D-12 Clinical Case Slide - Cervical and Thoracic Spine Thursday, May 31, 2018, 1: 00 PM - 2: 40 PM Room: CC-200E
HISTORY: A 47-year-old male competitive tennis player presented to a musculoskeletal clinic with nine day history of acute right-sided mid-thoracic back pain that started after serving a tennis ball. One week later, the patient developed a thoracic rash, treated as herpes zoster by his internist. Eight months later, he returned to the musculoskeletal clinic with one week history of acute bilateral thoracic back pain and one day history of left thoracic rash. He described two prior episodes of herpes zoster (10 years prior, 8 months prior) and mild varicella zoster as a child. He denied neurologic complaints or immunocompromise.
PHYSICAL EXAMINATION: Initial examination revealed normal neurologic findings, negative lower limb dural tension tests, and right mid-thoracic paraspinal muscle tenderness exacerbated by left trunk rotation. At follow up, examination was stable except for a new erythematous vesicular rash with surrounding allodynia in dermatomal distribution at the left mid-thoracic spine.
1. Acute recurrent herpes zoster
2. Thoracic radiculitis
3. Post-herpetic neuralgia
4. Thoracic paraspinal muscle strain
TEST AND RESULTS:
- MRI Thoracic Spine without Contrast: Multilevel degenerative changes. Moderate left foraminal stenosis at T7-8. Moderate to severe right foraminal stenosis at T9-10.
- HIV Ag/Ab: negative.
- Infectious Disease Consult: “heavy tennis playing may have resulted in re-activation of VZV.”
FINAL WORKING DIAGNOSIS:
1. Acute left thoracic radiculitis due to recurrent herpes zoster reactivation from heavy tennis playing
2. Acute right thoracic radiculitis due to zoster sine herpete versus thoracic neural foraminal stenosis
3. Chronic right thoracic pain due to post-herpetic neuralgia versus thoracic radiculitis
TREATMENT AND OUTCOMES:
1. Valtrex 1000mg PO TID x7 days and 1000mg TID at onset of any future symptoms
2. Topical lidocaine patch versus capsaicin patch for treatment of post-herpetic neuralgia neuropathic pain
3. Discussed possibility of gabapentin as an alternative option for management of post-herpetic neuralgia
4. 2-3 weeks rest from tennis, and rest from tennis at onset of any future symptoms
5. Follow up after MRI (patient has not yet followed up in the office)