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Evaluation and Management of Thoracic Spine Pain in the Primary Care Setting

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Evaluation and Management of Thoracic Spine Pain in the Primary Care Setting Published by: Boulder Neurosurgical & Spine Associates CONNECTIONS Justin Parker Neurological Institute IN SPINE & BRAIN TREATMENT Volume 2 www.bnasurg.com • www.jpni.org Edition 1 Winter 2015 Evaluation and Management of Thoracic Spine Pain in the Primary Care Setting Pathologic processes that can cause thoracic Neurological and clinical examination may be spine pain include degenerative disc disease, unremarkable or demonstrate lower extremity congenital connective tissue or skeletal disor- sensory and/or motor deficit. Myelopathy symp- ders, traumatic and spontaneous vertebral toms are noted for patients with herniations fractures, vascular malformations, infections, above the conus medullaris or sphincter and as- spinal or meningeal tumors and metastases. sociated bowel or bladder dysfunction for the This article will briefly discuss the epidemiology, lesions compressing the cauda equina can also red flags, clinical symptoms, diagnostic studies be seen. Radicular pain is a common initial T11 compression fracture T5-T6 tumor and management of thoracic spine conditions symptom in lateral disc herniations and may re- exclude fracture, infection or tumors. Although that every primary care provider should know in solve spontaneously in the absence of objective not a diagnostic finding, disc calcifications are order to diagnose this condition and refer the neurological findings. Central disc herniations found in about 70% of patients with thoracic patient appropriately. can cause symptomatic cord compression (such disc herniations. Further MR imaging should be as myelopathy) with associated paresthesias performed for these patients to determine the Epidemiology below the level of the lesion and warrant an MRI Thoracic spine pain is less prevalent than neck amount of neural compression and confirm the and immediate referral for neurosurgical location and size of the disc herniation. Imaging or low back pain, but is quite common in the pri- evaluation. mary care setting and can be equally disabling. studies play a significant role in the evaluation Prevalence ranged from 4.0 – 72.0% (one time Thoracic spinal stenosis symptoms are similar to of a painful thoracic spine, but interpretation occurrence), 0.5 – 51.4% (a period of 7 days), 1.4 lumbar stenosis and consist of neurogenic clau- requires close consideration of clinical history in – 34.8% (a period of 1 month), 4.8 – 7.0% dication, reduced walking tolerance, myelopathy conjunction with physical examination to make (a period of 3 months), 3.5 – 34.8% (a period of symptoms, back pain and radicular pain radiat- the diagnosis. ing to the thoracic, abdominal or groin area. 1 year) and 15.6 – 19.5% (over the course of Management Strategies a patient’s lifetime) according to a systematic Structural deformities The vast majority of nonspecific thoracic pain review performed by Briggs et al. (BMC, 2009). Kyphosis can occur at any age but, due to osteo- cases resolve without treatment within a few Degenerative Conditions porosis, compression fractures and disc degen- weeks. Surgical treatment depends on the under- Contrary to lumbar or cervical degenerative disc eration, it is most often encountered in an older lying pathology but, regardless of this, decom- diseases, thoracic disc degeneration and herni- patient population. In turn, scoliotic deformity pression, fusion and deformity correction proce- ations are less common, but they do occur and may be present at birth (congenital), in less dures performed on the thoracic spine are techni- are most often in the mid- to lower- thoracic re- than 3-year-old children (infantile), in the 3 to cally demanding due to a high risk of damage to gion. They can occur at any age, but young and 10 year age group (juvenile), in 10- to 17-year- the spinal cord. Early surgery is recommended for middle-aged adults are predominantly affected. old patients (adolescent) and adult degenera- the patients who develop myelopathic symptoms Patients complain of severe pain in the sternum, tive scoliosis. Besides cosmetic problems, leg to avoid permanent neurologic dysfunction or epigastrium or abdominal area or band-like pain weakness or gait difficulty, disabling pain and even paraplegia and to increase the chances of that radiates in an intercostal nerve distribution. sciatica symptoms are the most common com- a successful recovery. The majority of patients Due to this pain distribution, gastritis, gastric ul- plaints for which patients seek medical care. with radicular symptoms will respond to conser- cers, gallbladder disease, or renal calculi are of- vative management, which includes physical Imaging Studies ten suspected. therapy, intercostal nerve blocks, anti-inflamma- The primary role of plain radiographs when eval- tory or pain medications. Newer thoracoscopic- uating patients with thoracic spinal pain is to assisted minimally invasive methods are safe and effective treatment methods in appropriately The type of pain could also help to recognize the Alan T. Villavicencio, MD selected surgical candidates. need for a more extensive clinical evaluation. If Board-Certified: American Board of Neurological Surgery MD: Harvard Medical School, Boston MA pain is severe, constant and non-mechanical Residency: Neurosurgery, Duke University Medical Red Flags and Spine Emergencies without relief from bed rest or postural modifica- Center, Durham, NC Thoracic spine pain often has a musculoskeletal Fellowship: Orthopedic Spine Surgery, Institute for tions, which progresses despite treatment for Spinal Disorders at Cedars-Sinai, University of origin related to poor posture or overuse injuries. 2 to 4 weeks, a thorough clinical evaluation, California at Los Angeles, CA Generally these conditions are self-limiting, but diagnostic imaging studies and referral to a E. Lee Nelson, MD a small number of patients present with tho- Board-Certified: American Board of Neurological Surgery specialist are necessary. MD: Baylor College of Medicine & Texas Medical racic spine pain as the initial manifestation of Center, Houston, TX Ankylosing spondylitis should be suspected more serious pathological conditions and differ- Residency: Neurosurgery (Chief Resident), Baylor in patients between the ages of 17 and 40 who College of Medicine & Texas Medical Center, Houston, TX ential diagnosis should be performed to exclude complain of persistent thoracic spine pain Alexander Mason, MD other pain sources and, most importantly, emer- accompanied by severe morning stiffness, which Board-Certified: American Board of Neurological Surgery gent situations. MD: Ohio State University College of Medicine & improves with activity. The other joints like Public Health, Columbus, OH The most common causes of acute thoracic pain shoulder, elbow, hip or ankle may also be Residence: Neurosurgery, Cleveland Clinic Foundation, in younger adults are trauma and motor vehicle Cleveland, OH affected. Although ankylosing spondylitis Fellowship: Cerebrovascular & Skull Base Surgery, accidents. Clinical history, physical examination progresses slowly, an early diagnosis is chal- Emory University, Atlanta, GA and imaging studies are usually sufficient to lenging and there is an average of 8 – 11 years Sharad Rajpal, MD differentiate the source of such pain. However, Board-Certified: American Board of Neurological Surgery delay reported in the literature between the on- MD: University of Wisconsin, Madison, WI thoracic spine fractures could occur with even set of symptoms and time of diagnosis. Early Residency: Neurosurgery, University of Wisconsin, minor trauma such as strenuous lifting in peo- diagnosis and appropriate physical and medical Madison, WI Fellowship: Neurosurgery and Orthopedic Spine ple over the age of 50, especially if they have a therapies can lead to a complete symptomatic Surgery, Center for Spine Health, Cleveland Clinic, history of osteoporosis or are taking corticoste- remission in a significant number of patients. Cleveland, OH roids. Compression fractures are most often di- The longer the diagnosis is delayed, the worse Kara Beasley, DO, MBe agnosed at the lower part of the thoracic spine DO and Masters of Arts, Biomedical Ethics, the functional outcomes are and may eventually Midwestern University, Glendale, AZ and, due to vertebral body collapse, may result result in a spine fusion, increased risk of frac- Residency: General Neurosurgery, Phildelphia College in segmental instability, accelerated degenera- of Osteopathic Medicine, Philadelphia, PA tures, and progressive spine deformity. Fellowships: Stereotactic Radiosurgery, Cooper tion or kyphosis if left untreated. Some patients University Hospital, Camden, NJ and Functional Interscapular pain can also be referred from without neurological deficits could be managed and Restorative Neurosurgery, Cleveland Clinic, disc herniation or spinal dysfunction affecting Cleveland, OH conservatively, but patients with neurological the lower cervical spine. It should be high on the David Shafer, MD impairment will require surgery. MD: Drexel University College of Medicine, list of differential diagnoses as ordering Philadelphia, PA “Red flags” that may suggest cancer include a thoracic x-rays in such cases will provide little Residency: Neurosurgery (Chief Resident), University of past history of malignancy, pain at night, and diagnostic information and may further delay Colorado Department of Neurosurgery, Aurora, CO unexplained weight loss, especially in patients treatment. A thorough history, clinical and older than 50 years. About 30%
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