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A 47-year-old active female was referred to physical therapy with a 6-week history of right-sided interscapular thoracic back pain and neck stiffness of insidious onset. She felt that the increased intensity of her symptoms might be associated with her recently intensified weight-training program. Her pain was worsening and she was having difficulty getting into a comfortable position at night, although she could eventually get to sleep by adjusting her pillows. Over the past 3 months, she has lost 20 lb, attributing this loss to a planned diet and exercise program she started 6 months ago. Her initial neurologic examination was normal and her signs and symptoms were consistent with a musculoskeletal disorder. The physical therapist provided manual therapy and prescribed therapeutic exercise directed to the cervical and thoracic spine for two sessions over a 7-day period. At the third therapy visit, her back symptoms were unchanged and she noted her legs were feeling "heavy." She also reported having some problems climbing up stairs. The physical therapist repeated the neurologic screen and found that the initial physical therapy diagnosis of mechanical back pain was not consistent with new myelopathic signs and symptoms indicative of spinal cord compression. The therapist referred the patient to her primary care provider and an MRI scan was ordered. Subsequently, the patient was diagnosed as having a thoracic meningioma—an intradural extramedullary spinal cord tumor extending from T2 to T5 that was causing thoracic cord compression (Fig. 10-1).

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Figure 10-1.
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T1-weighted sagittal magnetic resonance image showing intradural extramedullary meningioma. (Reproduced from Song KW, Shin SI, Lee JY, Kim GL, Hyun YS, Park DY. Surgical results of intradural extramedullary tumors. Clin Orthop Surg. 2009;1:74-80. Figure 1A.)

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What signs and symptoms are associated with this diagnosis?

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What are the most appropriate examination tests?

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What are the examination priorities?

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INTRADURAL EXTRAMEDULLARY TUMOR: Spinal cord tumor that is located within the dura but outside of the spinal cord itself

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MENINGIOMA: Slow-growing tumor within the dura; arises from cells of the meningeal covering of the brain and spinal cord

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MYELOPATHY: Upper motor neuron disorder caused by compression or ischemia of the spinal cord

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SPINAL CORD TUMOR: Abnormal growth of cells in or surrounding the spinal cord

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  1. List the classification of spinal cord tumors.

  2. Describe the typical progression of compressive thoracic myelopathy caused by spinal cord tumors.

  3. Describe clinical examination findings that are helpful in differentiating musculoskeletal versus non-musculoskeletal pathology.

  4. Describe appropriate clinical examination tests that help rule in or rule out musculoskeletal back pain.

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PT considerations during examination of the individual with thoracic back pain and progressing neurologic signs and symptoms:

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  • General physical therapy plan of care/goals: Medical screening ...

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