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Forum Name: Neurology Topics

Question: Acute rt. thoracic pain-getting severe and causing headaches


 Diane Dale - Tue Jan 06, 2009 8:33 pm

Patient history of 15 year pain at spine and between spine and scapula which worsens to cause headaches occipital/temporal, frontal-all on right. . Patient had a severe flip/roll auto accident 22 years ago. Subsequent vomiting migraines and pain bilat through upper back which altered into the previous 15 years symptoms. Symptoms have worsened over the last 8 months to severe level. She is now 38, white, 135 lbs., 61 inches tall. No other known health issues. Palpation or massage into the T5-8 spinal area intensifies the problem. Recent x-ray shows right apex T9 and mild DJD. Recent MRI shows (5) 1mm herniations T3-8. No cord inpingement or stenosis noted. No neuro workup as yet. She had several rounds of steroids and lidocaine with "some" benefit, then botox with good result for 4 months. Doc who did Botox said she has Dystonia, but doesn't really fit description. Another Doc wants to do facet injections, but then stated it won't fix---would then do Rhizotomy, but also stated won't fix . She's my wife and getting desperate. Getting depressed and inactive. Have 2 children 5 and 8. Currently takes Excedrin like candy, but don't really help. She also did some P.T. after Botox, but didn't seem to help, although Botox did. We don't really know what's wrong with her, so not sure who to turn to next. Any help would be greatly appreciated. Thanks.
 John Kenyon, CNA - Mon Feb 16, 2009 10:17 pm

User avatar Hello -

The clinical picture presented is undoubtedly related to something in the area T3 - T8, but it is extremely puzzling because the nerves outlet through most of the thoracic spine innervate the viscera and not the associated musculature. This makes the notion of dystonia seem more correct than it appears on its face -- dystonia normally would not present this way. It would seem there might be some injury upstream of the suspect part of the spine which innervates the musculature of the back, shoulder and neck instead. I am wondering if, during the course of all this, there has been any MRI study of the cervical spine performed, especially in the area of C7 - T1; also has there been an MRI study of the brachial plexus? The relative botox success suggests an unusual form of dystonia or perhaps retrograde thoracic outlet symptoms (normally this would cause pain and/or neurological deficits in the chest or right arm and hand). It almost seems as though something higher up is causing bi-directional distress and the sort of local pain described, as well as associated tension headache. While this would be a fairly atypical presentation, that's why they coined the word "atypical": to describe the exceptions which prove various rules.

For this reason, I strongly recommend neurological evaluation including electromyelogram (EMG) and nerve conduction studies of the upper right extremity as well as the neck including scalene muscles, and MRI study of the C-spine, especially C3 - T-1. The multiple thoracic herniations of 1mm each are unlikely to be causing any sort of marked distress. I think the focus of studies up til now may have been mislead by the locus of the pain. At any rate a neurological workup is long overdue for the patient. This could well shift attention away from the thoracic spine and toward the C-spine (and perhaps even thoracic outlet) with an eye toward resolving pain in the musculature supporting (but not innervated by) the T-spine. This may well be why Botox seems to have been the most effective therapy so far, although it has been symptomatic only.

Pain management via neurologist would also likely be far more effective; NSAIDs are unlikely to be all that effective if the problem is located in the C-spine and/or thoracic outlet. Opioids, muscle relaxants and nerve pain blockers would seem more appropriate for the short-term.

I hope your wife will be seen by a neurologist -- perhaps one specializing in pain management -- soon. I believe the entire course of her distress may have been misleading due to the location of the pain. Lack of neurological workup only prolongs the discomfort. Patients with C-spine and TOS misalignments often suffer pain and tenderness in the areas described and do sometimes become depressed and despondent because of failure of medical staff to locate and adequately identify and treat the actual problem.

I hope this is helpful to you. Please follow up with us as needed and keep us updated as well. Good luck to you both.

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