interesting case

[matt c]

this case probably belongs in the persistent pain forum but cause im an osteo i thought id throw it in here.

Intersting case
55 yr old male, presented with mild burning/hyperalgesia/pins and needles sensation that moves around anywhere in his BL lower limbs, but mostly L leg and quad and soles of feet, also now the same sensation all over his genitals/saddle area and now his all over his abdomen, up to just above his umbilicus (ant and post) its worst upon deep insipiration
He has had abd ultrasound, all clear
has seen a neurlogist for all lower limb neuro conduction studies, all within normal limits.
Xray and ct scan on lumbar spine, all within normal limits again
he is taking a multi vitamin and B complex vitamins and magnesium.
He had a samll pneumothorax when 5 yrs old from a lung infection, otherwise rest history all clear
had an MVA about a yr b4 all his symptoms began, no reported injuries, wasnt huge impact.
Oh yeah, some of my findings, skin colour, turgor, temp, and general health of his lower limbs all seemed normal, pt is not over weight, no recent weight loss, but his thoracics from T8-T12 were rigid and that is being kind, it was like "cement" thru that area
thats all for now
Would just love peoples initial thoughts on this pt

[Luke Rickards]

I reckon someone needs to CT/MRI his Tx and Cx spine.

Can the symptoms be provoked?

[matt c]

hey louke thanks for reply, no i could not provoke his symptoms apart from upon deep inspiration makes the sensation worse on his abdomen only.
I was thinking the same re scan for cx and tx
im seeing him again on sat so ill keep you posted

[Erica]

Hi Matt,
Could be an overactive sympathetic nervous system. Symptoms are widespread enough. Is he a stressed individual? Any gastric symptoms? Did your assessment of his T spine have any effect on his symptoms?
Erica

[Diane]

Better get his organs imaged too. What does deep inspiration push down against? Lots of things in there that could be "bothering" his "segments".

[matt c]

hi erica and diane, yeah i would say he is a stressed kinda guy, quite worrisome, no gastric symptoms, assessment of his Tx spine did have any effect on his symptoms, realtively firm pressure over his Tx spine musculature revealed only localised tenderness, but i had to use quite alot of pressure, the abdominal US did image kidneys, liver, stomach, gb, spleen, panc, aorta and imaged normal

[SMEGC]

Any headahes reported???

I once had a migraine like headache (so said the specialist) which started with a sneeze that initiated pins and needles starting at the toes of both feet and slowly moved up my body to the abdomen and chest, then started in the finger tips and moved up to the top of my head covering my whole body in a fuzzy numbness/pins and needles for about 15min and then slowly faded away. Went to bed and woke 2 hours later with spliting headache, nausea and vomiting every 10 minutes for the following 10 hours (Slightly dehydrated by the time it finished)

End Story.

So any headaches??

[matt c]

hi clinton, no headaches
matt (also aussie osteopath)

[nari]

I'd also like to see CT or MRI of his cevical/thoracic area done. That's my initial reaction; otherwise it sounds like a very cranky sympathetic system.
If pathology is negative in his cement area, it would be very interesting to perform DNM.

Nari

[Luckbox]

This sounds like transverse myelitis. How fast did these symptoms come on.

[marcelk]

Are lab tests (blood, liquor) been done?
Any motor signs?
What's your idea on the rigid T8-12 region
(the spin. cord in that area almost covers
area of distribution of physical symptoms)

[matt c]

hi luckbox, symptoms began 12months ago and have progressively got worse, hi marcellk, all motor normal, im not sure bout the rigid area, im gonna get the patients Tx and Cx scanned for a better idea

[Luckbox]

Hi Matt,

Does this guy have any sphincter disturbances? How about Babinski's? 12 months? I think it's likely this is some type of space occupying lesion. The thoracic imaging is a must in this case.

Did the neurologist perform any type of exam or just EDX?

Keep us posted.

[matt c]

hi luckbox, patient doesnt have any sphincter disturbances but does have this sensation over his genitals, i saw him again the other day, he didnt have results of scans yet but will today or tomoz (ill keep u posted) he had improved slightly since last week, very slightly, his thoracics were less rigid also, neg babinski's, and the neurologist did perform nerve conduction studies, im not sure what EDX is?
matt

[matt c]

pt came back to see me, he had an xray of cx and tx spine, all results normal, he hasnt been for a ct or mri because he said he cant afford it but since his last treatment he has had some improvement in his symptoms, ie some good days and some days where the pain/burning is not changed, my treatment has concentrated on getting some movemetn into his rigid area of his thoracics and rib cage and also some movement/balance back into his pelvis and neuromobs and sent him away to do yoga 3 times a week which he reported makes him "feel nice" (he is ukranian) he also reported a reduction in his symptoms after yesterdays treatment

[edelberto]

hi, Matt!
Have you already thought about T9 syndrome from Maitland´s concept?
Edelberto

[oljoha]

There's that network of sympathetic nerves on the anterior part of the spine where nerves travel up and down up to 6 segments before exiting. Could be that this area is begging for some movement - it could be responsible for the widespread symptoms. Can't remember what it's called right now. Thus mobilization of the Tx spine would cause movement in those nerves ... atleast it's more comfortable than putting yer hands through his gut to reach it.

[matt c]

just thought id update on this pt, he rang me after his last treatment and said he wasnt coming back to see me, he was a really strange guy who believes that his pain was coming from bacteria in his stomach, he wouldnt believe anything else even tho he got some good albeit temporary relief from me, he had already hopped around to about a million other therapists and i think will continue to do so, he was also the most dithering worrysome man ive ever met, it took him more than 15 minutes to leave my room after he was dressed cause he wouldnt believe i gave back his credit card/priv health care card etc etc, he would double/triple quadruple chack everything, it was kind of disconcerting too see a man this wound up but i did my best in the situation and hope hes found some relief.....i doubt it tho

[Randy Dixon]

You know reading the above I wouldn't be surprised if he is taking a lot of vitamins and supplements. Many of them have B-vitamins and it could simply be an overdose of B, especially since he believes it has to do with his gut bacteria. I think people often have an intuitive feel for what is wrong with them which gets hijacked.

[nari]

A good call, Randy.
It may not explain his rigid Tx spine, but that could be a separate issue, a hangover from the MVA.
Certainly the neuro signs could be due to overdosing on B.
Does that seem to fit the picture, Matt?

Nari

[matt c]

Yeah i thought about vit b overload and even deficiency but he wasnt taking any supplelements at the time, but siad he had taken mutivitamins in the past.

[Sarah]

I know this is a very late response, but I would've inquired as to his urinary health. At his age, being male, I might suspect something visceral related to the renal/urologic system, perhaps even prostatitis or prostate cancer. Underlying kidney disorders can present as tightness through the lower thoracic area, and the kidneys press on the diaphragm when inflammed. Just a thought.

[Adiemusfree]

I thought I'd pitch in too - if XR and bloods etc are normal, it could well be a relatively simple case of 'central sensitisation' - and normal movement, reduction of anxiety around pain and movement and his other symptoms may well be indicated. After 12 months of symptoms the chances of it completely settling (with what sounds awfully like neuropathic pain with paraesthesia and burning) are minimal. If he's been given the all-clear from a neurologist, then it's probably not worth exploring more investigations - they may well maintain his anxiety about his problem and contribute to distress.

[John W]

I agree with Bronnie. This guy sounds like a brain waiting for a persistent pain problem to happen. In his case the HPA component might be predominating. Does anyone know if there are informative tests looking at cortisol levels? In Melzack's Prithvi Raj lecture paper from 2005 he states the following:
If the output of cortisol is prolonged, or excessive, or of abnormal patterning, it may produce destruction of muscle, bone, and neural tissue and produce the conditions for many kinds of chronic pain.

[Adiemusfree]

As far as I know, there aren't - but this is in NZ!!!