Cervical Case 1
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Cervical Case 5A 38 year-old man was rear-ended nine weeks earlier. His head was turned upwards and to the right as he looked in the rear view mirror on hearing the brakes of the car behind. He was not wearing a seat belt and was thrown forwards hitting his face on the steering wheel. He denied being knocked unconscious but could not remember anything that happened for about half an hour after the accident. He was taken to the emergency room after the accident where his neck was X-rayed and proved to be negative. He also had X-rays taken of his face as he complained of severe pain in the left side of his face. The X-rays demonstrated an undisplaced fracture of the zygoma, this area had not been painful for the last week or so. At the time of the accident he could not remember what pains he experienced but at the hospital thirty minutes after the accident he had severe pain in the right suboccipital area and both sides of the upper neck posteriorly. The patient was treated with narcotic analgesics for the facial pain and a soft collar for the neck and advised to see his own physician. He also experienced vertigo continuously at first and then intermittently after the first day. The emergency room physician said that this was just reaction to the accident and that it would disappear. After 3 days, the vertigo was felt only on lying down on his right side. He saw his family doctor the next day. The physician replaced the narcotics with Tylenol and told him to remove the collar. He took a couple of days off work and then returned to his work as a welder but was unable to tolerate the weight of the welding mask and had to come off work. The upper posterior neck pain improved only very slowly and at four weeks he was still off work but was moving better. The suboccipital pain was unchanged. The vertigo was felt more frequently now especially when he extended and right rotated his head. He also complained of non-vertiginous dizziness in the form of nausea and giddiness when turning his head to the left. This had been noticed over the previous few days as the range of motion increased. At four weeks, his physician referred him to an orthopedic surgeon who ordered an MRI which showed a posterior disc prolapse at C5/6. The surgeon referred him to physical therapy with a diagnosis of post-whiplash C5/6 disc prolapse for traction and ultrasound. What are your thoughts? Turn to page Cervical Case 5 Discussion This man is in trouble. He suffered a concussion as evidenced by his post-accident amnesia. The facial impact is a poor prognostic indicator and he have may occult cervical fractures such as subchondral or pedicular fractures or rim lesions. Severe pain only thirty minutes after the accident is not a good sign and the probability is that this pain was immediate but unremembered. Another problem that the patient faces is his work. Welding is a problem for the posttraumatic neck patient due to the weight of the mask and the positions that the welder has to adopt. The vertigo may have been the result of a vertebral artery injury, labyrinthine concussion or cervical joint receptor dysfunction. However, vertebral artery damage sufficient to cause immediate vertigo that lasted continuously for a day would probably have manifested more obvious central nervous signs and symptoms, sooner rather than later. Cervical joint receptor dizziness is also unlikely as the vertigo was a function of head position and motion not cervical movement as demonstrated by its onset in lying down on the right side. The most likely explanation for the vertigo is labyrinthine concussion and given the consistency of the provoking position it is likely otoconia displacement causing benign positional paroxysmal vertigo. The MRI diagnosis of a C5/6 disc prolapse is probably not relevant to the patient as there is no low cervical or upper limb pain. The objective tests need to be carried out carefully and progressively and on the assumption that the vertebral artery has been damaged. The sequence outlined on page 291 is as complete and as safe as any other sequence of testing. Objective Examination Gentle compression through the head did not reproduce pain and while there was some minor discomfort with isometric testing of both rotations and flexion, it was not severe nor was it associated with inhibited weakness. There were no cranial nerve signs although the body-tilting test (minimized Hallpike-Dix) produced some very mild vertigo on backward and forward tilting. No neurological deficits were noted when the long tracts or the spinal nerves were tested. The Sharp-Purser and other craniovertebral stability tests were negative. On testing the dizziness with reproduction tests (so-called vertebral artery tests), left head and neck rotation produced mild type 2 dizziness while combined rotation and extension reproduced his vertigo. Cranial nerve testing while the patient was dizzy was negative. Body rotation to the right produced the same mild type 2 dizziness that left neck rotation caused while extension and left rotation of the body under the head did not reproduce the patient's vertigo that was felt with head right rotation and extension. The patient was markedly limited into right rotation (45 degrees) and reproduced mild suboccipital pain. Left rotation was about 60 degrees moderately painful in the occipital region and produced dizziness. Extension was limited by about 50% and produced somewhat stronger right suboccipital pain than did the other movements. Flexion was just short of full range and painfree. Both side flexions were limited, right side flexion to about 50% of the expected range and left by about 25%, neither produced pain. Postero-anterior pressures over C2 and C3 produced pain and a jammed end feel while over the other levels these pressures were negative. As no working diagnosis could be reached concerning the musculoskeletal system, a biomechanical examination was carried out. There was restriction of both side flexions combined extension at the atlanto-occipital segment although full range could be obtained if hold-relax techniques were employed carefully. Both rotations were limited at the atlanto-axial segment although they could be increased to near normal with hold-relax techniques. Extension and right side flexion and left translation was limited at C2/3 and there was a restriction of inferior gliding of the right zygopophyseal joint. No movement dysfunctions could be felt at any other cervical level. What are your thoughts concerning the diagnosis and treatment of this complex patient. Turn to page Cervical Case 5 Discussion It is unlikely that this patient is suffering from vertebrobasilar insufficiency, as there is a distinct absence of neurological signs on cranial nerve testing while he was dizzy. More likely is that the vertigo felt on lying down and on extending and turning the head to the right is benign paroxysmal positional vertigo possibly due to displacement of otoconia (cupulolithiasis or canalolithiasis). In any event, it should be diagnosed and treated as ongoing vertigo makes it difficult if not impossible to recover cervical movement, especially those that cause the vertigo. The reason for this is that while the therapist is encouraging painfree movement, the patient is trying to avoid moving the head in order to prevent the onset of vertigo. The type 2 dizziness is likely due to cervical mechanoreceptor problems resulting from the movement dysfunctions in the upper neck. Again the lack of cranial nerve signs or other neurological symptoms tend to preclude the vertebrobasilar system as a cause of this dizziness. It would have been nice, from a diagnostic perspective, if the postero-anterior pressures or any of the segmental tests had reproduced this dizziness but typically they did not. The fracture tests (compression and isometrics) were negative but so they should be by this point in time. There is no concern with craniovertebral stability, the tests were negative, and a dens fracture will cause much more distress than this patient has suffered and would have been picked up by this point. Tearing of the transverse ligament is rare except as part of fracturing and again there is no evidence of this. That the range of motion losses at the atlanto-occipital and atlanto-axial segments were eliminated with hold-relax techniques demonstrates that the restrictions were caused by excess muscle tone or guarding, not articular restriction or spasm). Movement loss of this type in the presence of vestibular dysfunction causing vertigo is often due to reflex guarding to prevent the head moving and causing dizziness. This phenomenon is well known to vestibular rehabilitation therapists who commonly find range of motion increases as the vestibular problem begins to resolve with treatment. The biomechanical tests demonstrated an articular pathomechanical restriction (the so-called subluxation) of extension at the right C2/3 joint (demonstrated by loss of right side flexion in extension and of inferior gliding of the right zygopophyseal joint). The lack of findings in the lower neck strongly indicates that the disc bulging seen on the MRI is asymptomatic and irrelevant, as many of these are. Diagnosis 1. Paroxysmal vertigo (needs to fully diagnosed) from labyrinthine concussion 2. Extension pathomechanical hypomobility (subluxation) at the right C2/3 zygopophyseal joint 3. Cervical spine induced non-vertiginous dizziness from the C2/3 subluxation
This patient was referred back to his family practitioner for further investigation of the vertigo. The patient's physician then referred him to an otolaryngologist who diagnosed him as suffering from benign positional paroxysmal vertigo due to cupulolithiasis. He was then referred to a vestibular rehabilitation therapist for treatment. The vestibular rehabilitation therapist performed Epply's maneuver successfully and the patient was vertigo free within a week. When seen again by the orthopedic therapist, extension, right side flexion and right rotation had increased to almost full range, flexion left side flexion and left rotation were full range and painfree. Extension, right side flexion and right rotation were still painful in the right sub-occipital area. The patient continued to complain of type 2 dizziness on left rotation although this was less than previously experienced. The C2/3 right zygopophyseal joint, which remained restricted, was manipulated into extension after which the patient had full range motion in the neck in all directions. He still had some pain on extension and right rotation but this was considerably less than prior to the manipulation. He was given general exercises for neck movement and treated with segmental (as specific as possibly) PNF techniques over the next two weeks. He remained off of work during this period. At the end of this period, he was almost painfree except for a mild headache on waking some mornings and there had been no recurrence of his vertigo or dizziness. On returning to work, the neck pain and occipital headache recurred with two days. He was re-manipulated and became painfree immediately. However, work the next day caused the condition to relapse once more. A functional capacity examination was arranged for him, which he underwent after again having the C2/3 segment manipulated. The functional assessment demonstrated that without the helmet on, the patient was capable of doing his job but with it on, the symptoms recurred quickly and he was unable to perform. The patient was offered and accepted vocational re-training in sales by his company. He has minor relapses once or twice a year usually caused by unguarded movements and responds well to re-manipulation. 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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