Intermittent cervical traction: a progenitor of lumbar radicular pain.

Twelve patients treated with cervical traction for complaints of cervical radicular pain subsequently developed lumbar radicular discomfort. Intermittent cervical traction therapy had been initiated at 15 pounds and increased to 30 pounds. Lumbar spine roentgenographs in four patients demonstrated a transitional lumbar vertebrae and ten patients had evidence of spinal osteoarthritis with associated degenerative changes. Abnormal electroneuromyographs were found in four patients. In two additional patients with normal electromyographs, the spinal evoked potentials were asymmetrically slowed suggesting chronic lumbar root compromise. The onset of lumbar radiculopathy after intermittent cervical traction suggests that axial tension induced in the spinal cord's dural coverings can be transmitted to lumbar nerve roots. When these structures are tethered by anatomic variants and/or associated degenerative changes, spinal root excursion may be limited, and lumbar pain may be precipitated by traction.     

Intermittent cervical traction for cervical radiculopathy caused by large-volume herniated disks

OBJECTIVE: To describe the use of intermittent cervical traction in managing 4 patients with cervical radiculopathy and large-volume herniated disks. CLINICAL FEATURES: Four patients had neck pain radiating to the arm. The clinical examination was typical in all cases for radiculopathy of cervical origin. Magnetic resonance imaging (MRI) of the cervical spine revealed large-volume herniated disks in all patients. INTERVENTIONS AND OUTCOME: The treatment consisted of intermittent on-the-door cervical traction under the supervision of our physiotherapists. Complete symptom resolution for each patient occurred within 3 weeks. One patient who had an episode of recurrence 16 months after the first treatment was successfully managed again with cervical traction and physiotherapy. CONCLUSION: Cervical spine traction could be considered as a therapy of choice for radiculopathy caused by herniated disks, even in cases of large-volume herniated disks or recurrent episodes.     

An instance of an atypical intraspinal cyst presenting as S1 radiculopathy: a case report and brief review of pathophysiology

Intraspinal cysts are rare, but typically they originate from a degenerate zygapophyseal joint. These cysts have been commonly referred to as juxtafacet cysts and occur concomitantly with lumbar and occasionally lower-limb radicular pain. Documented cases have shown pseudoarthroses developing from nonhealing pars defects. Histologic analyses have found synovial tissue within these fibrocartilaginous accumulations. We present a case of S1 radiculopathy indicated by an intraspinal pseudocyst arising as a complication of a chronic spondylolytic defect. A brief review of the related pathophysiology is also included.     

Das akute vertebrale Schmerzsyndrom als Vorbote einer Diskushernie im Verlauf

Delayed presentation of a patient with radiculopathy after acute local vertebral pain syndrome is documented with reference to 102 cases of lumbar pain syndrome and 42 of cervical pain syndrome seen in practice. There is an elevated incidence of herniated lumbar disc among patients with initial impairment of the divergence and/or convergence at the facet joints. We suggest that before any manipulation therapy judged necessary is started patients with acute segmental dysfunction must be fully informed about the fact that radiculopathy or discal hernia can occur subsequently without any causal connection.     

Lumbar extension exercises in conjunction with mechanical traction for the management of a patient with a lumbar herniated disc

ABSTRACT

Low back pain resulting from lumbar disc herniation is a common reason for referral for physical therapy. There is no evidence to support the management of lumbar disc herniation and derangement using mechanical traction combined with lumbar extension exercises. Therefore, the purpose of this case report was to describe and discuss the use of mechanical traction in conjunction with lumbar extension exercises for a patient with a lumbar herniated disc. The patient was a 49-year-old male referred to physical therapy with a medical diagnosis of a lumbar herniated disc at L5-S1 with compression of the L5 nerve root confirmed by MRI. The patient's chief complaint was pain over the left lumbosacral and central lumbar region with radiating pain into the left buttock accompanied by numbness and tingling in the left lower leg and foot. The patient was seen for a total of 14 visits. The first 5 days (2 weeks) of therapy consisted of lumbar extension exercises. For the following nine visits (over a 3-week period), mechanical traction was added as an adjunct to the extension exercises. Outcome measures included the Oswestry Disability Questionnaire, Back Pain Function Scale (BPFS), and the Numeric Pain Rating Scale (NPRS). Results from initial evaluation to discharge (Oswestry: 36% to 0%; BPFS: 33/60 to 57/60; NPRS: 7/10 to 0/10) demonstrated that the patient no longer experienced low back pain and improved in terms of functional status and pain-related disability. The patient no longer complained of numbness and tingling in the left lower extremity and the goals for the patient had been attained. The data from this case report suggests lumbar extension exercises in conjunction with mechanical traction facilitated the patient's improvement in pain and return to prior level of function.     

Long-standing axis odontoid fracture in patient presenting with acute low back pain

Objective:To present the case of a patient affending for chiropractic care with acute low back pain. Incidentally, a previously unknown long-standing axis odontoid fracture was diagnosed, which resulted in a referral for neurosurgical management.Clinical features:A 63-year-old man presented for chiropractic care with a chief complaint of severe acute low back pain. His examination revealed evidence of lumbar and upper cervical subluxations. Subsequent X-rays revealed a double rotatory lumbar scoliosis and an axis odontoid fracture at its base. A cervical flexion X-ray revealed instability and a later computed tomography confirmed the fracture.Intervention and outcome:Due to poor patient compliance, a neurosurgical consultation and subsequent upper cervical arthrodesis did not take place until over 4 months after the initial diagnosis. A Brooks C1-C2 posterior fusion using Songer cables and an iliac crest bone graft resulted in a successful outcome. Prior to surgery, the patient's low back pain was managed by the chiropractor with a successful outcome.Conclusion:This case presents a rare, yet precarious situation with the chiropractic management of a patient with a potentially catastrophic condition. This clinical example also stresses the importance of careful clinical assessment and imaging procedures for patients before providing spinal adjustments in order to avoid a potential iatrogenic incident. This case report also demonstrates the successful outcome of specific chiropractic care in the amelioration of acute low back pain.     

Spinal manipulation or mobilization for radiculopathy: a systematic review

In this systematic review, we present a comprehensive and up-to-date systematic review of the literature as it relates to the efficacy and effectiveness of spinal manipulation or mobilization in the management of cervical, thoracic, and lumbar-related extremity pain. There is moderate quality evidence that spinal manipulation is effective for the treatment of acute lumbar radiculopathy. The quality of evidence for chronic lumbar spine-related extremity symptoms and cervical spine-related extremity symptoms of any duration is low or very low. At present, no evidence exists for the treatment of thoracic radiculopathy. Future high-quality studies should address these conditions.     

Treatment of cervical radiculopathy with flexion distraction

OBJECTIVE: To discuss the nonsurgical treatment of a cervical disk herniation with flexion distraction manipulation. CLINICAL FEATURES: A case study of cervical disk syndrome with radicular symptoms is presented. Magnetic resonance imaging revealed a large C5-C6 disk herniation. Degenerative changes at the affected level were demonstrated on cervical spine plain film radiographs. INTERVENTION AND OUTCOME: The patient received treatment in the form of flexion distraction manipulation and adjunctive therapies. A complete resolution of the patient's subjective complaints was achieved. CONCLUSION: Flexion distraction has been a technique associated with musculoskeletal conditions of the lumbar spine. Flexion distraction applied to the cervical spine might be an effective therapy in the treatment of cervical disk herniations. Although further controlled studies are needed, treatment of cervical disk syndromes with flexion distraction might be a viable form of conservative care.     

The Use of Lumbar Harness Traction to Treat a Patient with Lumbar Radicular Pain: A Case Report

Abstract

The purpose of this case study is to describe an intervention using standing lumbar harness traction to treat a patient with lumbar radicular pain. A 60-year-old male presented with a 3 month history of right buttock and posterior thigh pain. The patient had positive unilateral straight leg raise and slump tests, and ankle evertor weakness. He exhibited symptom alleviation with lumbar deloading tests. His main functional limitation was difficulty sitting. The patient was seen for five visits. Initial intervention included standing harness traction. The patient's status, including neurological signs and symptoms, was monitored. Passive psoas stretching and instruction in self-stretch for psoas, gastrocnemius, and soleus was later included. Functional instruction and training in body mechanics and back care was carried out prior to discharge. Harness traction reduced neurological signs and radicular pain in this patient. He exhibited good functional recovery after five visits. Harness traction intervention should be considered in patients with complaints of low back and leg pain who exhibit symptom alleviation with lumbar deloading tests.     

The value of intermittent cervical traction in recent cervical radiculopathy

ObjectiveOur objective is to assess the effect of mechanical and manual intermittent cervical traction on pain, use of analgesics and disability during the recent cervical radiculopathy (CR).MethodsWe made a prospective randomized study including patients sent for rehabilitation between April 2005 and October 2006. Thirty-nine patients were divided into three groups of 13 patients each. A group (A) treated by conventional rehabilitation with manual traction, a group (B) treated with conventional rehabilitation with intermittent mechanical traction and a third group (C) treated with conventional rehabilitation alone. We evaluated cervical pain, radicular pain, disability and the use of analgesics at baseline, at the end and at 1, 3 and 6 months after treatment.ResultsAt the end of treatment improving of cervical pain, radicular pain and disability is significantly better in groups A and B compared to group C. The decrease in consumption of analgesics is comparable in the three groups. At 6 months improving of cervical and radicular pain and disability is still significant compared to baseline in both groups A and B. The gain in consumption of analgesics is significant in the three groups: A, B and C.ConclusionManual or mechanical cervical traction appears to be a major contribution in the rehabilitation of CR particularly if it is included in a multimodal approach of rehabilitation.     

An unusual cause of ischemic claudication: a case report

A 56-year-old woman with a chief complaint of left lower-extremity numbness was referred by her gynecologist to the physical medicine clinic for workup of presumed lumbosacral radiculopathy. She had no history of low back pain, and her symptoms were elicited only with exercise. Results of her neurologic examination and lumbosacral radiographs were normal. Her medical history was significant for advanced cervical cancer, successfully treated with local surgery followed by high-dose pelvic radiation and chemotherapy 2 years before the current onset of symptoms. Subsequent workup with Doppler and arteriogram studies discovered a 3-cm area of diffuse stenosis of the left external iliac artery for which she was successfully treated with balloon angioplasty. This case presents an unusual cause of left leg claudication secondary to left iliac artery stenosis 2 years after pelvic radiation for cervical cancer and shows the necessity for a detailed evaluation of patients' medical histories.     

Cervical Radiculopathy Caused by a Vertebral Artery Loop: Is a Focused Fluoroscopic‐Guided Cervical Epidural Steroid Injection a Possible Treatment Modality?

We describe a case of a patient suffering with cervical radiculopathy due to vertebral artery loop with nerve root compression, treated with an epidural steroid injection. A 37‐year‐old man presented with a 2‐year history of right‐sided radicular pain along the C7 dermatome. Imaging showed a right‐sided loop of the vertebral artery at the V1–V2 transition with contact on the C7 nerve root. The pain was resistant to conservative treatment, and the decision was made to perform a focused fluoroscopy‐guided translaminar epidural steroid injection near the C7 nerve root. The procedure was uneventful, and the symptoms resolved completely after the procedure. Targeted epidural steroid injection might be a useful and safe diagnostic and therapeutic approach in patients affected by cervical radiculopathy due to a VA loop. To our knowledge, this is the first case of a VA loop associated with cervical radiculopathy treated with this technique.     

Breast pain: a symptom of cervical radiculopathy.

Eighteen women, all of whom had extensive but noninformative breast evaluations, including 10 mammograms and 4 biopies, were successfully treated by cervical traction for chronic breast pain. Each patient had distinct clinical or electromyographic evidence of cervical root compromise. Fifteen had roentgenographic evidence of cervical spondylosis, primarily at levels C6 and C7. Cervical angina, as a symptom constellation produced by cervical radiculopathy and mimicking coronary ischemic disease, is a well-defined entity. Less well recognized is persistent breast pain as a primary presenting symptom of cervical root compromise. In both instances, the early identification of the cervical radicular origin of the pain, with its quite different prognosis and associated therapeutic implications, can promptly help to allay the patient's physical and psychologic discomfort. The pathologic mechanism of pain production and the anatomic pattern of referral are described.     

Epidural gas-containing pseudocyst leading to lumbar radiculopathy: A case report

BACKGROUNDLumbar radiculopathy is a common symptom in the clinic and is often caused by lumbar disc herniation or osteophytes compressing the nerve root; however, it is rare for nerve roots to be compressed by epidural gas. Few symptomatic epidural gas-containing pseudocyst cases have been reported. Furthermore, the reported cases were due to a mix of gas and obvious osteophytes; therefore, it was hard to rigorously conclude that gas was the factor responsible for radiculopathy. We provide evidence that because no epidural gas accumulated before radiculopathy occurred and the symptoms were relieved after removal of the gas, the epidural gas-containing pseudocyst was the root cause of radiculopathy in this case.CASE SUMMARYAn 87-year-old man with a 3-wk history of right radiating pain was admitted to our hospital. Computed tomography (CT) and magnetic resonance imaging (MRI) examinations showed a vacuum phenomenon and huge lesions with low signal intensity located in the same area where the pain occurred. After carefully checking the images acquired in the last 3 mo, we found an abdominal CT examination performed 40 d prior because of abdominal pain. The CT images showed no gas-containing pseudocyst in the epidural space and notably, he had no leg pain at the time. To ensure a low-intensity intervention and complete decompression of the nerve, percutaneous endoscopic lumbar nerve decompression surgery was advised. A gas-containing pseudocyst was identified under endoscopy. The symptoms were relieved after surgery, and the postoperative images showed total disappearance of the vacuum phenomenon and lesions with low signal intensity on CT and MRI. Histological examination showed that the sampled gas-containing pseudocyst tissue was fibrous connective tissue.CONCLUSIONThis case thoroughly illustrates that an epidural gas-containing pseudocyst can result in radiculopathic pain through a comprehensive evidence chain. Percutaneous endoscopic decompression is a minimally invasive and effective treatment method.     

Directional Preference Following Epidural Steroid Injection in Three Patients with Acute Cervical Radiculopathy

Cervical radiculopathy is typically characterized by neurologic symptoms that are traced to disturbances of discrete spinal nerve root(s) due to inflammatory or mechanical etiologies. Here we present three patients diagnosed with cervical radiculopathy, whose directional preference only surfaced after either a cervical transforaminal or intralaminar nerve root epidural steroid injection. This retrospective observational case series describes three men who presented with cervical radiculopathy with 7‐9/10 neck pain, neck disability index (NDI) ranging between 44% and 90%, and an irreducible derangement upon McKenzie mechanical diagnosis and therapy (MMDT) evaluation. These patients demonstrated weaknesses, sensory changes, and/or decreased reflexes in the C5, C6, or C7 distributions. They each underwent a cervical transforaminal or intralaminar epidural injections at one or two levels, which uncovered their directional preference and facilitated further conservative treatment. These three patients experienced drastic improvements with each postinjection physical therapy session. They demonstrated decreased pain scores, centralization of pain, and a decreasing NDI trends throughout their treatments. They were all discharged with stable 0‐3/10 pain severity after four physical therapy sessions and NDI scores of 0%. These cases suggest an interplay between inflammatory and mechanical contributors to spine‐mediated pain and the treatment challenge this presents. Dissecting the components of spine pain can be challenging; however, delivery of skilled multidisciplinary care in an algorithmic fashion may be beneficial and provide the future framework for the management of cervical radiculopathy and other spine‐related conditions.     

MULTIDISCIPLINARY PAIN ABSTRACTS: 46

The aim of this study was to describe an association between the syndromes of lumbar spinal stenosis and chronic obstructive pulmonary disease (COPD) in patients presenting with symptoms of nocturnal lumbosacral radiculopathy. The study design was a retrospective review of 46 sequential inpatients referred with complaints of lumbosacral radicular pain associated with lumbar spinal stenosis. Half (23) were experiencing sleep disruptive nocturnal pain. Each had been hospitalized with a primary diagnosis of COPD. They were subsequently compared with another group of inpatients (23) who were also experiencing lumbar pain not necessarily increased at night. Each was also identified as having lumbar spinal stenosis without an antecedent history of COPD. In each case, lumbar spinal imaging studies (computed tomography or magnetic resonance imaging) were obtained. Pulmonary function tests were performed in those with COPD, and two-dimensional echocardiograms were obtained in all 46 patients. The ratio of women to men, their ages, surgical interventions, severity of lumbar spinal stenosis, and left ventricular function as compared one group with another was not significantly different. However, pulmonary artery pressures were notably elevated in those with COPD and nocturnal lumbosacral radiculopathy. This study suggests that in patients with COPD and lumbar spinal stenosis, pulmonary hypertension may be the dynamic link exacerbating nocturnal lumbosacral pain.     

Aeolus myth: chronic obstructive lung disease and nocturnal lumbosacral pain in association with lumbar spinal stenosis and pulmonary hypertension

OBJECTIVE: To describe an association between the syndromes of lumbar spinal stenosis and chronic obstructive pulmonary disease (COPD) in patients presenting with symptoms of nocturnal lumbosacral radiculopathy. DESIGN: Retrospective review of 46 sequential inpatients referred with complaints of lumbosacral radicular pain associated with lumbar spinal stenosis. Half (23) were experiencing sleep disruptive nocturnal pain. Each had been hospitalized with a primary diagnosis of COPD. They were subsequently compared with another group of inpatients (23) who were also experiencing lumbar pain not necessarily increased at night. Each was also identified as having lumbar spinal stenosis without an antecedent history of COPD. In each case, lumbar spinal imaging studies (computed tomography or magnetic resonance imaging) were obtained. Pulmonary function tests were performed in those with COPD, and two-dimensional echocardiograms were obtained in all 46 patients. RESULTS: The ratio of women to men, their ages, surgical interventions, severity of lumbar spinal stenosis, and left ventricular function as compared one group with another was not significantly different. However, pulmonary artery pressures were notably elevated (i.e., pulmonary hypertension) in those with COPD and nocturnal lumbosacral radiculopathy. CONCLUSION: This study suggests that in patients with COPD and lumbar spinal stenosis, pulmonary hypertension may be the dynamic link exacerbating nocturnal lumbosacral pain.     

Pancoast tumor presenting as cervical radiculopathy

A case of Pancoast tumor presenting as cervical radiculopathy is reported, including the clinical, EMG, and radiologic findings. A 64-year-old man with a two-month history of left shoulder pain and left arm numbness at the medial aspect of the hand and forearm presented for electrodiagnostic examination, and a severe C8 radiculopathy was documented. Subsequent radiologic evaluation (myelogram and routine chest x-ray) yielded the diagnosis of left apical lung tumor (Pancoast tumor), eroding through the C7 and T1 pedicles and T1 vertebral body, with cut-off of the left C8 nerve root. Pancoast tumor has long been implicated as a cause of brachial plexopathy. The EMG presentation of isolated cervical radiculopathy, however, has not been previously reported, despite the tumor's known tendency for local invasion which may include the nerve roots and even the spinal canal in its advanced stages. This patient's normal sensory studies argue against any significant coexisting lower brachial plexopathy. The possibility of Pancoast lesion should be considered not only in the presence of brachial plexopathy, but also when C8 or T1 radiculopathy is found.