Cervical Case 1
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Cervical Case 10Subjective Examination A 41 year-old woman complaining of posterior upper neck pain, right sub-occipital and occipital headache attends for treatment. The onset of the pain was three months earlier after a fall when she hit her head. She denied being knocked unconscious and could remember everything about the injury except for a few minutes afterwards. Mild upper neck pain, worse on the right, was felt immediately but this was much worse the next morning on waking. In addition to the occipital headache, the patient was also experiencing a mild deep diffuse ache throughout the head that was worse when she was tired or when she exerted herself. This had been present since the accident but had never been severe. She complained of difficulty concentrating, sleeping and staying motivated and felt tired and run down most of the time. She also complained of intermittent type 2 dizziness where she would become unsteady and lightheaded occasionally on rapid position changes from sitting to standing or the reverse or on suddenly turning. She denied vertigo and there was no predictable pattern of provocation to these episodes of dizziness. The neck and occipital pain was worse with prolonged sitting especially if she was reading. It flared up with strong exertion and the three or four times she had tried to go back to her work as a practical nurse, the exacerbation had been so acute that she only managed a day or two. When the pain flared up, it spread into both upper trapezii and from the occipital region over the head to the right eye. Essentially she had been off of work since the accident and was covered by Worker's Compensation. Previous treatments included chiropractic which relieved her neck and head pain for a day or so but did not give any long term relief and physical therapy in the form of ultrasound, stretching and cranial sacral. This provided no relief at all and if the stretching was overly vigorous increased her headaches. She had a past history of episodic low back pain over the previous four years that was associated with an on the job injury and she had taken some time off of work for this. Her medical history included treatment for depression ten years earlier. This improved with Elavil and she had not been troubled with it since but she did seem depressed during the interview. What are you thinking at this point and what does your objective consist of in this patient? Turn to page Cervical Case 10 Discussion This patient would be easy to label as chronic pain syndrome; hysterical or malingering based on her past injury and work record, her lack of motivation and vague symptoms and her previous history of depression. But such labeling would be unfair until all exhaustive tests had been carried out both by the therapist and by other, more appropriately trained health care practitioners. While much of what she does complain of is part of the clinical picture of the depressed patient with chronic pain syndrome and/or secondary gain issues, it is also part of the presentation of the patient with post concussion (posttraumatic head injury) syndrome. In addition, the pain and other symptoms started almost immediately after the accident, did not progress and are local without involvement of other body areas, a usual accompaniment to chronic pain syndrome. Her apparent depression may be real, and given her disability and ongoing pain, she would be entitled to be somewhat depressed or it may only be apparent because the therapist was sensitized to it by the previous history of depression. In any case, it is something for her physician to decide upon but she does need some guidance in the need to bring up the subject with her doctor. It is safer and fairer to assume this and prove or disprove it than to assume that there is physical basis for her disability. It is likely that she was concussed even though she denies being unconscious. The history of amnesia after the injury is almost pathognomic of concussion or worse. On the bright side, the symptoms are not progressing and the condition is three months old so more serious considerations such as a slow intracranial bleed can be excluded. There are two distinct types of headache with this lady, the typical cervical headache in the occiput with occasional spread occipitofrontally and orbitally when exacerbated and the diffuse deeper headache. The former is related to head and neck movements and postures while the latter is associated with tiredness and physical fatigue and is probably part of the head injury syndrome. The presence of dizziness may also be part of the head injury or it may be associated with chronic pain syndrome but as it came on very quickly after the injury, the former is the more likely possibility. Her cervical pain and occipital headache are typical and should normally respond to appropriate physical therapy. The fact that it did not suggests either inappropriate therapy or complicating factors that prevent effective therapy from working. Whatever else may be said of this patient she has had a head injury and in addition to the musculoskeletal examination requires a cranial nerve examination and perhaps a recommendation to her physician that a neuropsyche evaluation be carried out to try to determine if traumatic brain injury has occurred. There is no evidence from the history that there is any damage to the vertebral artery but this should be examined to exclude the possibility as far as the tests are able to do that and to try to find the source of her dizziness. The remainder of the examination is routine. Objective Examination The patient looked tired but otherwise had no obvious postural deficits or deformities. Cranial nerve testing was negative except that during the tracking tests for the 3rd, 4th and 6th nerves, she experienced mild short duration vertigo and longer lasting nausea. Body tilting tests did not reproduce her dizziness. Craniovertebral ligament stress testing, including Sharp-Purser's, were negative for both instability and symptomatology. Dizziness was not reproduced on any of the so-called vertebral artery tests and Hautard's test was negative. As the vertebral artery appeared to be OK (given the lack of cranial nerve signs and the negative tests), the Hallpike-Dix test was carried out. This reproduced her dizziness when the head was in both left and right rotation and extension. The dizziness came on almost immediately and disappeared within a minute. There were no cranial nerve signs discovered on testing while she was dizzy. She had full range cervical movements with extension and left rotation reproducing her neck and head pain. Both of these movements had a jammed (subluxed) end feel while all other movements of the neck were painfree and had normal end feels. There were no signs of neurological deficit. All neuromeningeal (dural and neural tension) tests were negative. Compression and traction were negative. Postero-anterior pressure over the spinous process of C2 and over the back of C1 neural arch reproduced her headache and local tenderness. The posterior suboccipital muscles were hypertonic and tender to moderate palpation. It seems probable that the occipital headache is due to a dysfunction in the craniovertebral joints but exactly where cannot be ascertained from the examination. A biomechanical examination is required. Passive physiological and accessory (arthrokinematic) movement testing determined that there was an extension pathomechanical hypomobility (subluxation) at the left atlanto-occipital joint and a flexion pathomechanical hypomobility at the left C5/6 zygopophyseal joint. Diagnose, treat and prognose. Turn to page Cervical Case 10 Discussion The absence of cranial nerve signs and the negative "vertebral artery tests" excludes, as far as possible, vertebrobasilar compromise as a source of her symptoms. However, it does seem clear that she should be assessed for traumatic brain injury due to the presence of her ongoing diffuse headache, lack of concentration, lack of motivation and general fatigue. She should also be assessed for vestibular function. Although she does not complain of vertigo, the ongoing dizziness could be due to a central vestibular dysfunction as evidenced by the Hallpike-Dix test. However, this test does involve considerable stress through the neck and the dizziness might cervicogenic even though positioning the neck in extension and rotation failed to produce dizziness unless the body was laid horizontally. This can easily be checked during treatment. If the neck is causing the dizziness and its pain improves, then the dizziness should likewise improve and if it does not, it is unlikely that it originates from the neck. The musculoskeletal dysfunction that is the cause of the neck pain and headache seems to be a flexion "subluxation" causing extension hypomobility of the left atlanto-occipital joint. But the source of most of the pain cannot be this joint as it is on the wrong side of the body although the minor left upper neck pain may be from this joint. A reasonable hypothesis is that the left hypomobility has caused undue strain on the right joint and this has become symptomatic. The lower cervical biomechanical dysfunction is probably unrelated to the patient's symptoms, asymptomatic articular hypomobilities are seen all of the time on manual therapy courses and the same can be expected of the general public. Diagnosis 1. Left atlanto-occipital pathomechanical extension hypmobility. 2. Probable posttraumatic head injury syndrome 3. Possible vestibular hypofunction
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