Cervical Case 1
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Cervical Case 2Subjective Examination A 35 year-old woman woke with pain three days earlier. The pain was felt over the right suboccipital region and the right neck on an intermittent basis. She related that the pain was worse with prolonged sitting especially if reading or watching TV and was much more severe for about an hour on waking. She described no neurological pain or paresthesia. The pain sites and intensity were unchanged since the onset. She could find no reason for the pain and had no past history of anything similar. She had no medical problems of note. The patient worked as an office cleaner. Objective Examination Right rotation and extension were about 30% limited with jammed end feels and pain. The other ranges were full range and painfree. Postero-anterior pressures over C2 and C3 were painful. Neurological testing was negative and there were no dural signs. Thoughts? Turn to page Cervical Case 2 Discussion No real cause for concern. This is the first episode but the pain is typically cervical in its distribution. The differential diagnostic examination affords no positive information although we can be fairly certain that the symptoms are not due to a disc herniation. A question that should have been asked considering the pain increase in the morning concerns sleeping. What position and how many and of what types of pillow do you use? She stated that she slept on her right side with one foam pillow. There is a need for a biomechanical examination. This was carried out and demonstrated restricted physiological and accessory intervertebral movements at C2/3 into extension on the right with a pathomechanical or jammed end feel. Diagnosis Right C2/3 zygopophyseal joint flexion pathomechanical hypomobility (extension subluxation). Treatment She was treated with active exercises after manipulation of C2/3 or non-rhythmical jerky mobilizations. The patient responded well to the first treatment with the patient painfree until she slept that night. The next morning the pain had returned and was as intense as ever. What do you do next? Turn to page Cervical Case 2 Discussion There are a number of reasons why treatment, particularly manual treatment helps initially but not over the long term. These include: 1. Insufficient, inadequate or inappropriate exercises being given. 2. The therapist treating the obvious joint dysfunction but failing to find the root cause of the problem. 3. The therapist failing to change adverse environmental factors. 4. The patient failing to comply with the exercise program or suggested changes in the environment. In this case, the foam pillow should be changed to feather or artificial feather and the patient warned about spending too much time reading or watching TV while sitting. The exercises were reviewed and corrected and the patient was painfree after three treatment sessions. Cervical Case 3Subjective Examination A 28-year-old nurse, while lifting a patient with a partner, experienced a sudden onset of severe right neck pain with referred non-lancinating pain in the right deltoid when her partner slipped and let go of the patient. The nurse was forced to take the full weight of the patient for a few seconds. When asked if her head was twisted into flexion, extension or rotation at the time of the accident she said not. The accident occurred six days earlier. She was initially treated by the physician with analgesics and time off work. Since the accident the pain had progressed with the referred pain now felt down the posterolateral upper and lower arm with mild aching in the index finger and thumb. Paresthesia had been present for the last two days in the index finger and thumb and lancinating pain on turning the head to the right and/or extending it was felt in the posterolateral upper and lower arm. X-rays were taken at the time of the injury and were read as negative. At this time, the physician's diagnosis was changed to cervical disc herniation and an anti-inflammatory was prescribed in addition to the analgesic. The physician also referred the patient for physical therapy. The patient had no past history of neck or arm pain and no medical history of relevance. Can you make any deductions from the history? Turn to page Cervical Case 3 Discussion Disc prolapses are not overly common in the cervical spine but this does seem to be the case with this patient. The immediacy of the pain argues for fairly substantial tissue damage. The mechanism of injury is likely to be compression as the patient did not relate any excessive movements occurring, so torque and shear are less likely to be the underlying causative forces. Compression in the absence of rotation or angular displacement is unlikely to damage the joints, ligaments or muscles as these are nowhere near the ends of their ranges but more likely to cause compression fractures or disc failure. The lancinating pain and the paresthesia are pathognomic of neural tissue involvement and again, it is difficult to see what else might be causing these other than compression by a disc. As no head or neck displacement of any great degree occurred, over-stretching of the spinal nerve roots or brachial plexus is unlikely and given her age, lateral stenosis is not a strong candidate especially as the X-ray was negative. The delayed onset of the lancinating pain would suggest an inflammatory component to the condition, while the delay in the onset of more distal referred pain and paresthesia could be indicative of a worsening condition. The distribution of the paresthesia into the index finger and thumb indicates involvement of the C6 root. The provisional diagnosis from the history is worsening C5/6 disc herniation with compression of the C6 spinal nerve or root. If the objective examination does not demonstrate considerable painful limitation of the cervical spine, the diagnosis will have to be reviewed. In addition, you can expect to find motor signs in the form of paresis in the C6 distribution. Objective Examination On observation, the patient was a healthy looking female without any obvious deformity or atrophy. There was severe limitation of motion in the neck. Flexion was about 30 degrees and produced neck pain, Extension was 20 degrees limited by spasm and caused lancinating arm pain with overpressure. Left rotation was almost full range and reproduced mild neck pain. Right rotation was 30 degrees and caused lancinating pain into the right arm and was limited by spasm. Left side flexion was limited to about 50% of the expected range and reproduced the non-radicular radiating pain in the right arm. Right side flexion was limited to about 75% of the expected range and produced neck pain. Compression produced neck pain and traction did not affect the patient. Postero-anterior pressures caused local pain and spasm when applied over C5 and C6. Sensation testing demonstrated loss of pinprick and light touch sensation over the radial aspect of the right index finger and over the dorsal aspect of the thumb. Pinprick was reduced in the same areas but also over the dorsolateral aspect of the forearm. There was moderate weakness of the elbow flexors and wrist extensors. Deep tendon reflexes were normal throughout the arms. There is no need of the upper limb neural tension (provocation) tests as these will not clarify the diagnosis nor help determine treatment. What is your diagnosis and treatment? Turn to page Cervical Case 3 Discussion Diagnosis This is almost certainly cervical disc compression with a C6 motor and sensory radiculopathy. The normal reflexes in the presence of motor and sensory deficits is a little uncommon but does occur and is probably indicates a better prognosis than if the reflexes were reduced or absent. Treatment Reducing the presumed inflammation is of paramount importance. This can be accomplished best by making sure that the patient is not continuously re-injuring it with unguarded movements. A hard collar will prevent this; as a general rule, if any cervical movement produces lancinating pain or paresthesia a collar is indicated. In addition, the patient needs to be instructed in rest and non-painful exercises and anti-inflammatory modalities can be applied. As traction did not increase the pain on testing, it can be cautiously applied but I would suggest that the effect of the above treatments be evaluated first. If there is significant inflammation present, traction may exacerbate it. If the patient's condition resolves rapidly with the initial measures then traction is unnecessary. If there is partial or minimal improvement, traction may be required to try to relieve any pressure on the neural tissues. In this case, the use of the collar, rest and anti-inflammatory modalities eliminated the lancinating pain in ten days but failed to affect the neck pain, arm ache, paresthesia or neurological deficits. Mechanical traction was applied over ten treatment sessions. This appeared to substantially reduce but did not eradicate the neck and arm symptoms and left the neurological deficits unchanged. The patient was at this time discontinued from treatment by the physician and returned to work. It seems likely that the collar, rest and modalities were effective at reducing the inflammation as demonstrated by the elimination of the lancinating pain. The traction possibly reduced some of the compression from the spinal nerve but was not able to completely clear it. Alternatively, there may have been some spontaneous reduction in compression force and the traction did nothing. When neurological deficits are established, gaining full recovery with physical therapy is difficult. Ideally, once the more acute pain had subsided and there was no further improvement with traction, a biomechanical examination would have been carried out and biomechanical treatment initiated if appropriate. However, in this case, the physician unexpectedly discharged the patient. Directory: cgi-bin cgi-bin -> Terry L. Root cgi-bin -> Rochester, ny 14620 585-395-2587 (work), 585-423-9603 (cell) cgi-bin -> Online Edition Newsletter of the North American Sport Library Network cgi-bin -> 2009 Master of Ceremonies: Allen Weiner cgi-bin -> Are There Any Who Are Wise? September 12, 2010 cgi-bin -> Job profile cgi-bin -> Position description cgi-bin -> 3030 Rev 06/2009 NonCompliance Tracking System cgi-bin -> Ruoff Place of Birth: Long Beach, California, U. S. A. 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