SUN-LB028 Diabetic Truncal Radiculopathy: An Underrecognized Cause of Thoracic and Abdominal Pain

Abstract

Introduction: Diabetic polyneuropathy involves peripheral, cranial or autonomic nerves causing well known clinical presentations, easily identifiable by clinicians. Rarely, diabetic neuropathy affects the intercostal neural roots causing severe and difficult to treat thoracic and abdominal pain. We present an interesting case where diagnosis of thoracic radiculopathy was made 8 years later. Case Presentation: A 62-year-old man with type 1 diabetes mellitus presented with a history of severe right lower thoracic and flank pain. He was diagnosed with diabetes at age 20 and developed complications such as peripheral polyneuropathy. His pain was sharp and burning in nature in a “band like” distribution in the right lateral subcostal margin. The intensity ranged from 3-10/10. Exam showed tenderness to touch in the right lateral subcostal margin with no sensory deficits. He visited different specialists within a year in attempts to obtain pain relief. Therapeutic attempts done included opiates, duloxetine, gabapentin and NSAIDs with minimal improvement. Initial workup included a normal bone scan and thoracic spine MRI which showed degenerative disk disease at the level of T7-T8. Corticosteroid injection at T7-T9 resulted in no pain relief. Then a pain specialist made the diagnosis of DTR. A T10 nerve block was given with significant relief. Since then, he has received intermittent nerve blocks with complete resolution of his symptoms. Discussion: Diabetic neuropathy is the most common complication of diabetes mellitus. Truncal roots originating from the spinal cord can be affected causing a distinct disorder termed Diabetic Truncal Radiculopathy (DTR). DTR is a rare form of diabetic neuropathy that is significantly underdiagnosed. DTR is of three types - Cervical, thoracic and lumbosacral. It is commonly unilateral following the distribution of an intercostal nerve in a band like pattern. The pain is described as burning or aching in nature, frequently intensified at night associated with sensitivity to touch. The patients are usually middle aged or older adults with long standing history of diabetes. There is certain preference for men with DM type 2. It is a diagnosis of exclusion. EMG typically demonstrates denervation potentials in the intercostal, anterior abdominal wall and paraspinal muscles. The differential diagnosis is primarily based on the localization of neural injury. Involvement of upper thoracic nerves causes chest pain whereas lower thoracic nerves causes upper abdominal pain. The management is similar to other diabetic related neuropathies but challenging. Intensive glycemic control is ineffective in pain relief. DTR should be considered as a possible cause of atypical flank or chest wall pain not explained by other causes. Simple interventions such as intercostal nerve blocks are successful in improving the pain, quality of life and functionality of patients. Unless otherwise noted, all abstracts presented at ENDO are embargoed until the date and time of presentation. For oral presentations, the abstracts are embargoed until the session begins. s presented at a news conference are embargoed until the date and time of the news conference. The Endocrine Society reserves the right to lift the embargo on specific abstracts that are selected for promotion prior to or during ENDO.