Cervical Case 1
Download 117.42 Kb.
|
- Navigate this page:
- Cervical Case 12
Cervical Case 11Subjective Examination A forty-two year old woman had been treated by another therapist for cervical pain with manipulative therapy (high velocity, low amplitude thrust techniques) for left occipital headaches. Her response to treatment had been to suffer vertigo for about an hour after each treatment. The headaches had improved slightly and the therapist had been unwilling to discontinue the treatment telling her that the vertigo was caused by cervical joint dysfunction and would eventually disappear. After four sessions she had discontinued treatment herself and went back to her doctor who then referred her to you.
Cervical Case 11 Discussion This case points out the requirement for adequate training in manipulative therapy. The techniques themselves can be very simple; unfortunately, so can some of the practitioners. On of the documented causes of severe adverse complications in manipulative therapy is the failure to recognize potential or actual neurological signs or symptoms. The previous therapist's contention that the post-manipulative vertigo was arthrogenic in origin could possibly be true, but it should not be the first assumption. The possibility that it was caused by vertebrobasilar ischemia had to be the foremost consideration and should have been excluded. There may have been compression of the artery during the manipulation that resulted in vasospasm either as a result of simple compression or possibly of intramural damage. The other possible cause of the vertigo is labyrinthine if the amount of head displacement was excessive during the manipulation and given the stupidity of the therapist in pursing manipulation in the face of it causing vertigo, anything is possible. The possibility that it was due to the cervical joint is present but for the most part, cervical dizziness comes in the form of type 2 (non-vertiginous) dizziness and when it does produce vertigo, it is relatively mild and of short duration. This is a patient who, at least potentially, is an accident waiting to happen and every care must be taken. It is not too much of leap to say that the less experienced therapist should probably refer this to another therapist with greater experience. Objective Examination The examination should be progressive and gradual so that it can be halted at the earliest sign or symptom of neurological involvement. The examination of the cranial nerves was negative. There were no long tract signs of motor paresis, spasticity, pain or light touch, vibration or proprioception sensation or vibration loss. There were no signs of segmental palsy and all neuromeningeal tests were negative. The craniovertebral ligament stress tests were negative. The dizziness (vertebral) tests were negative. She had full range movement in the neck with pain on flexion and left rotation. The biomechanical examination disclosed a flexion pathomechanical hypomobility (extension subluxation) at the left atlanto-occipital joint. Where do you go to here from here? Turn to page Case 11 Discussion The cause of the vertigo still has not been found, in fact we have not been able to reproduce it, which is not a good sign as it suggests that its onset is dependent on the thrust rather than on the position. The most stressful clinical vestibular test is the Hallpike-Dix but this should not be carried out in the standard manner until the vertebral artery has been eliminated as a diagnosis, which so far it has not. However, a modification that is more stressful than the body tilt test but less stressful on the neck can be carried out. In this modification the patient's head is not dropped over the end of the bed but laid upon it so no extension occurs. If the bed end can be tipped so as to extend the thorax rather than the neck this simulates the test even more closely. In this case, the patient's head was dropped on the bed so that the neck remained in neutral but the head did fall below the body's level, the requirement for the full test. No vertigo occurred and no nystagmus was seen (Frenzel glasses were not used so there may have been nystagmus) strongly suggesting that the vertigo that followed cervical manipulation did not originate from the vestibular structures but may have been caused by ischemia of the neural projections in the vestibular system. Diagnosis Cervicogenic headaches from a left atlanto-occipital flexion hypomobility Post-manipulative vertigo of unknown source Treatment The biomechanical dysfunction requires manipulation or mobilization but the source of the vertigo is unknown. I worry when I am unable to reproduce the patient's symptoms. In this case the problem was discussed with the physician and he was offered two choices: 1. Treat the patient with careful mobilization, avoiding thrust techniques 2. Refer the patient for vertebral artery studies (MRAs were unobtainable so it would have to have been Doppler or angiographic studies). The physician thought both approaches were reasonable. That is carefully treat the patient with non-thrust manual therapy while he set up an appointment with a specialist. Mobilization brought about a rapid resolution of her headaches, she became painfree in three treatments. There was no recurrence of her vertigo during or after the treatment so that when she saw the specialist, he decided to leave well enough alone and did not order any tests. It was more than possible that this patient had an anomaly of one of her vertebral arteries that made her susceptible to the thrust of manipulation. She was advised by the specialist not to ever have her neck manipulated again. Cervical Case 12Subjective Examination A 44 year-old woman attended for treatment for right orbital headaches that had been present for two days and which were diagnosed as being caused by "cervical migraine". She could not relate any cause and stated that they had started suddenly with mild aching which had built up to a severe pain within hours of the onset. The pain was there all the time but since the initial build up, was no more or less severe. She complained of photophobia and wore sunglasses whenever out in the sunlight or in a bright room. She did not associate the headache with neck movements or posture. She had no past history of similar pains although she did suffer from neck pain and headaches running from the right occiput over the head to the right eye episodically. The last episode of this was a year earlier and was treated successfully with manipulative therapy. She had no medical history of relevance. She worked as a legal secretary and did not smoke or drink alcohol. Objective Examination She had full range painfree movements in her neck. The temperomandibular joints opened equally, normally and painlessly. The was some loss of atlanto-occipital flexion bilaterally and atlanto-axial flexion and both rotations. Do you have a diagnosis and treatment plan. Turn to page Cervical Case 12 Discussion Isolated orbital pain is not typical of cervical headaches regardless of her past history of neck-head pain. If she had been experiencing neck pain then the eye pain would have been acceptable. In addition, there was no correlation between head and neck postures and/or movements and her eye pain. This was present at all times regardless of the posture of the head. The important tests with this lady will be the cranial nerve tests. If the cranial nerve tests turn out to be negative then the patient should have an ophthalmic examination if positive, a neurological one. In the event, the therapist immediately noticed that the right pupil was dilated and when tested, failed to respond to light. The patient was advised to go to the Emergency Room, this she did and was immediately prescribed another migraine medication and given an eye patch. Within days, the aneurysm ruptured and the patient suffered a third nerve palsy. This is a case where there was a very unusual symptom. Not orbital pain, this is relatively common, but isolated orbital pain whose usual causes are ophthalmic or neurological. Uncommon pains generally have uncommon causes. 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:
|