May 22

A 14-year-old boy with scoliosis and rib pain, What is your diagnosis? / Un niño de 14 años de edad con escoliosis y dolor torácico, ¿Cuál es su diagnóstico?

http://www.healio.com/orthopedics/spine/news/print/orthopedics-today/%7B9b6952ca-d1f2-4344-bfab-401819c6d760%7D/a-14-year-old-boy-with-scoliosis-and-rib-pain

A 14-year-old boy with scoliosis and rib pain

Un niño de 14 años de edad con escoliosis  y dolor torácico


Un niño de 14 años de edad se presentó a la clínica ortopédica para la evaluación de la escoliosis . Su pediatra había obtenido una radiografía de tórax reciente para evaluar más a un diagnóstico de costocondritis , y una escoliosis leve se señala de paso . El paciente negó haber tenido dolor de espalda, y no había notado anteriormente una prominencia o curvatura.

En entrevista a fondo , su única queja era un 2 – años de historia de dolor torácico intermitente que aisló a lo largo del borde inferior de las costillas anterior izquierda . Su dolor se agrava por actividades como el fútbol , el baloncesto y lucha libre , y de vez en cuando lo despertó por la noche. La fisioterapia y antiinflamatorios hubiesen sido de beneficio moderado, pero sus síntomas se conviertan en más persistentes .

Examen y de formación de imágenes

El examen clínico reveló un joven bien aparece con 5.5 la fuerza en todos los grupos musculares de las extremidades inferiores y superiores . Sensation estaba intacto a lo largo de las distribuciones C5- L1 y L2- S1 bilateral . Los reflejos eran 1 + y simétrica en todas las extremidades . Reflejos abdominales eran simétricos en todos los cuadrantes , y hubo un golpe de clonus bilateral. En la flexión hacia adelante , hubo un protagonismo torácica derecha suave que era flexible y sin dolor con el cara- flexión e hiperextensión . No hubo sensibilidad a lo largo de la caja torácica o la unión costocondral . Los síntomas del paciente eran irreproducibles en el examen .

A 14-year-old boy presented to the orthopedic clinic for assessment of scoliosis. His pediatrician had obtained a recent chest radiograph to further evaluate a diagnosis of costochondritis, and a mild scoliosis was incidentally noted. The patient denied having back pain, and had not previously noticed any prominence or curvature.
On thorough interview, his only complaint was a 2-year history of intermittent chest pain which he isolated along the inferior border of his left anterior ribs. His pain was aggravated by activities such as football, basketball and wrestling, and occasionally woke him at night. Physical therapy and anti-inflammatories had been of moderate benefit, but his symptoms were becoming more persistent.

Examination and imaging

Clinical examination revealed a well appearing young man with 5/5 strength in all lower and upper extremity muscle groups. Sensation was intact throughout the C5-L1 and L2-S1 distributions bilaterally. Reflexes were 1+ and symmetric in all extremities. Abdominal reflexes were symmetric in all quadrants, and there was one beat of clonus bilaterally. On forward bending, there was a mild right thoracic prominence which was flexible and painless with side-bending and hyperextension. There was no tenderness along the ribcage or the costochondral junction. The patient’s symptoms were irreproducible on exam.

Figure 1. The patient’s preoperative PA scoliosis radiograph (a) with enhanced PA image centered at T7-T8 (b) are shown.

Figure 1. The patient’s preoperative PA scoliosis radiograph (a) with enhanced PA image centered at T7-T8 (b) are shown.
Images: Warth LC and Weinstein SL
Posteroanterior (PA) scoliosis film demonstrated a mild 15° right thoracic scoliosis (Figures 1a and 1b), and on close inspection there was as subtle lucency with no clear left-sided pedicle at the T8 level, a so-called ‘winking owl’ sign. This prompted further evaluation with a bone scan (Figure 2), which also demonstrated isolated uptake at this level and subsequently a limited CT scan (Figures 3a and 3b).

Figure 2. Whole body technetium bone scan demonstrates radiotracer uptake in the left pedicle of T8.

Figure 2. Whole body technetium bone scan demonstrates radiotracer uptake in the left pedicle of T8.

Figure 3. Preoperative axial (a) and sagittal (b) CT cuts demonstrate a lytic lesion at T8.

Figure 3. Preoperative axial (a) and sagittal (b) CT cuts demonstrate a lytic lesion at T8.

What is your diagnosis?

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