Cervical Case 1
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Cervical Case 8A 53 year-old man complaining of mild neck and left deltoid and lateral upper arm ache is referred. The aching had been present in the neck on and off for about five years with the initial onset unremembered but unassociated with any specific incident. The deltoid and lateral arm ache had come on about three years ago, again from no apparent cause. Recently, he had felt pins and needles around the lateral aspect of the elbow. The pain and paresthesia was made worse by prolonged sitting especially driving and also if he stood for too long. Sleeping eased the symptoms. The patient had received chiropractic and physical therapy in the past initially with good results but recently with no improvement. A recent X-ray showed degeneration in the lower cervical levels. Objective Examination The patient had a head forward posture with a deep crease running horizontally across the base of the neck. There was generalized stiffness in the neck with all movements being somewhat limited with a capsular end feel and with none of the movements reproducing the patient's pain. There were no neurological deficits and the upper limb tension tests were negative Postero-anterior pressures did not produce pain but were stiff from C5 to T1. A biomechanical examination disclosed equal flexion and extension stiffness bilaterally at C5-C7 except for an extension hypermobility at C5/6 beneath the crease in the neck. Diagnose, prognose and treat. Turn to page Cervical Case 8 Discussion The paresthesia is a neurological symptom so we need to try to figure out what is causing it. It seems mechanically provoked as evidenced by the increase in symptoms with standing and driving. However, a disc lesion is not the cause as his range of motion is not acutely disturbed nor do any of the movements provoke pain. The stiffness in the neck is generalized and seems local to the lower levels (as seen from the postero-anterior pressures. Radiographic evidence of degeneration is not a clinical diagnosis. Many individuals function quite happily without knowing that there is degeneration present. However, in this case, it has probably caused the stenosis. Biomechanically there is an extension hypermobility at C5/6 but otherwise generalized flexion and extension hypomobility throughout the rest of the lower cervical spine. Diagnosis Left C5 degenerative lateral stenosis with compromise of the C5 spinal nerve or root. Typically lateral stenosis in the neck produces more paresthesia than pain. Having identified it, what now? Turn to page Cervical Case 8 Discussion The symptoms appear to be linked with his posture, not because he has a head forward posture but because the symptoms are worse when he is in a head forward posture such as during standing and driving. In this theory, the angulation that occurs at the hypermobile C5/6 segment with the increased lordosis closes down the intervertebral foramen and producing symptoms on the side that is predisposed to stenosis by increased degenerative changes. The link can be demonstrated by having the patient sit in an exaggerated head forward position until the pain and perhaps the pins and needles come on which should be sooner that in normal sitting. "Correcting" the posture should relieve the symptoms faster than would normally occur. In this case, the link was established and treatment was aimed at improving the patient's posture and so relieving the stress on the C5/6 segment. The upper thoracic spine was examined for hypomobilities that may have been contributing to the problem. These were manipulated. The craniovertebral joints, particularly the atlanto-occipital were mobilized to increase flexion. The patient was then instructed in total body correction to bring the head more vertical in both static and dynamic working postures. With practice, the patient was able to reduce the pain and paresthesia provided he remembered to avoid the head forward posture. When he did go into this position, the pain recurred. Prognosis If the patient can remember to maintain an optimal posture, then there should be no major recurrences and what does recur should be quickly remedied by the appropriate postural correction. Cervical Case 9Subjective Examination A five-year old girl is referred with a diagnosis of torticollis. She complained of pain in the right anterolateral neck that had been present for two days. There was no apparent cause and the pain had been present continuously since the onset. Any movement increased her pain. She woke frequently during the night with acute pain. She had no past history of similar pain and no medical history of relevance. Objective Examination On observation her neck was rotated to the left and side flexed to the right. Any attempt to correct the torticollis caused severe pain so all movements except right rotation and right side flexion were impossible without acute pain and the girl crying. There were no neurological deficits. The upper limb neural tension (provocation) tests, as far as they could be tested given the torticollis, were not painful. What are your thoughts on this patient and where do you go from here? Turn to page Cervical Case 9 Discussion This case is loaded with red flags: 1. There is no apparent cause and this is especially significant in children as cumulative stress (repetitive strain) has not had a chance to make its presence felt. 2. Childhood pain in non-athletes is always something to be careful with, especially in the absence of trauma. 3. The pain is continuous a pain state that could indicate inflammation or something more serious. 4. There has been no improvement in her condition. Children generally shake off minor musculoskeletal problems quickly and this persistence is not a good sign. Diagnosis Palpation of the right cervical glands demonstrated swelling and extreme tenderness. This young girl had an upper respiratory tract infection that involved her cervical glands. She was referred back to her physician who put her on antibiotics that cleared the torticollis in two days. 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. Citizenship Download 117.42 Kb. Share with your friends:
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