3/3/2017. Acute spine disorder (< 4weeks duration) Subacute spine disorder (4-12 weeks duration) Chronic spine disorder (>12 weeks duration)

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1 William Hsu BSc DC DACBR March 4, 2017 Acute spine disorder (< 4weeks duration) Subacute spine disorder (4-12 weeks duration) Chronic spine disorder (>12 weeks duration) Neurologic symptoms and signs pain radiating below the knee or beyond the elbow, as intense as the low back or neck pain, often radiating into the foot or hand with numbness or paresthesia in a dermatomal distribution with positive nerve root tension signs, abnormal motor power, sensation or deep tendon reflexes (MSR) 1

2 T - Trauma R Range of motion A Alcohol/smoking U Unresponsive to care/unusual natural history/symptoms M Motor/sensory/reflexes A - Age 16 year old avid female snowboarder collided with and flipped over another snowboarder and landed hard on her buttocks on March 15/05. Pain in the lower thoracic spine. Presented to our clinic on March 23/05. 2

3 Acute mild compression fractures from T10 to T12. Referral to emergency room. Plain films of the thoracic spine were taken on March 24/05. 3

4 Patient was told the plain films are inconclusive. Patient is scheduled for CT on March 30/05. 4

5 T8 T8-9 disc T9-10 disc T11-12 disc T10-11 disc The patient was told that there is no compression fracture. CD containing CT images of the thoracic spine was submitted for second reading. Lets have a closer look at the CT images. 5

6 T8 T8-9 disc T9-10 disc T11-12 disc T10-11 disc Sclerosis of the trabeculae is present at the superior portion of the vertebral bodies, beneath the superior endplates from T9 to T12 Acute endplate impaction fractures from T9 to T10. 6

7 Because of the natural thoracic kyphosis, fracture that do occur at these levels are usually caused by flexion forces and often not associated with any neurological deficit. As at other levels, these wedge fractures appear on CT as alterations in the density and trabecular pattern of the spongiosa Can be quite subtle on axial projections; however, sagittally reconstructed views, the loss in height of the vertebral bodies is much more apparent. 74 year-old man with left interscapular pain after tripping while going upstairs two weeks ago Recent blood test shows excessive protein being investigated Ordered rib series to check for rib fracture Courtesy of Intern Doucet Nov. 25,

8 A well-defined lucent lesion at the medial humeral neck with endosteal thinning A missing pedicle at left T3 No rib fracture Additional thoracic and left shoulder views for closer look 8

9 Looks like there is a pedicle at left T3, but can not explain why the missing pedicle on oblique rib view asked for an AP spot view of the upper thoracic spine T2 looks squished on AP view 9

10 The missing left T3 pedicle is still seen on one of the left shoulder views Lucent lesion in the medial humeral neck is still visible 10

11 The AP spot view confirms the missing left T3 pedicle as well as the deformed T2 vertebral body Lytic metastasis or multiple myeloma 11

12 Called family GP to inform the x-ray findings GP responded that the further lab test shows abnormal electrophoresis for M protein and confirming the diagnosis of multiple myeloma 75 year-old male with mild thoracic pain Recent contracted C. Difficile and is currently undergoing weekly kidney dialysis secondary to the damage caused by the infection Courtesy of Dr. Nadine Ellul July 12,

13 Suggestion of endplate destruction is detected at T9 anteroinferior corner. The AP view shows the absence of right lateral half of T9 inferior endplate where the ossified anterior longitudinal ligament is also seen. Blunting of the right posterior costophrenic sulcus is visualized. Radiographic suggestion of endplate destruction at the right lateral half of T9 inferior endplate. In light of the recent C. Difficile infection, the findings are suggestive of early stage of spondylodiscitis. Confirmation with a CT scan is recommended 13

14 Thoracic x-ray were taken 2 days later which showed no endplate destruction; however, persistent pleural effusion with blunting of the right posterior costophrenic sulcus is seen. 72 year old woman with 6 weeks of progressively worsening thoracic pain Seen at Emergency room 3 weeks ago Physical exam and x-ray thoracic spine Was told to have degenerative disc disease Given medication and to check back in 6 weeks Worsening thoracic pain prompted the patient to seek alternative care 14

15 Diffuse pain in the thoracic spine A mild kyphosis in the mid thoracic spine Unremarkable neurological exam Intern wish to treat the patient, but the clinician decided to x-ray the patient despite the fact the patient was x-rayed 3 weeks ago 15

16 Severe destruction of inferior ½ of T6 and superior ½ of T7 vertebral bodies with nonexisting intervening disc A focal kyphoscoliosis Questionable left paraspinal soft tissue swelling DDx: Aggressive neoplasms or infection Ask the intern to obtain previous films from the Emergency room at the hospital Review that afternoon Minimal disc narrowing at T6-7 with a very faint endplate erosion With rapid destruction of adjacent vertebrae and disc, infection was considered the diagnosis Tuberculous spondylodiscitis 16

17 31 year-old female with thoracic pain after a T- bone accident 1 year ago (Dec. 2014). Chiropractor questions if the deformity of T8 vertebral body on MRI study on August 26, 2015 is associated with the car accident. Chest x-ray images 7 years ago are available for comparison. Courtesy of Dr. O Neill December 14, 2015 Sag T1 Sag T2 Sag STIR August 26, 2015 (one year after MVA) 17

18 18

19 Mild anterior wedged deformity of T8 is visualized with Schmorl s nodes at superior and inferior endplates. Smaller Schmorl s nodes are also detected at the inferior endplates of T9 and T10. There is no marrow edema associated with these Schmorl s nodes. A focal posterolateral disc protrusion is seen at left T11-12 with slight extension into the entrance of left T11-12 intervertebral foramen; however, no neural compression is seen. Old Schmorl s nodes at T8, 9 and 10 with wedged deformity of T8. A left posterolateral disc protrusion at T11-12 with no neural compression. Clinical significance of this finding is unknown. Clinical correlation is recommended. 6 years prior to the MVA 19

20 6 years prior to the MVA 6 years prior to the MVA August 26, 2015 (one year after MVA) Same deformities of T8, T9 and T10 with same location and magnitude of deformities on chest x- ray obtained 6 years prior to the MVA. Not related to the MVA in December

21 53 year-old male with chronic stiffness in mid thoracic spine. Chiropractor suspects DISH Courtesy of Dr. Rebecca Scott August 21,

22 Anterior vertebral squaring or barrelling with bridging syndesmophytes 22

23 Suggestive of seronegative spondyloarthropathy. Recommended lumbar study to confirm. Fusion of both sacroiliac joints. Syndesmophytes with anterior vertebral squaring. Facet fusion. 23

24 Findings are consistent with longstanding seronegative spondyloarthropathy. 24 year-old motorcross athlete Vertical impact on dirt bike. Approximately 40 feet. Complaining pain in mid thoracic. No neuro. Courtesy of Dr. Mark Symchych 24

25 Moderate anterior wedged deformities of T7, T8 and 9 with no obvious step defect or a zone of condensed trabeculae. These are associated with irregular endplates, osteophytosis and disc narrowing and a prominent thoracic kyphosis These findings are consistent with Scheuermann s disease An abrupt angulation of the right lateral vertebral border is seen at T9. In addition, there is a focal bulge of the left paraspinal soft tissue stripe. Frontal and lateral alignment of the thoracic vertebral bodies is maintained. The pedicles are intact on the frontal view. There is mild anterior wedging of the T7 vertebral body, height loss approximately 10%. There is moderate anterior wedging of the T8 and T9 vertebral bodies, height loss approximately 30-40%. Slight bowing of the posterior vertebral cortex of T9 suggests this may represent an acute injury. There is mild compression of the superior endplate T10, height loss less than 10%. As there are no prior studies for comparison, a CT may assist in further evaluation and confirmation. 25

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28 Mild anterior wedge compression deformities of T8 and T9 are identified. Maximal loss of vertebral body height is estimated at 33% or less. I suspect that the compression injuries are remote in nature. No paravertebral soft tissue hematoma is identified, nor definite fracture line. Schmorl's nodes are identified from T6-T7 to T11-T12. Anterior marginal osteophyte is seen from T4-T5 to T9-T10. IMPRESSION: Remote, mild anterior wedge compression injury of the T8 and T9 vertebral bodies. There is no definite evidence for acute bony or facet injury. 28

29 An obvious step defect is seen at the right lateral vertebral body of T9 with a similar but more subtle cortical disruption on the left. Furthermore, a subtle zone of condensed trabeculae is seen beneath the T9 superior endplate Recent compression fracture of T9 with subtle cortical disruptions and a zone of condensed trabeculae in addition to the Scheuermann s disease involving T6 to T10 vertebral bodies. 28 year-old female with thoracic pain after a MVA. Chiropractor would like to know the age of the T6 compression fracture. Courtesy of Dr. Nejad February 26,

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31 A bony deformity of T6 is visualized with opposing V-shaped endplates, slightly larger pedicles, anterior wedged deformity and wider interpediculate distance with kyphosis. No paraspinal soft tissue swelling is seen. A congenital butterfly vertebra at T6 with associated kyphosis. 42 year-old male with 4.5 months of mid thoracic pain. Started after landing from jumping up to shoot a basketball. Intense pain initially; now constant mid T/S pain (5-6/10). Tightness in chest. Pain with deep inspiration, lifting small objects and landing off curb. Minimal and temporary relief with physio and acupuncture. Feels better with traction exercise. X-ray 1 month after onset was read as normal. Courtesy of Dr. Melanie Lopes 31

32 Onset of symptom is July 23, Who would go head a give a trial of spinal manipulation? Give your reason. 2. Who would reassess the patient? Give your reason. 3. Who would re-x-ray? Give your reason. 4. What else would you do? Why? X-ray 1 month after onset of symptoms 32

33 X-ray 1 month after onset of symptoms Mild anterior wedged deformity of T5 vertebral body with indistinct cortical borders of the pedicles and inferior endplate. Minimal paraspinal soft tissue swelling lateral to T5. Mild anterior wedged deformity of T5 with indistinct pedicles and inferior endplate with mild left paraspinal soft tissue swelling. The findings are very suggestive of aggressive bony lesion such as lytic metastasis or plasmacytoma. Further imaging investigation such as a CT scan is recommended. 33

34 Dec. 11/15 T5 T10 Dec. 11/15 T5 T10 34

35 Dec. 11/15 T5 T10 35

36 Dec. 11/15 36

37 Plain films August 30/15 Second interpretation Dec. 10/15 Chiro phoned family GP Dec. 10/15 CT Dec. 11/15 MRI + Surgery Dec. 12/15 Histology from T5 pedicle/body plasma cells Diagnosis multiple myeloma Chemotherapy January, 2016 Solitary, monoclonal plasma cell tumor of bone or soft tissue, with no evidence of multiple myeloma (MM) elsewhere Often represent early (stage 1) MM Present with focal bone pain Conversion Convert to MM after radiation tx ~ 50% Extramedullar plasmacytoma: 36% conversion Median time to conversion is 2-3 years Demographic Mean age 55 ( younger than MM) Higher incidence in men and African Americans Most common skeletal site Vertebral body Pathological fracture is common May confuse with hemangioma 37

38 ~50% of bony destruction must occur before there are radiographic abnormalities 75% of patients with MM with have positive radiographic findings The presence of 2 clearly defined lytic lesions indicates high tumor burden and Stage III disease PET/CT has been found to aid in detection of unsuspected sites of medullary and extramedullary disease Treatment Isolated plasmacytoma without systemic MM Radiation therapy 2/3 of solitary plasmacytoma of bone have complete response 1/3 has partial Indolent course: median survival ~ 10 yrs When to reassess/when to image Trauma - seizure Range of motion significant loss Alcohol/smoking Unresponsive to care/unusual natural history/symptoms M Motor/sensory/reflexes A - Age 38

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