3Rowing at Iowa Beginning 16th year as an intercollegiate sport 60-70 rowers on teamVarsity and NovicePractice for 2½ hours on water and 1 hour with strength & conditioning coach
4Case Presentation20 YO female rower for the University of Iowa. No previous experience as a rower prior to enrolling at Iowa in 2005.Onset: April 12, 2007 during spring season - 3 weeks left in her seasonCC:Swelling and pain at left anterior rib cagePainful left upper back;Pain while rowing in practiceNumbness at left mid back below scapulaOccasional dyspneaPrevious hx: None; gradual onset with no acute episodeContinued to participate in practices until symptoms worsened and performance became affectedSymptoms initially only with rowing but now during ADL’s
5Examined by certified athletic trainer in athletic training room Assessment: Possible costochondritis; posterior rib stress reaction; paraspinal straintreated with therapeutic modalitiesCold/ice bagallowed to continue rowing, as tolleratedAfter one week her symptoms failed to improveShe was referred to UISMC and orthopaedic physician on April 18, 2007
7Physical Examination by Orthopaedic Team Physician – 4/18/07 Examination findings:Slight prominence of the costochondral joint from anterior left side of chestPalpable tenderness in left paraspinal musclesNumbness noted in the left thoracic paraspinal areaPosterior thoracic pain is aggravated with motion in all directionsUpper extremity function was normalNeurologic exam: normalRadiograph studies:
8L-Spine Standing AP & Standing Lateral Flexion/Extension views X-raysL-Spine Standing AP & Standing Lateral Flexion/Extension viewsFindings/Impression:There is no evidence of a fracture or dislocation. The osseous structures are in gross anatomic alignment. There is no soft tissue abnormalityNegative exam
9Impression Costochondritis left anterior rib cage Referred pain posteriorlyThoracic radiculopathy
10Plan Provided prescription for naproxen – 500 mg BID MRI imaging was offered to rule out thoracic disk herniation if sx.’s fail to improve or worsenProgress to be followed by staff athletic trainerShe was able to finish out spring season but not without resolution of symptoms; treated symptomatically.
11Status as of August 22, 2007 prior to start of 2007-2008 season 2-3 months of no rowing during summerUnproductive chiropractic treatments during summerResolution of left anterior chest swellingSame amount of continuous pain, described as a “pinching” just below scapula on left sideWhen active, pain increased but was less severe than when she would rowPatch of numbness was still present just below left scapulaNumbness had slightly migrated to right side of back and up right side of her back to just above right scapulaShe had not noticed any UE weakness
12Return Visit to Orthopaedic Team Physician – 8/22/07 Examination findings:Palpable tenderness about T10 just to left of thoracic spine. No other tendernessNumbness noted inferior to left scapulaNo palpable tenderness of anterior chest wallIncrease of pain with lateral bending and twisting. No pain with flexion & extensionChest X-rays - normal
13Plan MRI imaging was scheduled to rule out thoracic disc herniation Reasoning?Persistent painPatch of numbnessPain with movementTo look deeper for a cause
17Thoracic & Cervical MRI Findings A small syrinx within the midthoracic spinal cord from the T6 through portion of T8 levels, measuring 1.8 mm max. diameterAbove and below syrinx, thin central high T2 signal appeared most consistent with normal spinal CSF central canalNo abnormal focus on enhancementNo underlying lesion was identifiedSpinal cord signal was otherwise unremarkableNo central stenosisCervical & thoracic spine exhibited no degenerative changesNormal configuration of the intra cranial posterior fossa structures, without evidence for Chiari malformation
18SyrinxA syrinx is a fluid-filled cavity within the spinal cord (syringomyelia) or brain stem (syringobulbia).Taber’s Cyclopedic Medical DictionarySymptoms include flaccid weakness of the hands and arms and deficits in pain and temperature sensation in a capelike distribution over the back and neckSx.’s not reported by this patient
19Syrinxes usually result from lesions that partially obstruct CSF flow. At least ½ of syrinxes occur in patients with congenital abnormalities of the craniocervical junction (eg, herniation of cerebellar tissue into the spinal canal, called Chiari malformation), brain (eg, encephalocele), or spinal cord. For unknown reasons, these congenital abnormalities often expand during the teen or young adult years.A syrinx can also develop in patients who have a spinal cord tumor, scarring due to previous spinal trauma, or no known predisposing factors. About 30% of people with a spinal cord tumor eventually develop a syrinx.Source: Merck Manual online
20Referral to Spine Team Physician - 8/27/07 Exam FindingsLE neurovascular exam – normalTenderness to palpation over posterior rib at T8 level on leftChest x-ray showed a possible lytic lesion on left 8th rib posteriorlyNo indication of myelopathic findings – syrinx is not likely cause of her symptomsPlan: Obtain CT scan of 7th – 9th posterior ribs
21CT Scan of RibsAxial CT scanning of the mid and lower thoracic spine and medial aspect of of the ribs was performed without intravenous contrastFINDINGS:No lytic or sclerotic lesions were identified in the medial aspects of posterior ribs.No abnormal soft tissue masses were identified.There were no degenerative changes of the visualized thoracic spineIMPRESSION: No abnormality in the medial aspects of the mid and lower thoracic ribs.
22Where do we stand at this point? Ongoing symptoms of back pain in middle aspect of spine, left side“Numbness” in her back on left sideMid thoracic spine and left paraspinal tendernessMRI showed syrinx that was determined to not be cause of symptomsCT scan showed no abnormal findingsChest x-ray read as normalTreatment with therapeutic modalities: heat, e-stim, icePrior pain in left anterior aspect of ribs has resolvedStill experiencing pain while rowing – participation is limited
23Plan Continue local therapeutic modalities Neurosurgery consult for possible facet or nerve root injectionMedrol dose pack for competitionsFollow-up with team orthopaedic physician and/or Spine Team orthopaedic physician prnAllowed to participate, as tollerated
24Referral to UIHC Pain Clinic – Neurosurgery Consult Received costovertebral/costotransverse injection on 11/02/07Allowed to return to rowing activityPatient reported that “the injection helped for a little while but then wore off.”
25Additional Referral and Treatment Medication changed from Naproxen to PiroxicamSecond series of 2 injections at T9 and T11 on 11/28/07Prescribed Lidoderm patches by Pain Clinic physicianTreatment with iontophoresis in athletic training roomTreatment with T.E.N.S.
26Spring 2008 Rowing Season 2008 Winter Training Trip Stationary bicycle – no erging, only drill work on waterFebruary – May 2008Continued to row until pain forced her to restRepeated this pattern throughout spring 2008Reported previous injections had somewhat helped because pain was not as intensePersistent symptoms of skin sensitivity and “numbness”Attended follow-up care with UIHC Pain ClinicAllowed to finish out season, as tolerated
27Fall 2008 Rowing SeasonResumed practicing with recurrent symptoms of pain, tenderness over posterior ribs, just to left of thoracic spine, and mid-back and left side numbnessSymptoms presented during rowing and strength training activities, diminished with restContinued to participate in most practices and competed in all fall racesEnd of fall season follow-up with Spine team orthopaedic physician
28Follow-up Examination with Spine Team Orthopaedic Physician – 12/15/08 Review of 8/22/07 MRI findingsBenign other than incidental thoracic syrinx not felt to be contributing to her symptomsNeurovascular exam was normalPlan:Repeat thoracic spine MRI with contrast to evaluate any progression of syrinxRenew prescription for Lidocaine patches
29Repeat Thoracic Spine MRI with Contrast IMPRESSION:Stable mid thoracic small syrinxNo lesion visualizedPLAN:Refer back to team orthopaedic physician and Pain Clinic for continuation of care
30Spring 2009 Rowing SeasonParticipated, as tollerated, in Winter Training TripContinued to experience pain and numbness sx.’sTreatment with:Lidoderm patchesT.E.N.S.IontophosesisNSAID - PiroxicamParticipated in spring practices and races“good days and bad days”Finished out rowing career on May 17, 2009Graduated from the University of Iowa
31Discussion Hx. of chest/rib pain in rowers Discovery of benign syrinx by MRIMultidisciplinary team approach to care of patientMultiple treatments used with varied resultsEven with best efforts, there was a failure to achieve complete relief of symptomsConclusive diagnosis?
32ConclusionsMRI showed a midthoracic small spinal cord syrinx that was concluded to not be cause of her symptomsPersistent mid-thoracic back pain and numbness“It’s not about what it is, but what it isn’t”No rib stress fractureNo herniated thoracic discNo abnormal soft tissue massesNo degenerative changes of thoracic spine