by the Academic Board of the American Academy of Spine Physicians
A 62-year-old male had a two-month history of pain in the midthoracic region, with radiation around to the right anterior chest. His family doctor obtained a chest X-ray, which was unremarkable. The patient went to his chiropractor; he had several episodes of non-radiating neck pain treated successfully by his chiropractor over the past two years. Thoracic spine X-rays taken by the chiropractic physician showed some spondylotic changes, no bony erosion and normal-appearing neural foramina.
Chiropractic manipulative therapy, massage, ultrasound and electrical stimulation did not help. The patient stopped seeing the chiropractic physician and found an acupuncturist. Acupuncture therapy did not help. His family doctor ordered rib X-rays; no rib fractures were noted. The patient saw an ad in the local newspaper about biofeedback therapy, which did not help, either. Eventually, the patient returned to the chiropractic physician, who ordered an MRI of the thoracic spine. Herniation of the T7-8 disc was noted. The herniation was central and to the right, extending into the region of the foramen with compromise of the nerve root at that level. The chiropractor referred the patient to one of the two neurosurgeons with whom he collaborated.
On examination, the neurosurgeon discovered the patient had developed patchy areas of numbness in the distribution of the thoracic nerve root. He reviewed the MRI and recommended an operative procedure. The neurosurgeon performed a laminectomy and drilled down the lateral bone on the right. The nerve root was visualized and decompressed. Intraoperative ultrasound was then used by the neurosurgeon; it showed compression of the spinal cord greater than that suggested on the MRI. In his operative report, the neurosurgeon stated that the spinal cord was "rocking over the herniated disc material."
Postoperatively, the patient no longer had the radiating pain. The patient asked why his condition took so long to diagnose. The neurosurgeon told him it was a difficult diagnosis to make; many other conditions could cause the same symptoms, and less than one percent of disc hernia-tions occurred in the thoracic region. The neurosurgeon told him to see the chiropractor for a follow-up and to thank him for making the difficult diagnosis, especially since the patient had significant spinal cord compression not appreciated as such on the compression not appreciated as such on the MRI. The patient did.
The Point
When faced with intractable symptoms, continue the evaluation. Sometimes, what is seen in the spinal canal on MRI is not as bad as what actually exists in the patient.
The American Academy of Spine Physicians
Elgin, Illinois
Tel: (847) 697-4660
www.spinephysicians.org
aasp@spinephysicians.org
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