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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)

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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.

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Acute mild compression fractures from T10 to

T12.

Referral to emergency room.

Plain films of the thoracic spine were taken on

March 24/05.

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Patient was told the plain films are inconclusive.

Patient is scheduled for CT on March 30/05.

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T8 T8-9 disc

T9-10 disc

T10-11 disc

T11-12 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.

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T8 T8-9 disc

T9-10 disc

T10-11 disc

T11-12 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.

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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, 2010

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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

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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

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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

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The AP spot view confirms the missing left T3

pedicle as well as the deformed T2 vertebral body

Lytic metastasis or multiple myeloma

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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, 2011

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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

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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

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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

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Severe destruction of inferior ½ of T6 and

superior ½ of T7 vertebral bodies with non-

existing 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

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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)

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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

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6 years prior to the MVA

August 26, 2015 (one year after MVA) 6 years prior to the 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 2014.

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53 year-old male with chronic stiffness in mid thoracic spine.

Chiropractor suspects DISH

Courtesy of Dr. Rebecca Scott

August 21, 2014

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Anterior vertebral squaring or barrelling with bridging syndesmophytes

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Suggestive of seronegative spondyloarthropathy.

Recommended lumbar study to confirm.

Fusion of both sacroiliac joints.

Syndesmophytes with anterior vertebral squaring.

Facet fusion.

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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

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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.

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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.

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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, 2013

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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

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Onset of symptom is July 23, 2015

1. 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

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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.

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Dec. 11/15

T5

T10

T5

T10

Dec. 11/15

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T5

T10

Dec. 11/15

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Dec. 11/15

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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

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~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

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