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33 Year Old Male with Lower T-Spine Pain (Lumbarization & Other Pathologies)

Exit forum ID Forum Discussion 33 Year Old Male with Lower T-Spine Pain (Lumbarization & Other Pathologies)

This topic contains 2 replies, has 2 voices, and was last updated by   Christopher Stepien September 27, 2017 at 3:54 pm.

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  • #3175

    Christopher Stepien
    Participant

      I have a 33 year old male with

      • Lx:¬†bilateral, lower T-Spine pain.
      • Qu: Burn
      • Sev: 7/10
      • P+: crawling around with daughter for 15 minutes, standing still for 30 minutes, sitting for 30 minutes, “tighter” 1st thing in the morning (although not more painful), worse as the day goes on.
      • P-: moving, changing postures (goes to 0/10 when earlier in the day, dissipates to 2/10 later in the day), swimming, sitting forward
      Other relevant info:
      • Car accident at age 24, hit from behind – pain started at this time and has gradually got worse over last 9 years.
      • Has LB acheyness, almost constantly
      Test:
      • T-Flexion – Flat for 7-8″ from T8ish on down. – He feels a mild stretch.
      • T-Rot = Full Bilaterally, although he feels severe tightness in whole mid-to-lower LB.
      • QLF = Flat from 0-2″, 2-4″, 4-6″
      • Sitting with exaggerated extension or QLE = severe tightness from T9-L2 bilaterally.
      • SHF L = 2f, gets mild LBP, can push through and pain gets moderate
      • SHF R=4f, gets mild LBP, can push through and pain gets moderate
      • SLPF = 100%, bilateral posterior knee stretch (moderate), really hard to do.
      • KHE = 100% bilaterally
      • SLR = did not measure
      • Good Morning Capacity at 15# for 15 reps = Easy
      Palpation:
      • Moderate adhesion in lumbar erector spinae and lower thoracic erector spinae.
      MRIS:
      • T7-T8 tiny left posterior paracentral disc protrusion – no contact with spinal cord.
      • Loss of normal lordosis
      • Mild inflammation in L2-L3 interspinous ligaments (I found this and verified by the imaging doctor myself bitches – lol)
      • S1 Lumbarization with fusion of bilateral TPs to rest of sacrum.
      Treatment so far:
      I’m 9 treatments in and have probably given him 20% relief – the pain when sitting all the way back is no longer severe, but still moderate. I’ve implemented loaded good mornings due to the worsening pain by the end of the day. QLF has improved from L4 down. Thoracic flexion has improved 1-2″ closer to T7-ish, although I don’t know how to objectively measure this because I have to move the whole pencil down to continue observing how flat his lower thoracic and lumbar spine is while sitting in T-flexion.
      Questions:
      • The only thing I can observe that is the pain generator in QLE or sitting is the mild inflammation in the interspinous ligaments, but this doesn’t make sense because this is now very chronic? And if I can’t get him to Sit-Slide-Lean, I can’t deload the pain generator. So I’m lost here.
      • Can the thoracic facet capsules be adhesed?
      • When do the thoracic multifidi and rotatores start? How low?
      This patient is tall, so he’s hard to treat.
      At this point, I’m going to tell him “I don’t know what’s causing your pain and I can’t help you anymore.” I feel like that’s the right thing to say at this point.
      #3177

      Adam Holen D.C.

        I have more questions than anything with this, trying to think through it. When you treat SS and thoracic erectors, is there significant/relevant adhesion left? Same with QLF, is there still something that can be fixed (albeit hard to treat)? Why not measure SLR? Couldn’t an entrapped sciatic nerve cause tension on the cord where he has a protrusion, but no stenosis? Same with limited hip flexion causing excess stress on his lumbar spine. My (wild) guess on symptomatic extension would be pushing the cord agains’t the disc bulge.

        I understand it can be frustrating for only 20% symptomatic improvement in 9 visits, but what else is this guy going to do? Get adjusted, acupuncture, stretching/strengthening, k-tape, a pamphlet on back pain? If his problem is non-surgical, you offer the best option for him.

        #3178

        Christopher Stepien
        Participant

          Super helpful Adam.

          To be honest, I feel moderately competent in the thoracic erectors in the mid-T spine. I feel far from competent from T9-T12. I’d say I’m putting 3# per square inch on mild adhesion in T-Spine.

          For QLF, yes, there’s more to fix.

          Initially, I hadn’t measured SLR because I didn’t see how, even if restricted, this would be contributing directly in the diagnosis. But I agree, the nerve tension could be affecting the spinal cord.

          As far as limited hip flexion, because his symptoms produce the same LB symptom, his sacralization is likely what is causing the end range (not adhesion) and I moved this down the diagnostic list.

          I agree with “what else is he going to do.” I’ll keep on this for now. : )

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