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thoracic pain benign or threatening

Case Study: Thoracic spine pain, post bike ride

Differentiating common benign diagnoses from more threatening problems can pose a challenge for even the most astute clinician. We are often lulled into a sense of complacency by familiar presentations that routinely respond to our MVP (most valuable procedure)- manipulation. But what if the diagnosis is something more sinister?

Check out this video of a real-life presentation of thoracic spine pain that presented this week.

This case diagnosis was fairly obvious, as the clinical findings were strongly suggestive of compression fracture:

  • Acute or “active” compression fracture will likely limit spinal range of motion. (1)
  • The inability to lie supine on an exam table with only one pillow supporting the head (Supine Sign) has relatively high sensitivity (81%) and specificity (93%) for vertebral compression fracture. (2)
  • Palpation may demonstrate localized tenderness over the site of acute compression.  (3)
  • Seated Closed Fist Percussion of the spine has a sensitivity and specificity near 90% for vertebral compression fracture. (2)
  • The Heel Drop Test may increase pain originating from compression fracture. (4)

Osteoporotic vertebral compression fractures (OVCF) typically affect only thoracic and lumbar vertebrae.  The thoracolumbar junction (T10-L2) seems to be particularly vulnerable, as stress to this region is increased by the transition from the relatively inflexible thoracic spine into the comparatively mobile lumbar spine. The most common sites for OVCF are T6-T8, T11-L1, and L4.  (5,6)

Most patients with OVCF are asymptomatic.  In fact, only 23-33% of OVCF’s are clinically evident. (7,8) The typical symptomatic presentation for OVCF is axial back pain that is described as “aching” or “stabbing”. The severity of pain may range from minimal to disabling.

Clinicians should inquire about a history of potential trauma in all post-menopausal females and elderly patients with thoracic or lumbar complaints.  Vertebral compression injuries occur when axial loads, usually combined with flexion, exceed a bone’s capacity to support that load. In healthy vertebrae, significant energy is required to cause a bony compression injury (i.e. motor vehicle accident or fall). In osteoporotic vertebrae, osteoclastic activity has overtaken osteoblastic activity, diminishing bone density and progressively lowering the threshold for injury to the point that fractures may occur with seemingly minimal loads. Researchers speculate that some OVCF’s occur gradually in response to sustained stress rather than from any single insult.

Next week we will discuss the current “best practice” treatment for Osteoporotic Vertebral Compression Fracture. Visit ChiroUp.com for a detailed synopsis of the current chiropractic evidence-based management of OVCF and 90 other conditions.

References      
1. Papa JA. Conservative management of a lumbar compression fracture in an osteoporotic patient: a case report. J Can Chiropr Assoc. 2012 Mar; 56(1): 29–39.
2. Langdon J, Way A, Heaton S, Bernard J, Molloy S. Vertebral compression fractures – new clinical signs to aid diagnosis. Annals of The Royal College of Surgeons of England. 2010;92(2):163-166.
3. Lee YL, Yip KM. The osteoporotic spine. Clin Orthop 1996;323: 91–7.
4. McGill S. Low Back Disorders: Evidence-based Prevention and Rehabilitation. Human Kinetics, 2007. p. 192
5. Haczynski J, Jakimiuk A. Vertebral fractures: a hidden problem of osteoporosis. Med Sci Monit. 2001 Sep-Oct;7(5):1108–17.
6. Patel U, Skingle S, Campbell GA, Crisp AJ, Boyle IT. Clinical profile of acute vertebral compression fractures in osteoporosis. Br J Rheumatol. 1991;30:418–421.
7. Kim DH, Vaccaro AR. Osteoporotic Compression Fracture of the Spine; current options and considerations for treatment. Spine Journal 6 (2006) 479-487
8. Rao RD, Singrakhia MD. Painful osteoporotic vertebral fracture. J Bone Joint Surg 2003; 85A(10):2010–22.

About the Author

Dr. Tim Bertelsman

Dr. Tim Bertelsman

DC, CCSP, DACO

Dr. Tim Bertelsman graduated with honors from Logan College of Chiropractic and has been practicing in Belleville, IL since 1992. He has lectured nationally on various clinical and business topics and has been published extensively. He has served in several leadership positions within the Illinois Chiropractic Society and currently serves as President of the executive board.

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