Transcript Thoracic Back Pain in an Intercollegiate Female Rower

Mike Lawler M.A., ATC, LAT
Senior Associate Athletic Trainer
The University of Iowa
 Introduction
 Case presentation
 Discussion
 Conclusions
 Rowing at Iowa
 Beginning 16th year as an intercollegiate sport
 60-70 rowers on team
 Varsity and Novice
 Practice for 2½ hours on water and 1 hour with strength
& conditioning coach
Case Presentation
 20 YO female rower for the University of Iowa. No previous
experience as a rower prior to enrolling at Iowa in 2005.
 Onset: April 12, 2007 during spring season - 3 weeks left in
her season
 CC:
 Swelling and pain at left anterior rib cage
 Painful left upper back;
 Pain while rowing in practice
 Numbness at left mid back below scapula
 Occasional dyspnea
 Previous hx: None; gradual onset with no acute episode
 Continued to participate in practices until symptoms
worsened and performance became affected
 Symptoms initially only with rowing but now during ADL’s
 Examined by certified athletic trainer in athletic training
room
 Assessment: Possible costochondritis; posterior rib stress
reaction; paraspinal strain
 treated with therapeutic modalities
 Cold/ice bag
 allowed to continue rowing, as tollerated
 After one week her symptoms failed to improve
 She was referred to UISMC and orthopaedic physician on
April 18, 2007
Musculoskeletal Injuries 1994 - 2006
Low Back
Knee
Chest/Rib
Upper Back
Ankle
Wrist
Shoulder
Patella
Hip
Foot
Tibia
Neck
Elbow
Forearm
Fibula/Calf
Finger
Other
TOTAL
104
49
40
26
25
23
17
17
16
16
13
8
7
6
3
2
3
375
27.7%
13.1%
10.7%
6.9%
6.7%
6.1%
4.5%
4.5%
4.3%
4.3%
3.5%
2.1%
1.9%
1.6%
0.8%
0.5%
0.8%
100%
Physical Examination by
Orthopaedic Team Physician – 4/18/07
Examination findings:
 Slight prominence of the costochondral joint from anterior
left side of chest
 Palpable tenderness in left paraspinal muscles
 Numbness noted in the left thoracic paraspinal area
 Posterior thoracic pain is aggravated with motion in all
directions
 Upper extremity function was normal
 Neurologic exam: normal
 Radiograph studies:
X-rays
 L-Spine Standing AP & Standing Lateral
Flexion/Extension views
 Findings/Impression:
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There is no evidence of a fracture or dislocation. The osseous
structures are in gross anatomic alignment. There is no soft
tissue abnormality
Negative exam
Impression
 Costochondritis left anterior rib cage
 Referred pain posteriorly
 Thoracic radiculopathy
Plan
 Provided prescription for naproxen – 500 mg BID
 MRI imaging was offered to rule out thoracic disk
herniation if sx.’s fail to improve or worsen
 Progress to be followed by staff athletic trainer
She was able to finish out spring season but not without
resolution of symptoms; treated symptomatically.
Status as of August 22, 2007 prior to
start of 2007-2008 season
 2-3 months of no rowing during summer
 Unproductive chiropractic treatments during summer
 Resolution of left anterior chest swelling
 Same amount of continuous pain, described as a “pinching”
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just below scapula on left side
When active, pain increased but was less severe than when
she would row
Patch of numbness was still present just below left scapula
Numbness had slightly migrated to right side of back and
up right side of her back to just above right scapula
She had not noticed any UE weakness
Return Visit to Orthopaedic
Team Physician – 8/22/07
Examination findings:
 Palpable tenderness about T10 just to left of thoracic
spine. No other tenderness
 Numbness noted inferior to left scapula
 No palpable tenderness of anterior chest wall
 Increase of pain with lateral bending and twisting. No
pain with flexion & extension
 Chest X-rays - normal
Plan
 MRI imaging was scheduled to rule out thoracic disc
herniation
 Reasoning?
 Persistent pain
 Patch of numbness
 Pain with movement
 To look deeper for a cause
Thoracic & Cervical MRI Findings
 A small syrinx within the midthoracic spinal cord from the
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T6 through portion of T8 levels, measuring 1.8 mm max.
diameter
Above and below syrinx, thin central high T2 signal
appeared most consistent with normal spinal CSF central
canal
No abnormal focus on enhancement
No underlying lesion was identified
Spinal cord signal was otherwise unremarkable
No central stenosis
Cervical & thoracic spine exhibited no degenerative
changes
Normal configuration of the intra cranial posterior fossa
structures, without evidence for Chiari malformation
Syrinx
 A syrinx is a fluid-filled cavity within the spinal cord
(syringomyelia) or brain stem (syringobulbia).
Taber’s Cyclopedic Medical Dictionary
 Symptoms include flaccid weakness of the hands and
arms and deficits in pain and temperature sensation in
a capelike distribution over the back and neck

Sx.’s not reported by this patient
 Syrinxes usually result from lesions that partially
obstruct CSF flow.
 At least ½ of syrinxes occur in patients with congenital
abnormalities of the craniocervical junction (eg,
herniation of cerebellar tissue into the spinal canal,
called Chiari malformation), brain (eg, encephalocele),
or spinal cord. For unknown reasons, these congenital
abnormalities often expand during the teen or young
adult years.
 A syrinx can also develop in patients who have a spinal
cord tumor, scarring due to previous spinal trauma, or
no known predisposing factors. About 30% of people
with a spinal cord tumor eventually develop a syrinx.

Source: Merck Manual online
Referral to Spine Team Physician - 8/27/07
 Exam Findings
 LE neurovascular exam – normal
 Tenderness to palpation over posterior rib at T8 level on
left
 Chest x-ray showed a possible lytic lesion on left 8th rib
posteriorly
 No indication of myelopathic findings – syrinx is not
likely cause of her symptoms
 Plan: Obtain CT scan of 7th – 9th posterior ribs
CT Scan of Ribs
 Axial CT scanning of the mid and lower thoracic spine
and medial aspect of of the ribs was performed
without intravenous contrast
 FINDINGS:
 No lytic or sclerotic lesions were identified in the medial
aspects of posterior ribs.
 No abnormal soft tissue masses were identified.
 There were no degenerative changes of the visualized
thoracic spine
 IMPRESSION: No abnormality in the medial aspects
of the mid and lower thoracic ribs.
Where do we stand at this point?
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Ongoing symptoms of back pain in middle aspect of
spine, left side
“Numbness” in her back on left side
Mid thoracic spine and left paraspinal tenderness
MRI showed syrinx that was determined to not be cause
of symptoms
CT scan showed no abnormal findings
Chest x-ray read as normal
Treatment with therapeutic modalities: heat, e-stim, ice
Prior pain in left anterior aspect of ribs has resolved
Still experiencing pain while rowing – participation is
limited
Plan
 Continue local therapeutic modalities
 Neurosurgery consult for possible facet or nerve root
injection
 Medrol dose pack for competitions
 Follow-up with team orthopaedic physician and/or
Spine Team orthopaedic physician prn
 Allowed to participate, as tollerated
Referral to UIHC Pain Clinic –
Neurosurgery Consult
 Received costovertebral/costotransverse injection on
11/02/07
 Allowed to return to rowing activity
 Patient reported that “the injection helped for a little
while but then wore off.”
Additional Referral and Treatment
 Medication changed from Naproxen to Piroxicam
 Second series of 2 injections at T9 and T11 on 11/28/07
 Prescribed Lidoderm patches by Pain Clinic physician
 Treatment with iontophoresis in athletic training
room
 Treatment with T.E.N.S.
Spring 2008 Rowing Season
 2008 Winter Training Trip
 Stationary bicycle – no erging, only drill work on water
 February – May 2008
 Continued to row until pain forced her to rest
 Repeated this pattern throughout spring 2008
 Reported previous injections had somewhat helped
because pain was not as intense
 Persistent symptoms of skin sensitivity and
“numbness”
 Attended follow-up care with UIHC Pain Clinic
 Allowed to finish out season, as tolerated
Fall 2008 Rowing Season
 Resumed practicing with recurrent symptoms of pain,
tenderness over posterior ribs, just to left of thoracic
spine, and mid-back and left side numbness
 Symptoms presented during rowing and strength
training activities, diminished with rest
 Continued to participate in most practices and
competed in all fall races
 End of fall season follow-up with Spine team
orthopaedic physician
Follow-up Examination with Spine Team
Orthopaedic Physician – 12/15/08
 Review of 8/22/07 MRI findings
 Benign other than incidental thoracic syrinx not felt to
be contributing to her symptoms
 Neurovascular exam was normal
Plan:
 Repeat thoracic spine MRI with contrast to evaluate
any progression of syrinx
 Renew prescription for Lidocaine patches
Repeat Thoracic Spine MRI with Contrast
 IMPRESSION:
 Stable mid thoracic small syrinx
 No lesion visualized
 PLAN:
 Refer back to team orthopaedic physician and Pain
Clinic for continuation of care
Spring 2009 Rowing Season
 Participated, as tollerated, in Winter Training Trip
 Continued to experience pain and numbness sx.’s
 Treatment with:
 Lidoderm patches
 T.E.N.S.
 Iontophosesis
 NSAID - Piroxicam
 Participated in spring practices and races
 “good days and bad days”
 Finished out rowing career on May 17, 2009
 Graduated from the University of Iowa
Discussion
 Hx. of chest/rib pain in rowers
 Discovery of benign syrinx by MRI
 Multidisciplinary team approach to care of
patient
 Multiple treatments used with varied results
 Even with best efforts, there was a failure to
achieve complete relief of symptoms
 Conclusive diagnosis?
Conclusions
MRI showed a midthoracic small spinal cord syrinx
that was concluded to not be cause of her symptoms
2. Persistent mid-thoracic back pain and numbness
3. “It’s not about what it is, but what it isn’t”
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No rib stress fracture
No herniated thoracic disc
No abnormal soft tissue masses
No degenerative changes of thoracic spine
Thank you