Cervical Case 1
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Cervical Case 13Subjective Examination A 24-year old man was involved in a front-end collision as a driver. He suffered mild pain in the lower cervical region immediately after the accident but this was much worse the next morning (15 hours later). He saw his physician the following morning with moderate pain (about a 6 on a 1-10) scale in the lower neck and a moderate occipital headache (a 4 on the same scale) which he had first felt on waking. The neck pain and the headache were fairly constant and due to the short duration of the problem, he had not had an opportunity to discover what activities and postures increased the pain. He had not experienced any numbness, paresthesia or dizziness. He denied any past history of neck pain or ongoing headaches nor had he any past medical history of significance. He worked as an auto-mechanic. His physician referred him to physical therapy and he attended two days after his appointment with his doctor, that is four days after the accident. At this time, the lower cervical pain had leveled off and was made worse with prolonged flexion when reading or if he watched TV for more than an hour. The headache was a little worse and was felt in the especially strongly in the morning and after reading. He had not returned to work at his point. X-rays of his cervical region were negative. Objective Examination His range of motion was reduced in flexion to about 75% of the expected range in extension to about 50% of the expected range. Flexion and extension produced lower cervical pain. Both rotations were slightly limited to about 90% of their normal range and both were uncomfortable in the lower neck at the ends of range. There was no neurological deficit in the form weakness, sensory loss or reflex changes. His cranial nerves were not tested. Do you have any thoughts as to diagnosis at this point? Is there anything that concerns you? Turn to page Cervical Case 13 Discussion The occipital headaches are spatially and functionally dissociated from the lower cervical pain. From a spatial perspective, this does happen, but it is not common, usually there are at least times when the pain runs between the painful areas. The headache was worse with prolonged neck flexion but none of the tests were able to reproduce the headache. Again this is not rare nor even uncommon and one re-assuring aspect is that the headaches were linked to neck flexion. At this point in time, there was not enough information to make a diagnosis or a specific or a rational treatment plan. A biomechanical examination was carried out. The craniovertebral joints were normally mobile and testing did not provoke headache or any other pain either at the time nor later. There was a bilateral extension hypomobility at C7/T1 with a pathomechanical end feel. Flexion had a normal end feel (that is normal range) but was painful at the end of range. All other segments appeared to be moving normally. Diagnose prognose and treat. Turn to page Cervical Case 13 Discussion There should be some concerns with this case, but to be honest, this one escaped me. The lower cervical dysfunction is simple enough, a symmetrical flexion subluxation (jamming) causing a pathomechanical extension hypomobility. The treatment consisted of traction manipulation that afforded immediate and complete relief from his lower cervical pain and gave him full range of motion. The prognosis should be good. The pain onset was delayed, it was a flexion rather than an extension injury. There were no referred pain (except possibly the headache), there was no pre-existing headache prior to the accident, he is young and there was nothing seen on the X-ray. He was treated three times as there was slight and diminishing recurrence of the lower neck pain between treatments and maintained a painfree state in the cerivcothoracic region for a week after the third treatment. The headache is another matter. There were no clinical findings that would explain the headaches and these did not improve with treatment so the idea that they were being referred from the lower cervical dysfunction, a real possibility, was unlikely to be true. The patient was referred back to his physician. I had no idea what was causing the headaches but I was reasonably sure that they were not emanating from his neck. I did not see the patient again but about a month later, the emergency room physician phoned me asking what I had done with this patient. The patient had suffered a hind brain stroke as a result of a vertebral artery injury. Instead of seeing his physician when I sent him out, he had seen a chiropractor who had started a course of manipulation for craniovertebral subluxations, which I had not found. He had four sessions of manipulation and about 10 days after the final treatment, he had stoked from a ruptured vertebrobasilar pseudoaneurysm. This case occurred many years ago before I tested routinely for vertebral artery compromise. At this time, only those patients relating symptoms of brainstem functional compromise were tested by me. I learned much from this case. First, you do not need dizziness or any other non-musculoskeletal symptoms to have damaged the vertebral artery. Second and from this first point, all patients need to be tested for vertebral artery sufficiency before manipulative or any other therapy that may threaten the hind brain vascular system. Third be careful of pains that do not have an obvious association with other symptomatic areas and where local joints do not have movement dysfunction. Fourth, If the possible source of the referred symptoms is improving and the referred symptoms are not, the chances are that the symptoms are not referred from here. Would testing the vertebrobasilar system have demonstrated the insufficiency and thereby prevented the stroke, there is no way of knowing. However, the best ways in this patient of preventing the stroke is to treat only those clinical signs that are obvious. My feeling is that the chiropractor, who probably was not using a biomechanical assessment, depended on the headache to determine what spinal levels required treatment. In my opinion, in the absence of pain provocation when these levels were tested and the absence of biomechanical findings, the craniovertebral joints were not a viable target for treatment. On the other hand, either the chiropractor did some damage to a previously undamaged vertebral artery or the artery was damaged at the time of the injury and my assessment was inadequate. With hind-sight and the current thoughts on testing for neurovascular sufficiency, my examination was certainly less than it could have been, but whether it would have demonstrated arterial damage is another matter. However, two principles come through in this case. Do not treat an area unless you can find objective evidence of an underlying dysfunction (that is do not treat symptoms biomechanically) in fact be downright suspicious of it, and secondly, if treatment is failing to improve the condition quickly, reconsider your premise. Cervical Case 14Subjective Examination A thirty-two year old female was involved in an automobile accident when the car she was driving was rear-ended while stopped at an intersection. She complained of immediate moderate pain in the left posterolateral neck, which was worse that evening, five or six hours later. The next morning, the pain in the neck was a little worse and had extended to include the left deltoid region to the middle of the humerus. She also complained of paresthesia in the left index finger and thumb and up the posterolateral aspect of the forearm to the lower third of the radius, which she had first felt while washing her hair in the shower that morning. She worked as a computer technician and decided to take the day off work. She saw her doctor that day and he prescribed anti-inflammatory medication and told her to go back to work after the weekend (this was Thursday). She stated that at this time she had problems moving her neck especially putting it backwards and to the left both of which movements were very painful and restricted. She rested over the next few days and was feeling better by the time she returned to work on Monday. The shoulder pain had disappeared and the posterolateral neck pain was much easier. She still felt the paresthesia mildly when washing her hair. She worked over the next two days. During this time, the neck pain gradually worsened and the deltoid pain had resumed and had spread to the elbow. The paresthesia was much stronger but remained in the same location. The range of motion in the neck decreased and flexion now caused her paresthesia. She saw her physician again on Thursday. He advised her to continue working and to increase her medication and that the she could work through the pain. By the middle of the following week, the symptoms had increased to the point where she simply could not continue to work. She returned to her physician who took her off work and referred her to physical therapy. On attendance, she stated that the neck pain was present mainly on movement and on prolonged flexion. It did wake her occasionally while sleeping although she could not say what provoked it, sleeping position or movement. The lateral upper arm pain was present to some extent all of the time but was worse when the neck was worse. The paresthesia was intermittent being felt whenever the neck was flexed or when washing her hair and more recently whenever she lifted her arm more than about 90 degrees from her side. She did not complain of dizziness or paresthesia anywhere other than in the left hand. She denied any past history of cervical problems and had no medical history of relevance. X-rays were negative and her physician did not feel that an MRI or CT scan was necessary. Objective Examination Cranial nerve, long tract and fracture tests were negative. Progressive dizziness testing through Hautard’s test was negative. Craniovertebral ligament testing was negative. Flexion was about 50% of the expected range and reproduced neck and lateral upper arm pain and her paresthesia. Extension was about 75% of the expected range and caused local posterolateral neck pain. Right side flexion was full range but reproduced her paresthesia. Left side flexion was about 50% of right side flexion and produced posterolateral neck pain and her paresthesia. Right rotation was full range and painfree. Left rotation was about 50% of right and produced posterolateral neck pain, left lateral upper arm pain and the paresthesia. Muscle testing found mild fatigable weakness of the lateral rotators of the left shoulder and moderate fatigable weakness of the left elbow flexors and wrist extensors. There was slight loss of pinprick sensation over the paresthetic area but no loss of light touch in this or any other area. Her reflexes were equal and normal on both sides. Moderate to strong compression of the cervical spine produced left neck pain. Traction did not have any effect. Do you have a diagnosis, treatment plan and prognosis for this lady. Cervical Case 14 Discussion Diagnosis From the patient’s signs and symptoms it seems likely that she has a disc herniation compressing the 6th nerve root. The amount of compression seems moderate in that the sensation loss and weakness are not profound and there is no change in the deep tendon reflexes. Possibly she damaged her disc in the accident and this caused some compression of the 6th nerve root but her persistence with working may have caused more herniation and increased nerve compromise. There is no evidence either from her subjective examination or from the objective examination that there is any central neurological or neurovascular involvement. Traction did not make her symptoms worse (although they did not relieve them either) and so it is not contraindicated as a treatment. The lack of lancinating pain would suggest that the nerve root is not inflamed and she should be able tolerate traction. As a point of interest, I did not use the upper limb neuromeningeal tension or provocation tests, as there did not seem any point. The clinical signs were very clear, distinctly affected range of motion with some of the reproducing her paresthesia. The paresthesia and hypoesthesia in a clearly delineated C6 zone and her weakness distributed in the C6 myotome. Treatment She should remain off of work until the continuous pain subsides and changes to intermittent pain. A hard collar is a definite consideration in this patient as physiological movements are causing arm pain and paresthesia. Mechanical traction is also a possibility after a trial treatment or two with manual traction to ensure that it will not exacerbate her condition. Prognosis There are factors that suggest a good prognosis and factors that indicate a bad one. On the plus side, the pain was delayed and there was no immediate severe loss of motion. On the poor side is the over-riding presence of neurological symptoms. This presence is one of the worse prognostic factors in post-whiplash patients. The patient was treated with a hard collar, manual and then mechanical traction and painfree exercises every day. She was also advised on sleeping positions and her pillows were reduced from two to one. In order to keep her off of her stomach, with a golf ball in her pajama pocket. This treatment scheme was continued, with modifications and additions, for three weeks. The patient noted no improvement in the last two treatment sessions. The collar was removed at this point. The lateral arm pain was no longer present, the posterolateral neck pain was very local to left mid neck. The paresthesia was still present but was less noticeable and was felt on overhead arm movements away from the side such as hair washing. On examination, the range of motion had increased extension was limited to about 10% of the expected range and caused local soreness. Flexion was full range and painfree. Right side flexion was slightly limited while all other movements were full range and painfree. The muscle weakness was observed only on testing the wrist extensors and was very mild starting at a Grade 4+ and reducing to a 3+ over six repetitions. Pinprick sensation was normal and the tendon reflexes remained normal. This lady had made substantial improvement but had no leveled off. Where do you go from here? Does she need any other clinical examinations? Do you continue with her current treatment or change it? Does she go back to work? Turn to page Cervical Case 14 Discussion I would not (nor did I) return her to work at this point. She had already had one poor experience with too early a return to work especially when you consider what work she would be doing and the position (neck flexion) that she would be doing it in. Additionally, the presence of the nerve root signs and symptoms especially of the ongoing paresthesia would suggest that her condition is precarious and could easily slide back into its former acute state. There does not seem a lot of point in continuing with the traction, the range of motion is almost normal, the neurological signs have for the most part disappeared and she has not noted in recent improvement with this treatment. So what treatment do we initiate? There is not enough information to make this decision so further information must be generated from the biomechanical examination. We also have to wonder about the ongoing paresthesia after the articular signs have optimized. This may be the time to carry out the upper limb neuromeningeal mobility tests. The biomechanical examination demonstrated a left C2/3 zygopophyseal joint extension hypomobility with a pathomechanical end feel suggesting a flexion subluxation of the left C2/3 zygopophyseal joint. The other cervical joints were biomechanically normal. The lack of biomechanical findings at the lower cervical levels removes a mechanical dysfunction as the cause of the paresthesia. This led to upper limb tension testing. The results of this was that paresthesia was produced with right neck flexion, abduction and extension of the shoulder and extension elbow. The paresthesia was significantly worse when the wrist was flexed in this position. Diagnosis C2/3 flexion subluxation is suggested by the movement restriction and the pathomechanical end feel. The absence of arm pain and biomechanical signs in the lower cervical levels together with the paresthesia and the radial nerve upper limb tension test would suggest adhesions or edema of the 6th spinal nerve (presumptive based on the initial compression). Treatment The biomechanical dysfunction at the left C2/3 zygopophyseal joint was treated with manipulation (non-rhythmical end range mobilizations could have been used) and the movement was regained immediately with an immediate subsidence in the neck pain and its complete disappearance over the next couple of days. The paresthesia was treated with careful and graded stretches for 6th cervical spinal nerve and roots and its continuation into the arm. The paresthesia disappeared within ten days of starting the stretches on an alternate day basis. In addition to the neural stretches, she was also treated with progressive resisted exercises and work conditioning. The patient returned to work six weeks after accident and had a relapse within one week. A phone call from her told me that all of the original pain recurred but this time she also experienced severe radicular pain in the left arm to the thumb. An MRI at this time confirmed the presence of a left posterior to posterolateral herniation of the C5/6 disc with compression of the C6 root. Eventually, she had surgery. 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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