perplexing case

[Guest guest]

Hello listmates:

I have an interesting patient for you folks!

49 yo male, mechanical engineer, 72", 198 lb.

Problem began approximately 5 years ago. No trauma but problem began shortly after onset of a "bad cold". Patient had to travel back east (plane) and antibiotics were demanded by patient and utilized.

Patient describes symptoms as "invisible rash" "that manifests itself as a burning sensation in my crotch and buttocks area but without any signs of irritation. Problem worsens as day progresses and seems to be associated with the roughness of my clothing and how much sitting I do (but not 100%). At times it gets so bad that the only relief I can get is to lie down and be in the nude. I have had the following tests and treatments as recommended by my PCP without and results or relief."

1. Numerous exams

2. Ultrasound (diagnostic)

3. MRI (back)

4. Local application of lidocaine

5. Dermatologist evaluation - prescribed Zoloft

6. Neurologist prescribed Tegretol (resulted in toxic reaction) and Neurontin

7. Hematologist

8. Physical therapy for back (exercise and some mobilization)

9. Physical therapy as pelvic floor problem (biofeedback- 3 month trial)

10. Acupuncture (10 sessions)

Pt. revealed that problem is triggered by any contact/washing between scrotum. MRI revealed DDD L3-4, L4-5, L5-S1. Small central bulge at L5-S1. L4-5 bilateral protrusions at origin of neural foramen and right laterally at L4-5.

Complete low back examination was unremarkable, w/o any positive neurologic/orthopedic findings. Moderate lumbosacral paraspinal and quadratus lumborum rigidity w/o notable tenderness was present.

I proposed to the patient a short trial course of mobilization and manipulation of the low back to restore segmental and global motion/mobility. I have treated the patient on occasion and he noted a transient "cramping sensation" in the inner right thigh/groin with side-posture manipulation (mainly noted with set/up tension).

I suggested to his PCP (one of the MD's I work with) that a saddle block may be diagnostic for determining nerve root/cord involvement.

My working dx. is that a minor cord irritation (central bulge at L5-S1) is causing these signs/symptoms. I was encouraged by stimulation of "cramping" in the area of complaint by my side posture positioning (it suggests mechanical irritation to me), but I would be happy to hear any and all other suggestions, point's of view regarding additional tests, possible dx., etc.

Thanks!

D. Seitz, DCTuality Physicians730-D SE Oak StHillsboro, OR 97123

[Guest guest]

,

How about a lesion in the higher center?

CT of the head possibly?

Freeman has stressed utilizing the head CT's because they are inexpensive in cases of MTBI and allow the provider to rule-out many possible lesions. Perhaps this is an instance to where a head CT might be applicable.

Granted this is a sensory disorder, and it is our tendency to think periferial nn lesion, but maybe it's from the higher center.

What is the patient's mental status, occupation, general level of happiness or stress levels in his life? Do you feel that given his psyhco-social considerations that he is a reliable witness to his own subjective complaints?

Let us know what the outcome is if the disorder is eventually identified.

Thanks for the post.

sbs

perplexing case

Hello listmates:

I have an interesting patient for you folks!

49 yo male, mechanical engineer, 72", 198 lb.

Problem began approximately 5 years ago. No trauma but problem began shortly after onset of a "bad cold". Patient had to travel back east (plane) and antibiotics were demanded by patient and utilized.

Patient describes symptoms as "invisible rash" "that manifests itself as a burning sensation in my crotch and buttocks area but without any signs of irritation. Problem worsens as day progresses and seems to be associated with the roughness of my clothing and how much sitting I do (but not 100%). At times it gets so bad that the only relief I can get is to lie down and be in the nude. I have had the following tests and treatments as recommended by my PCP without and results or relief."

1. Numerous exams

2. Ultrasound (diagnostic)

3. MRI (back)

4. Local application of lidocaine

5. Dermatologist evaluation - prescribed Zoloft

6. Neurologist prescribed Tegretol (resulted in toxic reaction) and Neurontin

7. Hematologist

8. Physical therapy for back (exercise and some mobilization)

9. Physical therapy as pelvic floor problem (biofeedback- 3 month trial)

10. Acupuncture (10 sessions)

Pt. revealed that problem is triggered by any contact/washing between scrotum. MRI revealed DDD L3-4, L4-5, L5-S1. Small central bulge at L5-S1. L4-5 bilateral protrusions at origin of neural foramen and right laterally at L4-5.

Complete low back examination was unremarkable, w/o any positive neurologic/orthopedic findings. Moderate lumbosacral paraspinal and quadratus lumborum rigidity w/o notable tenderness was present.

I proposed to the patient a short trial course of mobilization and manipulation of the low back to restore segmental and global motion/mobility. I have treated the patient on occasion and he noted a transient "cramping sensation" in the inner right thigh/groin with side-posture manipulation (mainly noted with set/up tension).

I suggested to his PCP (one of the MD's I work with) that a saddle block may be diagnostic for determining nerve root/cord involvement.

My working dx. is that a minor cord irritation (central bulge at L5-S1) is causing these signs/symptoms. I was encouraged by stimulation of "cramping" in the area of complaint by my side posture positioning (it suggests mechanical irritation to me), but I would be happy to hear any and all other suggestions, point's of view regarding additional tests, possible dx., etc.

Thanks!

D. Seitz, DCTuality Physicians730-D SE Oak StHillsboro, OR 97123

[Guest guest]

In a message dated 1/10/02 10:47:55 AM Pacific Standard Time,

dcdocbrian@... writes:

<<

Hello listmates:

I have an interesting patient for you folks!

49 yo male, mechanical engineer, 72 " , 198 lb.

Problem began approximately 5 years ago. No trauma but problem began

shortly after onset of a " bad cold " . Patient had to travel back east (plane)

and antibiotics were demanded by patient and utilized.

Patient describes symptoms as " invisible rash " " that manifests itself as a

burning sensation in my crotch and buttocks area but without any signs of

irritation. Problem worsens as day progresses and seems to be associated with

the roughness of my clothing and how much sitting I do (but not 100%). At

times it gets so bad that the only relief I can get is to lie down and be in

the nude. I have had the following tests and treatments as recommended by my

PCP without and results or relief. "

1. Numerous exams

2. Ultrasound (diagnostic)

3. MRI (back)

4. Local application of lidocaine

5. Dermatologist evaluation - prescribed Zoloft

6. Neurologist prescribed Tegretol (resulted in toxic reaction) and

Neurontin

7. Hematologist

8. Physical therapy for back (exercise and some mobilization)

9. Physical therapy as pelvic floor problem (biofeedback- 3 month trial)

10. Acupuncture (10 sessions)

Pt. revealed that problem is triggered by any contact/washing between

scrotum. MRI revealed DDD L3-4, L4-5, L5-S1. Small central bulge at L5-S1.

L4-5 bilateral protrusions at origin of neural foramen and right laterally at

L4-5.

Complete low back examination was unremarkable, w/o any positive

neurologic/orthopedic findings. Moderate lumbosacral paraspinal and

quadratus lumborum rigidity w/o notable tenderness was present.

I proposed to the patient a short trial course of mobilization and

manipulation of the low back to restore segmental and global motion/mobility.

I have treated the patient on occasion and he noted a transient " cramping

sensation " in the inner right thigh/groin with side-posture manipulation

(mainly noted with set/up tension).

I suggested to his PCP (one of the MD's I work with) that a saddle block may

be diagnostic for determining nerve root/cord involvement.

My working dx. is that a minor cord irritation (central bulge at L5-S1) is

causing these signs/symptoms. I was encouraged by stimulation of " cramping "

in the area of complaint by my side posture positioning (it suggests

mechanical irritation to me), but I would be happy to hear any and all other

suggestions, point's of view regarding additional tests, possible dx., etc.

Thanks!

D. Seitz, DC

Tuality Physicians

730-D SE Oak St

Hillsboro, OR 97123

>>

,

I wonder what blood tests have been run. Dermatological symptoms and spinal

pain following a viral infection may indicate rheumatological disorder. They

are often associated with skin lesions. Have you run a sed rate? RA panel?

Many serum negative arthropathies will demonstrate strange rashes. Has he

seen a good rheumatologist? I highly recommend Carolyn Coyle MD at Providence

med center (503) 215-6819. She's incredible at DDX and also has worked well

with me for about 2 1/2 years. I've learned a lot from her.

As another alternative:

I had a strange case about 15 -16 years ago similar to this, but the patient

kept getting persistent hives. The hives never totally went away and would

wax and wane for over 3 months. Her condition was also following infection

and antibtiotic therapy. I used micro-current on her liver with a heat pack

for 20 min then did a 'liver pump' (a move I learned from an old doc named

Failor-no longer alive.) It was incredible. Failor warns of the skin problem

becoming worse so you need to inform the patient that it's a possibility and

have them keep some antihistimine on hand. I repeated the liver pump and the

microcurrent 3xs in 7-10 days. The first time her hives covered her body and

she was quite uncomfortable, but since I'd warned her, she just took one dose

of benedryl. The second and third treatments actually dissolved any hives

that were left. By the end of three treatments, the whole problem cleared and

never came back. My theory on it is that it may have been a toxic liver

reaction to the antibiotics. I was too new at the business to run all the

blood tests so I never found out if the patient had an arthropathy.

Call me if you don't know what a liver pump treatment consists of. I can prob

explain it over the phone or if you're close by, show you. I'll give you the

micro current settings then too. It may be a totally different problem, but

......very interesting case you have.

Minga Guerrero DC

(503) 669-1966

ps, I leave for Cabo Jan 19-26.

[Guest guest]

speaking at a seminar several years ago mentioned new dying

techniques which found nerves within the intervertebral disc.

He also mentioned clinical trials in which patients with back pain were

injected with Prednisone and Lidocane (not certain of the exact drugs).

In some people facet injections wiped out the pain.

In others disc injections wiped it out.

The conclusion being that disc damage can be the source of pain and not

necessarily facet inflammation.

This doesn't have a direct bearing on your case but raises the issue of new

discoveries even in our " advanced " state.

--

Dr. Abrahamson

> From: " Seitz " <dcdocbrian@...>

> Date: Thu, 10 Jan 2002 10:49:13 -0800

> " Oregon DC's " < >

> Subject: perplexing case

>

> Hello listmates:

>

> I have an interesting patient for you folks!

>

> 49 yo male, mechanical engineer, 72 " , 198 lb.

>

> Problem began approximately 5 years ago. No trauma but problem began shortly

> after onset of a " bad cold " . Patient had to travel back east (plane) and

> antibiotics were demanded by patient and utilized.

>

> Patient describes symptoms as " invisible rash " " that manifests itself as a

> burning sensation in my crotch and buttocks area but without any signs of

> irritation. Problem worsens as day progresses and seems to be associated with

> the roughness of my clothing and how much sitting I do (but not 100%). At

> times it gets so bad that the only relief I can get is to lie down and be in

> the nude. I have had the following tests and treatments as recommended by my

> PCP without and results or relief. "

>

> 1. Numerous exams

> 2. Ultrasound (diagnostic)

> 3. MRI (back)

> 4. Local application of lidocaine

> 5. Dermatologist evaluation - prescribed Zoloft

> 6. Neurologist prescribed Tegretol (resulted in toxic reaction) and Neurontin

> 7. Hematologist

> 8. Physical therapy for back (exercise and some mobilization)

> 9. Physical therapy as pelvic floor problem (biofeedback- 3 month trial)

> 10. Acupuncture (10 sessions)

>

> Pt. revealed that problem is triggered by any contact/washing between scrotum.

> MRI revealed DDD L3-4, L4-5, L5-S1. Small central bulge at L5-S1. L4-5

> bilateral protrusions at origin of neural foramen and right laterally at L4-5.

>

> Complete low back examination was unremarkable, w/o any positive

> neurologic/orthopedic findings. Moderate lumbosacral paraspinal and quadratus

> lumborum rigidity w/o notable tenderness was present.

>

> I proposed to the patient a short trial course of mobilization and

> manipulation of the low back to restore segmental and global motion/mobility.

> I have treated the patient on occasion and he noted a transient " cramping

> sensation " in the inner right thigh/groin with side-posture manipulation

> (mainly noted with set/up tension).

>

> I suggested to his PCP (one of the MD's I work with) that a saddle block may

> be diagnostic for determining nerve root/cord involvement.

>

> My working dx. is that a minor cord irritation (central bulge at L5-S1) is

> causing these signs/symptoms. I was encouraged by stimulation of " cramping "

> in the area of complaint by my side posture positioning (it suggests

> mechanical irritation to me), but I would be happy to hear any and all other

> suggestions, point's of view regarding additional tests, possible dx., etc.

>

> Thanks!

>

> D. Seitz, DC

> Tuality Physicians

> 730-D SE Oak St

> Hillsboro, OR 97123

>

[Guest guest]

You might consider evaluating the muscles he uses - Serratus, Scalenes, Levator, rotator cuff, Pectoralis, neck muscles,Deltoid, Coracobrachialis, Latissimus, Rhomboids as a start. Test each and see who is working and who is not. I have studied Myotonic Facilitation with Dr Todd Turnbull - here in Portland, and learned how to turn muscles back on when they seem to forget their jobs. This can make a tremendous difference in function. And remember it is muscles that hold bones in place.

On other levels, there are emotional factors that may be involved. Old habit patterns and memories can also trigger pain. They are fascinating to work with.

Good wishes with him and let us know what works.

Joan Schultze, DC

543 Third Street Suite A-3

Lake Oswego, OR 97034

(503) 636-6186

Perplexing case

Li'l help here:I've got a patient, mid 60's male, non-smoker, relatively healthy appearing, not overweight. He's been EVERYWHERE for this condition, has had an MRI etc... zippo. His symptoms are, as best as I can describe them, a bilateral tightening of the rib cage on exertion, when standing for longer periods or when working with his hands out in front of his body. Rest seems to be the only thing that makes the pain go away and it goes away rather quickly, but comes back the same if he gets active again. The problem has been going on for FOUR YEARS! and seems to be progressing somewhat.Can someone come up with an explanation for me? Dr. House??Thanks,B. Cockman, DC

[Guest guest]

You might consider evaluating the muscles he uses - Serratus, Scalenes, Levator, rotator cuff, Pectoralis, neck muscles,Deltoid, Coracobrachialis, Latissimus, Rhomboids as a start. Test each and see who is working and who is not. I have studied Myotonic Facilitation with Dr Todd Turnbull - here in Portland, and learned how to turn muscles back on when they seem to forget their jobs. This can make a tremendous difference in function. And remember it is muscles that hold bones in place.

On other levels, there are emotional factors that may be involved. Old habit patterns and memories can also trigger pain. They are fascinating to work with.

Good wishes with him and let us know what works.

Joan Schultze, DC

543 Third Street Suite A-3

Lake Oswego, OR 97034

(503) 636-6186

Perplexing case

Li'l help here:I've got a patient, mid 60's male, non-smoker, relatively healthy appearing, not overweight. He's been EVERYWHERE for this condition, has had an MRI etc... zippo. His symptoms are, as best as I can describe them, a bilateral tightening of the rib cage on exertion, when standing for longer periods or when working with his hands out in front of his body. Rest seems to be the only thing that makes the pain go away and it goes away rather quickly, but comes back the same if he gets active again. The problem has been going on for FOUR YEARS! and seems to be progressing somewhat.Can someone come up with an explanation for me? Dr. House??Thanks,B. Cockman, DC

[Guest guest]

I’ve had a patient with similar unilateral

complaints that had a chronically strained serratus anterior.

Ted Forcum, DC, DACBSP

'08 US Olympic Team Chiropractor

ACA Sports Council, President

Back

In Motion Sports

Injuries Clinic, LLC

11385

SW Scholls Ferry Road

Beaverton, Oregon 97008

503.524.9040

www.bimsportsinjuries.com

The information contained in this

electronic message may contain protected health information confidential under

applicable law, and is intended only for the use of the individual or entity

named above. If the recipient of this message is not the intended

recipient, you are hereby notified that any dissemination, copy or disclosure

of this communication is strictly prohibited. If you have received this

communication in error, please notify Back In Motion Sports Injuries Clinic,

LLC at 11385

SW Scholls Ferry Road, Beaverton, OR-97008. and purge the communication

immediately without making any copy or distribution.

From:

[mailto: ] On Behalf Of Sharron Fuchs

Sent: Thursday, July 16, 2009 7:18

AM

Brad

Cc: Oregon DCs

Subject: Re:

Perplexing case

What level(s) are the MRIs at?

s. fuchs dc

Sent from my iPhone

On Jul 15, 2009, at 9:12 PM, " Brad " <brad21gmail> wrote:

Li'l help here:

I've got a patient, mid 60's male, non-smoker, relatively healthy appearing,

not overweight. He's been EVERYWHERE for this condition, has had an MRI etc...

zippo. His symptoms are, as best as I can describe them, a bilateral tightening

of the rib cage on exertion, when standing for longer periods or when working

with his hands out in front of his body. Rest seems to be the only thing that

makes the pain go away and it goes away rather quickly, but comes back the same

if he gets active again. The problem has been going on for FOUR YEARS! and

seems to be progressing somewhat.

Can someone come up with an explanation for me? Dr. House??

Thanks,

B. Cockman, DC

[Guest guest]

I’ve had a patient with similar unilateral

complaints that had a chronically strained serratus anterior.

Ted Forcum, DC, DACBSP

'08 US Olympic Team Chiropractor

ACA Sports Council, President

Back

In Motion Sports

Injuries Clinic, LLC

11385

SW Scholls Ferry Road

Beaverton, Oregon 97008

503.524.9040

www.bimsportsinjuries.com

The information contained in this

electronic message may contain protected health information confidential under

applicable law, and is intended only for the use of the individual or entity

named above. If the recipient of this message is not the intended

recipient, you are hereby notified that any dissemination, copy or disclosure

of this communication is strictly prohibited. If you have received this

communication in error, please notify Back In Motion Sports Injuries Clinic,

LLC at 11385

SW Scholls Ferry Road, Beaverton, OR-97008. and purge the communication

immediately without making any copy or distribution.

From:

[mailto: ] On Behalf Of Sharron Fuchs

Sent: Thursday, July 16, 2009 7:18

AM

Brad

Cc: Oregon DCs

Subject: Re:

Perplexing case

What level(s) are the MRIs at?

s. fuchs dc

Sent from my iPhone

On Jul 15, 2009, at 9:12 PM, " Brad " <brad21gmail> wrote:

Li'l help here:

I've got a patient, mid 60's male, non-smoker, relatively healthy appearing,

not overweight. He's been EVERYWHERE for this condition, has had an MRI etc...

zippo. His symptoms are, as best as I can describe them, a bilateral tightening

of the rib cage on exertion, when standing for longer periods or when working

with his hands out in front of his body. Rest seems to be the only thing that

makes the pain go away and it goes away rather quickly, but comes back the same

if he gets active again. The problem has been going on for FOUR YEARS! and

seems to be progressing somewhat.

Can someone come up with an explanation for me? Dr. House??

Thanks,

B. Cockman, DC

[Guest guest]

Great place to start Joan. Serratus is a must here, but the pain could be coming from just about anywhere. I would also look at his posture. Has he lost lordosis in the lumbar spine, hyperkyphotic with ant head etc.? Breath patterns will also come into play in this area. Some postural correction exercises can go a long way to support the other muscle specific work and make it all "hold" better. The restorative yoga that does and the Egoscue work that we do at our movement center can break a lot of these postural pain patterns. 's idea about having him perform the offending action in the office should be tried if the pain generator is elusive. I am only saying it because I didn't see it mentioned. Chiropractic alone of

course may be enough to "cure" the patient of much of the pain for a period. Then, the exercise and massage work would support the intent of the adjustments. Great combo.Best,Jay Lindekugel, DCConcordia Chiropractic Center5425 NE 33rd Ave.Portland Or. 97211From: Joan Schultze <joanschultze@...>Brad <brad21@...>; Sent: Thursday, July 16, 2009 9:05:34 AMSubject: Re: Perplexing case

You might consider evaluating the muscles he uses - Serratus, Scalenes, Levator, rotator cuff, Pectoralis, neck muscles,Deltoid, Coracobrachialis, Latissimus, Rhomboids as a start. Test each and see who is working and who is not. I have studied Myotonic Facilitation with Dr Todd Turnbull - here in Portland, and learned how to turn muscles back on when they seem to forget their jobs. This can make a tremendous difference in function. And remember it is muscles that hold bones in place.

On other levels, there are emotional factors that may be involved. Old habit patterns and memories can also trigger pain. They are fascinating to work with.

Good wishes with him and let us know what works.

Joan Schultze, DC

543 Third Street Suite A-3

Lake Oswego, OR 97034

(503) 636-6186

Perplexing case

Li'l help here:I've got a patient, mid 60's male, non-smoker, relatively healthy appearing, not overweight. He's been EVERYWHERE for this condition, has had an MRI etc... zippo. His symptoms are, as best as I can describe them, a bilateral tightening of the rib cage on exertion, when standing for longer periods or when working with his hands out in front of his body. Rest seems to be the only thing that makes the pain go away and it goes away rather quickly, but comes back the same if he gets active again. The problem has been going on for FOUR YEARS! and seems to be progressing somewhat.Can someone come up with an explanation for me? Dr. House??Thanks,B. Cockman, DC