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False negative thoracic x-ray

F&W Case Report 2013; 7: 1
Postel D MSc PT, Keesenberg DM MSc PT

Patient, a man of 58 years old, consult a physiotherapist with complaints of cramp and very severe back pain level T6-T10 and radiating pain to the ribs. Valium in combination with ibuprofen and paracetamol is prescribed by the GP. These have little effect. In addition, blood tests and an x-ray of the lungs are examined. Both showed no abnormalities.

Provocative moments are coughing, sneezing, straining and moving. The symptoms are less by quiet sitting and lying. Patient's request is to reduce the pain from the level of NRS 9 at this point.

History: 2x myocardial infarction, left shoulder subacromial bursitis, scoliosis convex right without torsion exposed by leg length discrepancy left> 1.5cm, 30 pack years.

After anamnesis and examination, there was a strong relationship between the complaints of the  the thoracic vertebrae and costal pain. But here was a discrepancy between the reported pain and limitation of the thoracic function. There was a pain when knocking on the thoracic vertebrae and no pain was reported during axial compression. The diagnoses was: chronic facet syndrome with increased thoracic kyphosis with a suspected vertebral fracture on the level between T6-T8. The patient was sent in for an x-ray of the spine. This showed only a slight thoracic spondylotic change and no vertebral fractures.

Meanwhile the physiotherapy was started to increase mobility of the caudal level of T6-T8 in extension direction by mild posterior/anterior pressure. Also local pain relief technics were used (deep transverse friction) for the intercostal space. Despite the negative results of the x-ray the treatment is continued without any mobilization techniques of the painful area T6-T8. The pain score decreased from NRS 9 to NRS 3 after 5 treatments.Therefore no analgesia was necessary any more.

Given the residual complaints the patient decided to visit a manual therapist. Due to a spinal manipulation performed by the manual therapist, a severe pain of NRS 9 arises. The patient returns with this story to the physiotherapist and asked for treatment again. In the meantime, the GP decided the patient should consult a neurologist. An MRI was performed of the spine and showed no abnormalities whereupon a CT scan was made. After consultation between the neurologist and internist there was doubt about a possible thickening of the pancreas and the vertebral fracture. A PET scan of the abdomen, pancreas, lungs and spine followed. Eventually, the PET scan showed indeed a vertebral fracture at the level T8. No other abnormalities were observed. The x-ray that was performed earlier was false negative. Ultimately, after nine treatments this patient had a  significant reduction of back pain with an score of NRS 4.

This case report shows that the physiotherapists main instruments are the anamnesis and the clinical examination. These clinical outcomes are the basis fot the treatment protocol. X-ray imaging can be an additive diagnostic instrument for the physiotherapist but should always be interpreted acording to the clinical outcomes. For example, an X-ray is sensitive to detect a fracture, but is not specific to distinguish between an acute or longer prevalent vertebral fracture.