Cervical Case 1
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Cervical Case 6Subjective Examination A 36 year-old women attends your clinic. Two days earlier while she was lifting a heavy suitcase from the trunk of her car she experienced a sudden onset of acute non-radicular (somatic) pain in the right neck and deltoid area plus and paresthesia in the dorsolateral forearm. She also experienced immediate vertigo that lasted an hour but has not been present since. The following day in addition to her previous symptoms she experienced radicular (lancinating) pain in the dorsolateral aspect of the upper and lower arm. The patient had no previous history of neck or arm pain or vertigo. X-rays where negative. The physician diagnosed her as a C5 radiculopathy from a cervical disc herniation. Objective Examination On observation there was no torticollis or any other unusual signs. Right rotation, right side flexion and extension where both severely limited and caused lancinating pain and parasthesia reproduced into the right posterolateral upper and lower arm. There was hypoesthesia to pinprick in the right posterolateral forearm. Profound weakness was felt when right elbow flexion strength was tested while wrist extension was only slightly weak. The biceps deep tendon reflex was reduced when compared with the left arm. All other reflexes were normal. Are there any other tests you would like to do? Can you make a diagnosis and begin management of this patient. Turn to page Cervical Case 6 Discussion The lancinating pain and paresthesia would suggest either a C5 or C6 dermatome involvement, however, there are no symptoms into the hand, specifically in the thumb or index finger so more probably it is the C5 spinal nerve that is being compromised. The delay in the onset of the lancinating pain would indicate an inflammatory process rather than pre-existing adhesions at the spinal nerve or nerve root level. The C5 involvement is further demonstrated by elbow flexor weakness, biceps tendon hyporeflexia and hypoesthesia along the 5th cervical dermatome. It is less likely to be a C6 radiculopathy as there is no involvement of the brachioradialis reflex or the sensation of the thumb and index finger and the wrist extensor weakness is mild. I think that most of us would have used mechanical traction and a hard collar on this patient as we have very little else to offer a frank disc herniation with neurological deficit. However, the patient's vertigo has not been considered and is the atypical factor in this case. There is no good really good explanation for it. It is not likely to arise from the neck problem as it came on very suddenly and then disappeared even though the cervical pain remained. There was no direct or indirect trauma to the head consequently cerebral and brainstem concussion or contusion can be essentially ruled out as can labyrinthine concussion. However, if the patient produced a strong Valsalva maneuver there is the possibility that a dramatic change in middle ear pressure might have ruptured the tympanic or vestibular membrane. However, there was no ear pain or noises associated with the vertigo as is frequently the case with middle ear damage and the vertigo abated rapidly. Another possibility is the vertebral artery is being compressed or has been damaged by the presumed herniating disc. In this case, there may have been reactive vasospasm that lasted for a short while and did not recur, the patient's pain is preventing her from moving into the compromising position. The objective examination must investigate the vertigo. In fact this patient was very lucky. During the movement tests, she complained of blurred vision when she turned her head to the right. Initially the therapist ignored this and carried on with the testing. However, at the end of the examination, the patient asked what the therapist thought might have caused the dizziness, this made the therapist re-think. Right rotation was again tested with the therapist facing the patient who noticed very mild left lateral nystagmus. What are you going to do now and what do you think is happening? Turn to page Cervical Case 6 Discussion Diagnosis The patient was referred to a neurosurgeon who ordered a magnetic resonance angiogram (MRA). The MRA demonstrated indentation and reduced filling of the right vertebral artery. The diagnosis was now disc prolapse with radiculopathy and compression of the vertebral artery. Both the therapist and the physician had ignored the vertigo because it was short lived and the patient did not make a fuss of it. This case demonstrates a need for a routine examination of the balance system in any patient who manifests any symptoms of a disturbance in the system. This especially important in those patients who may have damaged the system of its arteries through trauma or when treatment is a potential threat to the vertebral artery. The patient should have undergone a cranial nerve examination and general dizziness reproduction testing before range of motion testing. A symptomatic vertebrobasilar accident is a rare occurrence and even rarer when it results from this type of indirect trauma. However, it is a possibility and at the very least, the patient should have been asked about central neurological symptoms. Has there been any diplopia, visual field defects, other forms of dizziness/nausea, tasted disturbances, hearing difficulties, dysphagia etc. A cranial nerve examination could have been carried out and this might or might not have reproduced signs, although it is probable that occlusion would have to have been present for this. Vertebrobasilar patency testing in the clinic is certainly required in some form. Even if this was only having the patient go through the range of cervical motion while observing for central neurological signs and symptoms and re-testing some of the cranial nerves. Cervical Case 7Subjective Examination A ten-year old boy in obvious distress is referred with a diagnosis of acute torticollis and a prescription of "assess and treat". He is complaining of severe right posterior neck pain of less than a day's duration, the pain starting on waking this morning (four hours ago). The previous day he had roughhousing with his friends but cannot remember any particular incident that might have caused the problem. His mother did not send him to school and he has spent the morning lying down waiting to see the physician. He has no past history of neck pain or any medical history of significance. The physician gave him Tylenol and referred him to physical therapy. Objective Examination On observation, this was a normal health boy with a left torticollis that was side flexed right and rotated right and slightly extended so that the patient looked a little upwards and to the left. He had full painfree ranges into left rotation and flexion but attempts to right rotate or left side flex his neck produced acute neck pain. Right side flexion had almost full range but produced moderate pain and extension was full range provided it was carried out in the line of the deformity. The end feel on right rotation and left side flexion was spasm, which was palpated in the sternomastoid. Diagnose, prognose and treat. Turn to page Cervical Case 7 Discussion Diagnosis This is a typical case of adolescent torticollis. The etiology is not well understood but spasm of the sternomastoid appears to be a fairly consistent component. However, as always, the spasm is an effect rather than a cause and the problem seems to lay in the articulations of the upper neck. Prognosis If you treat patients with this condition they tend to recover in about seven days, if you do not treat them they recover in a week. However, while treatment does not shorten overall the recovery, it reduces the acute pain and restores full function within a day leaving the patient with some mild soreness to contend with over the next six days or so. Treatment One advocated treatment is to manipulate the dysfunctional segment, usually the atlanto-axial or C2/3. But if you are not keen on manipulating children, which I would rather avoid, another effective treatment is available. Manual traction repeated many times during the initial treatment session and applied through the line of the deformity is extremely and almost uniformly effective and reducing at least 80% of the patient's pain within a few hours. Hot packs applied prior to the traction helps the patient relax and a soft collar appears to help prevent relapse, at the very least, it is comforting to the patient. The child is instructed to lay down in a comfortable position for that day and night. Usually by the next morning, the patient is ready to get rid of the collar and return to school. Usually further treatment is unnecessary. If this did not recover quickly and easily, what would you be thinking and what would you do? Turn to page Cervical Case 7 Discussion I have never encountered this situation but a few possibilities arise. 1. There could be a frank partial rotatory dislocation at the atlanto-axial segment. 2. Infection causing inflammation of the cervical glands can irritate the sternomastoid but this usually occurs in younger children 3. Primary bone cancer may cause acute torticollis 4. The traction technique is poor and is tending to correct the deformity, this makes matters worse 5. Traction is insufficient as a technique and manipulation does not to carried out.
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