a volume phenomenon and temporary increased pain.

    Your statement of “osteopenia of rib head, like a hole in rib head and 10th pedicle, probbably from rubbing” would be unusual for a t10 rib. Holes in a joint bone surface are somewhat common with a very degenerative bone-on-bone joints such a a highly degenerative facet or disc space but I cannot remember ever seeing them in a costovertebral joint, especially in a floating rib. The pedicle of the thoracic vertebra do not articulate with the rib, so why this pedicle should be osteopenic does not make sense to me. I assume the MRI note no tumor in this area.

    Your treating physicians suggestion “He suggested blocking also this 10th cv joint (terapheutic with steroid)” looks like sound suggestion. It is very unlikely that a local injection will cause significant local osteoporosis and a diagnostic injection will prove this area is the pain generator. For patients with severe osteoporosis that need surgery, I put them on Forteo for 6 weeks.

    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.
    Casper
    Participant
    Post count: 10

    Thank you for your reply. I don’t know about that rib head lesion, nobody knows, on MRI there are no signs of malignancy, like no bone marrow edema, it is sharp borders, and I don’t have symptoms like that, the symptoms started suddenly on ballet class and never had any pain or disconfort prior to that. I know that synovial cyst are dark on T1, but when I was trying to find which cysts are both hyperintense on T1 and T2, everything I found were this hemorrhagic facet cysts of sudden onset or filled with proteinaceous tissue. Or you think it could be fat pads out od that facet joint? That small lesion on the pedicle 10 is only right side, could this be osteoid osteoma? My neurosurgeon can’t exclude that, it looks really benign. What other small lesion could it be on pedicle? Is there any way to confirm this, like bone scintigraphy or something? Also what do you think about increasing muscle pain when moving arm above head, I have a felling that it puts more tension on the joints, I have muscle guarding contracture level 10 and 11 so I am thinking probsbly that facet joint?

    Donald Corenman, MD, DC
    Moderator
    Post count: 8660

    Osteoid osteoma is possible. Symptoms include pain, not made worse with activity. The pain is commonly relieved by NSAIDs. Pain is commonly worse at night and can wake you up from sleep. Typically, bone scans will show a hot spot over the pedicle but this should be mimicked by the MRI. The CT scan will show a thickened nidus in the pedicle.

    The lat dorsi connects from the humerus to the lower spine so arm elevation can put stress on this region.

    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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