Chapter 2 Diagnostic Algorithms. 3 Thoracic Spine Pain Algorithm

Transcription

1 Chapter 2 Diagnostic Algorithms 3 Thoracic Spine Pain Algorithm

2 Date revised 2/4/03 Thoracic Spine Pain Algorithm THORACIC SPINE PAIN - ALGORITHM Thoracic spine radiographs for evaluation of spinal infection. Radiographs positive for infection? Immediate referral to orthopaedist. Thoracic spine radiographs for evidence of pathologic fracture, MM, or other lytic processes. If not found, however suspicious is high, order bone scan. For MM perform lab. Refer if found positive; if radiographs negative and suspicion is low, follow acute/ uncomplicated case algorithm If level of suspicion is high based on history, however films are equivocal, refer for bone scan or MRI. X-ray for compression fracture. If positive, management includes rest and NSAIDS; if negative, follow acute/uncomplicated case algorithm. (D) Thoracic spine radiographs for osteoid osteoma or indirect sign of osteoid osteoma (acuteangle scoliosis). (E) Radiographs positive for osteoid osteoma? Refer to orthopaedic surgeon. Evaluate with electrocardiogram and/or chest film. Refer if abnormal. If unremarkable, and/or if reproducible mechanically, trial treatment of SMT for acute mechanical pain. (F) Although negative for osteoid osteoma, suspicion is high due to history and acute angle scoliosis? Limited trial of treatment for 2 weeks with SMT. If unresponsive, referral to orthopaedist or bone scan to evaluate further. Follow acute/uncomplicated case algorithm Patient presents with a complaint of pain in the midback Patient has a fever with associated night pain and/or -gibbous diformity -history of intravenous drugs -diabetes? (A) Older patient with -weight loss -history of cancer -night pain -failure of conservative care? (B) Older patient with sudden onset of thoracic pain with a history of major trauma or either: -history of corticosteroid use, or -postmenopausal? (C) Patient is young with no fever and has sharp pain at night relieved by aspirin? Patient has associated chest pain? Thoracic Spine Pain Algorithm Page 2 Educational & Patient Care Protocols 1

3 Thoracic Spine Pain Algorithm Page 2 From Thoracic Spine Pain Algorithm Page 1 Traumatic onset of thoracic pain; pain with inspiration? Order radiographs. Include PA chest and oblique views of area. (G) X-ray positive for rib fracture or pneumothorax? If fracture is still likely due to degree of pain, manage with rest and NSAIDS. Do not adjust area. If pain is reduced substantially in a few days, consider rib subluxation and adjust the corresponding vertebra cautiously. (H) Insideous onset of mild/moderate constant pain; is patient hyperkyphotic? Perform prone extension test to differentiate between functional and structural kyphosis. (I) Patient is in teens, mainly structural kyphosis? In a younger patient consider postural problems; evaluate and recommend exercise for correction. In older patients go to box 10. Scoliosis suspected due to past history or visual observation of back? Perform Adams test. (K) Angular rotation (rib humping) evident; rotation >7? If pneumothorax or multiple fractures are evident, refer to ED> If rib fracture is single or incomplete, manage with rest and NSAIDS. If patient needs stronger medication, refer to MD. Order AP and lateral thoracic films. If associated scoliosis is evident, order full-spine films. (J) X-ray patient using full-spine view. If scoliosis is evident take lateral bending view. Go to scoliosis algorithm. (J) Go to Box 39 Scheuermann s disease evident on radiographs? If Scheuermann s is evident, eliminate flexion activites. Give thoracic extensorstrengthening exercise and pectoral and hamstring stretching. Patients with >60 kyphosis may benefit from a Boston brace. Educational & Patient Care Protocols 2

4 Thoracic Spine Pain Algorithm Page 3 From Thoracic Spine Pain Algorithm Page 2 Pain is felt with a particular posture or movement to one side? Pain felt on side opposite of bending or resited movement to same side? Muscular involvement. Use myofascial approaches coupled with SMT. Follow acute/uncomplicated case algorithm. Pain felt with Kemp s or with motion testing? Mechanical joint problem. Use SMT. Follow acute/ uncomplicated case algorithm. Insideous onset of pain in a dermatomal, unilateral pattern? Skin is hypersensitive, with sharp pain followed several days later by skin lesions? Herpes zoster (shingles). Usually self-resolving. If not, refer for medical management. (L) Investigate history, lab results, and X-ray for indications of diabetes or severe spinal degeneraton. Pain is felt at superior medical border of scapula? Levator scapulae syndrome is likely. Follow acute/ uncomplicated case algorithm. Reevaluate patient. Educational & Patient Care Protocols 3

5 Reference Consulted Souza, Thomas A. Differential Diagnosis and Management for the Chiropractor, Protocols and Algorithms, Gaithersburg, MD; Aspen Publisher, Inc Educational & Patient Care Protocols 4 Chapter 2 3