Listserve: Doctor 2 doctor

Case Question: Thoracic Numbness

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A 53-year-old male patient with mid-thoracic pain is complaining of a numb sensation by the right shoulder blade (T5-6). No history of specific trauma, but the man’s work is physically demanding. Has a history of sinus infections and severe acid reflux (non-responsive to medications).

Ortho were negative. Grade-4 muscle weakness was noted in the patient’s rhomboids/middle trap. Static palpation revealed spinous tenderness at T5 and T6 with muscle spasm on the right rhomboid/middle trap. Percussion was mildly tender at the SP and mildly more tender at the T5-6 angle of ribs.

We took AP/LAT thoracic series. Disc spaces and bone mineralization appeared normal. No fractures noted. George’s line had an anterior 5 mm break at T2 with some encroachment of the T2-3 foramen. There was an increased thoracic kyphosis with notable head forward and increased lumbar lordosis. From the AP, there were about 15-degree curvatures on the left in lower thoracic and on the right on the cervical-thoracic junction.

We initially treated the patient for four weeks with spinal manipulations and middle trap and rhomboid strengthening exercises. The pain and muscle weakness resolved and the patient was released with instructions for home exercise. The patient was compliant, but the pain returned three weeks later. He does not recall a specific trauma to the area, but described moving his washer and dryer to make repairs, and having a tree limb hit his thighs on different occasions since being released.

He waited an additional three weeks before returning to my office, stating the pain (2/10 on visual analog score (VAS)) had subsided but was replaced with numbness (2-3/10 on VAS).

Not sure where to go from here. My thoughts are MRI (but the disc space appears normal, so is it warranted for possible foraminal encroachment), Nerve Conduction Velocity (NCV) with Somatosensory Evoked Potentials (SSEP) to determine impingement, or thoracic obliques/or a rib series? The patient states reflux is aggravated by heavy protein meals, but denies fatty food exacerbating back pain (rule out referral from gall bladder).

What would you suggest?-JW

With the lack of marked clinical findings, I do not think further, more expensive imaging of the thoracic spine would be my next area of investigation. I would look into the cervical spine-especially at the C5-C6 level-for a major/easily identifiable subluxation with possible disc decay. I have found this level of the cervical spine to project/refer pain into the thoracic/shoulder blade area. Prior to the expense and trouble of ordering an MRI at this time, I would investigate the mid-lower cervical spine. Without major x-ray evidence of a massively altered spinal segmental subluxation with massive degenerative disc disease/decay, I would follow up on your idea of an MRI into the thoracic spinal area. You did not mention any lab work being reviewed. Is that under consideration?-TB

Did you evaluate the cervical spine to assess for a cervical disc? Stanley Hoppenfeld speaks about the C5-6 medial cervical disc Herniated Nucleus Pulposus (HNP) causing scapulothoracic pain and/or paresthesia. I think that sometimes we have to create added stresses to make some things show up-rather like doing Linder’s cervical flexion with a straight leg raise test (SLR) to make a lumbar disc show up.-RB

I have seen similar symptoms in patients who were eventually diagnosed as having ulcers. Has he had a recent gastrointestinal checkup?-RG

That would make sense, considering his gastroesophageal reflux disease (GRD). Also, I had a patient with fairly normal Ts rads, who turned out to be a T-HNP. One surgery later and the patient did not want to return. His VAS dropped to I or 2/10 at worst, and only when he was tired. He did well with that fusion.-DP

Go with the neuro tests first.-AJ

I would like to thank everyone for your thoughts. Some DDX for the thoracic numbness were

Poster/or Heart Artery Occlusion:

I saw the patient again this morning and he does have some shortness of breath that he was told was pre-asthma (due to a chronic viral infection). Within the past year, he’s had a heart check-up with a cardiologist and was told he was in great shape. Not able to totally rule this one out.

Ulcer Referral:

He had an esophageal herniation and has acid reflux. He went to see an internist during our prior trial of chiropractic care, and was given Nexium. The internist performed lab work, so we did not. The patient still notices heavy protein meals reproduce a similar, but less intense, pain.

HNP Thoracic/Cervical:

I agree that more testing is expensive and may not be warranted as he consistently reports 0-2/10 on the VAS. Re-exam did not reveal atrophy (extremity pinwheel was normal, but I did not test the trunk), and C-compression and distraction were negative. Since T-HNP is so rare, and the last cervical trauma the patient can remember was over 18 years ago, I am not sure if it is appropriate. I will order cervical x-rays to test for possible disc decay at C5-C6 level.

Biomechanical:

Slouching or hunching does not reproduce the pain, but side bending sometimes can. He notices the pain the most when driving for more than 1-2 hours at a time in a bucket seat. The pain is better with activity and worse with a hard day. This seems most indicative of chronic overuse/strain.

A concern of mine is the patient’s complaint of joint soreness for several hours up to a day every time I adjusted (12 times). Usually, that soreness only lasts about four to five treatments for the rare (5-10 percent) patient in my office. He stated three weeks after release that he noticed things became painful, tingly, then numb in the mid back. Why would that persist?-JW

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