Chiropractic management using Cox cervical flexion-distraction technique for a disk herniation with left foraminal narrowing in a 64-year-old man

OBJECTIVE: The purpose of this case report is to describe chiropractic management of a patient with a C6/C7 left posteromedial disk herniation with foraminal narrowing and concomitant neurological compromise in the form of left upper extremity radiating pain and hypoesthesia/anesthesia using Cox flexion-distraction technique. CLINICAL FEATURES: A 64-year-old man presented to a chiropractic clinic with complaints of neck/left shoulder pain and hypoesthesia/anesthesia into the palmar side of his left hand. Magnetic resonance images of the cervical spine revealed a left posteromedial C6/C7 disk herniation along with foraminal narrowing. In addition, there were other levels of degeneration, most noted at the C3/C4 spinal level, which also had significant left-sided foraminal narrowing. INTERVENTION AND OUTCOME: Treatment included Cox flexion-distraction protocols aimed to reduce nerve root compression along with supportive physiological therapeutic interventions to aid with pain reduction and functional improvement. The patient was treated a total of 10 times over a course of 4 weeks. The patient reported being pain-free and fully functional 8 months following the conclusion of care. CONCLUSION: This case study demonstrated the use of Cox flexion-distraction for treatment of a patient with a cervical disk herniation, foraminal narrowing, and associated radiating pain and radiculopathy in the left upper extremity.     

Use of cervical spine manipulation under anesthesia for management of cervical disk herniation, cervical radiculopathy, and associated cervicogenic headache syndrome

OBJECTIVE: To demonstrate the benefits of cervical spine manipulation with the patient under anesthesia as an approach to treating a patient with chronic cervical disk herniation, associated cervical radiculopathy, and cervicogenic headache syndrome. CLINICAL FEATURES: The patient had neck pain with radiating paresthesia into the right upper extremity and incapacitating headaches and had no response to 6 months of conservative therapy. Treatment included spinal manipulative therapy, physical therapy, anti-inflammatory medication, and acupuncture. Magnetic resonance imaging, electromyography, and somatosensory evoked potential examination all revealed positive diagnostic findings. INTERVENTION AND OUTCOME: Treatment included 3 successive days of cervical spine manipulation with the patient under anesthesia. The patient had immediate relief after the first procedure. Her neck and arm pain were reported to be 50% better after the first trial, and her headaches were better by 80% after the third trial. Four months after the last procedure the patient reported a 95% improvement in her overall condition. CONCLUSION: Cervical spine manipulation with the patient under anesthesia has a place in the chiropractic arena. It is a useful tool for treating chronic discopathic disease complicated by cervical radiculopathy and cervicogenic headache syndrome. The beneficial results of this procedure are contingent on careful patient selection and proper training of qualified chiropractic physicians.     

Chiropractic treatment of postsurgical neck syndrome with mechanical force, manually assisted short-lever spinal adjustments

OBJECTIVE: To describe a case of postsurgical neck pain, after multiple spinal surgeries, that was successfully treated by chiropractic intervention with instrumental adjustment of the cervical spine. CLINICAL FEATURES: A 35-year-old woman had chronic neck pain for over 5 years after two separate surgeries of the cervical spine: a diskectomy at C3/4 and a fusion at C5/6. Surgeries were performed 6 months apart in an attempt to resolve persistent neck pain and spasm of the cervical musculature. Neither surgery was effective in relieving the patient's pain. Five years after the second surgery, a third surgery was recommended by the patient's physicians to alleviate the chronic pain. The patient sought chiropractic evaluation of her condition to avoid further surgical intervention. INTERVENTION AND OUTCOME: The patient was treated with conservative instrumental chiropractic manipulation, consisting of mechanical force, manually assisted short-lever spinal adjustments rendered with an Activator Adjusting Instrument (AAI) II. She comfortably tolerated the treatment and responded favorably to this therapy. All chronic symptoms had resolved within 30 days of instituting the chiropractic instrumental adjustments with an AAI. More interestingly, longitudinal examination over the next 2 years showed that the patient experienced no residual effects or further recurrences of her previous chronic problem after her initial course of chiropractic care. CONCLUSION: Chiropractic treatment of postsurgical neck syndrome may be effectively treated, in certain cases, by mechanical force, manually assisted adjusting procedures with an AAI. The use of instrumental adjustment methodology may provide chiropractic physicians with an effective alternative to manual manipulation in those cases in which the patient's surgical history or presenting symptoms make forceful manipulation of the spine, particularly performed at end range, inappropriate. This approach may be contemplated by physicians faced with managing this type of condition. Further study should be made in this regard, in an academic research setting, to determine the safest and most effective approaches to managing postsurgical patients in a chiropractic setting.     

Case study: acceleration/deceleration injury with angular kyphosis

OBJECTIVE: To discuss the case of a patient who received upper cervical chiropractic care after trauma-induced arcual kyphosis in the cervical spine. A practical application of conservative management for posttrauma cervical spine injury in the private office setting is described. Clinical Features: A 17-year-old female patient suffered an unstable C3/C4 motor segment after a lateral-impact motor vehicle collision. Additional symptoms on presentation included vertigo, tinnitus, neck and shoulder pain, and confusion. Intervention and Outcome: Conservative management consisted exclusively of upper cervical-specific adjustments guided by radiographic analysis and paraspinal bilateral skin temperature differential analysis of the cervical spine. During 10 weeks of care and 22 office visits, all symptoms subsided and the instability of C3/C4 motor segment appeared to be completely resolved. CONCLUSION: This study provides support for the use of upper cervical chiropractic management in cervical spine trauma cases. The clinical work-up consisted of physical examination, radiographic analysis, computer-administered and scored cognitive function testing, and audiometric examination. After conservative care, these examinations were repeated and demonstrated that the objective findings concurred with the subjective improvements reported by the patient.     

Reliability study of detection of somatic dysfunctions in the cervical spine

A reliability study was conducted to determine whether palpatory findings on the cervical spine, obtained under normal chiropractic clinical conditions were reproducible. Forty normal freshman chiropractic students underwent static and motion palpation of their cervical spines by three different chiropractors. Intra- and inter-examiner reliability of findings was assessed by concordance statistics (weighted kappa). There was statistically significant agreement of findings for all three examiners only for fixations in the lower cervical spine. There was a total lack of statistical agreement of fixation findings, both intra- and inter-examiner, in the middle cervical area. Agreement of fixation findings was intermediate for the upper cervicals and also for the other palpation parameters that were used (e.g. muscle spasms and pain) throughout the cervical spine. The results generally indicate a relatively high level of replicability of palpatory findings in a normal asymptomatic population by 'typical' chiropractors. The relation of these palpatory findings to vertebral lesions, or subluxations, are unknown.     

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.     

Chiropractic care of a pediatric patient with myasthenia gravis

OBJECTIVE: To describe the chiropractic care of a pediatric patient with complaints associated with myasthenia gravis.Clinical features A 2-year-old girl was provided chiropractic care at the request and consent of her parents for complaints of ptosis and generalized muscle weakness (ie, lethargy), particularly in the lower extremities. Prior to entry into chiropractic management, magnetic resonance imaging of the brain and acetylcholine receptor antibody tests were performed with negative results. However, the Tensilon test was positive and the diagnosis of myasthenia gravis was made by a pediatrician and seconded by a medical neurologist.Intervention and outcome The patient was cared for with contact-specific, high-velocity, low-amplitude adjustments to sites of vertebral subluxation complexes in the upper cervical and sacral spine. The patient's response to care was positive and after 5 months of regular chiropractic treatment her symptoms abated completely. CONCLUSION: There are indications that patients suffering from disorders "beyond low back pain" as presented in this case report may derive benefits from chiropractic intervention/management.     

Vertebral artery dissection in a patient practicing self-manipulation of the neck

OBJECTIVE: The purpose of this case report is to describe a patient who regularly practiced self-manipulation of her neck who presented with shoulder and neck pain and was undergoing a vertebral artery dissection. CLINICAL FEATURES: A 42-year-old female patient sought care for left shoulder pain with a secondary complaint of left lower neck pain. Twelve days prior, she had had "the worst headache of her life," which began in her left lower cervical spine and extended to her left temporal region. The pain was sudden and severe, was described as sharp and burning, and lasted 3 hours. She reported nausea, vomiting, and blurred vision. INTERVENTION AND OUTCOME: Initial history and examination suggested that the patient's head and neck pain was not musculoskeletal in origin, but vascular. She repeatedly requested that an adjustment be performed, but instead was referred to the local emergency department for further evaluation. Magnetic resonance angiogram revealed a dissection of the left vertebral artery from C6 to the C2-C3 interspace and a 3-mm dissecting pseudoaneurysm at the C3 level. She underwent stent-assisted percutaneous transluminal angioplasty combined with antiplatelet therapy (clopidogrel) and experienced a good outcome. CONCLUSION: This case suggests that careful history taking and awareness of the symptoms of VAD are necessary in cases of sudden head and neck pain. More research is needed on the relationship between vertebral artery dissection and self-manipulation of the neck.     

Immediate and lasting effects of a thoracic spine manipulation in a patient with signs of cervical radiculopathy and upper extremity hyperalgesia: A case report

Patients with cervical radiculopathy (CR) may present with accompanying symptoms of hyperalgesia, allodynia, heaviness in the arm, and non-segmental pain that do not appear to be related to a peripheral spinal nerve. These findings may suggest the presence of central or autonomic nervous system involvement, requiring a modified management approach. The purpose of this case report is to describe the treatment of a patient with signs of CR and upper extremity (UE) hyperalgesia who had a significant decrease in her UE pain and hypersensitivity after a single thoracic spine manipulation (TSM). A 48-year-old female presented to physical therapy with acute neck pain radiating into her left UE that significantly limited her ability to sleep and work. After a single TSM, the patient demonstrated immediate and lasting reduction in hyperalgesia, hypersensitivity to touch, elimination of perceived heaviness and coldness in her left UE, and improved strength in the C6-8 myotome, allowing for improved functional activity capacity and tolerance to a multi-modal PT program. Based on these results, clinicians should consider the early application of TSM in patients with CR who have atypical, widespread, or severe neurological symptoms that limit early mobilization and tolerance to treatment at the painful region.     

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.     

Are tender points associated with cervical radiculopathy?

OBJECTIVE: To determine if there is an association between cervical radiculopathy and tender spots in the neck and upper extremity on the side of radiculopathy. DESIGN: Prospective cross-sectional study. SETTING: Outpatient spine clinic within an academic institution. PARTICIPANTS: Convenience sample of 16 subjects with unilateral cervical radiculopathy. Twelve subjects had C7 radiculopathy and 4 had C6 or C8 radiculopathy. INTERVENTION: Bilateral pain-pressure threshold measurement (14 muscles) of the neck and upper extremity. MAIN OUTCOME MEASURE: Side-to-side difference in pain-pressure threshold. RESULTS: Differences in frequency of tender spots were found only in the deltoid and flexor carpi radialis. Overall, more tender spots were found on the side of radiculopathy (75 vs 34, P < .01). Among subjects with C7 radiculopathy, the number of tender spots in C7 innervated muscles was greater on the side of radiculopathy (23 vs 7, P < .02). In contrast, no significant difference in the number of tender spots between sides was found when only non-C7 innervated muscles (P > 0.1) were considered. CONCLUSIONS: Cervical radiculopathy was associated with increased tender spots on the side of radiculopathy, with predilection toward muscles innervated by the involved nerve root.     

Cervicocephalic kinesthetic sensibility in patients with chronic, nontraumatic cervical spine pain.

OBJECTIVE: To investigate cervicocephalic kinesthetic sensibility (head repositioning accuracy to subjective straight ahead) in patients with chronic, nontraumatic cervical spine pain. DESIGN: A prospective, 2-group, observational design. SETTING: An outpatient chiropractic clinic in the United Kingdom. PARTICIPANTS: Eleven patients (6 men, 5 women; mean age +/- standard deviation, 41.1 +/- 13.3 yr; range, 18-55 yr) with chronic, nontraumatic cervical spine pain (mean duration, 24 +/- 18 mo), with no evidence of cervical radiculopathy and/or myelopathy or any other neurologic disorder. Eleven asymptomatic, unimpaired volunteers (5 men, 6 women; mean age, 39.3 +/- 10.3 yr; range, 28-54 yr) with no history of whiplash or other cervical spine injury or pain served as controls. MAIN OUTCOME MEASURES: Cervicocephalic kinesthetic sensibility was investigated by testing the ability of blindfolded participants to relocate accurately the head on the trunk, to a subjective straight-ahead position, after a near-maximal active movement of the head in the horizontal or vertical plane. The active cervical range of motion and the duration and intensity of neck pain were also recorded. RESULTS: Mann-Whitney U testing indicated that the patient (P) group was no less accurate in head repositioning than the control (C) group for all movement directions except flexion (median global positioning error [95% confidence interval], P = 5.7 degrees [5.03-9.10], C = 4.2 degrees [3.17-5.32]; p <.05). CONCLUSIONS: Nontraumatic neck pain patients show little evidence of impaired cervicocephalic kinesthetic sensibility. These results contrast with studies of chronic cervical pain patients in which the origin was not controlled or involved a cervical whiplash injury.     

Vertigo, tinnitus, and hearing loss in the geriatric patient

OBJECTIVE: To document clinical changes after a course of chiropractic care in a geriatric patient with vertigo, tinnitus, and hearing loss. Clinical Features: A 75-year-old woman with a longstanding history of vertigo, tinnitus, and hearing loss experienced an intensified progression of these symptoms 5 weeks before seeking chiropractic care. Radiographs revealed a C3 retrolisthesis with moderate degenerative changes C4-C7. Significant decreases in audiologic function were evident, and the RAND 36 Health Survey revealed subjective distress. Intervention and Outcome: The patient received upper cervical-specific chiropractic care. Paraspinal bilateral skin temperature differential analysis was used to determine when an upper cervical adjustment was to be administered. Radiographic analysis was used to determine the specific characteristics of the misalignment in the upper cervical spine. Through the course of care, the patient's symptoms were alleviated, structural and functional improvements were evident through radiographic examination, and audiologic function improved. CONCLUSION: The clinical progress documented in this report suggests that upper cervical manipulation may benefit patients who have tinnitus and hearing loss.     

Missed cervical spine fracture: chiropractic implications

OBJECTIVE: To discuss the case of a patient with an anterior compression fracture of the cervical spine, which had been overlooked on initial examination. CLINICAL FEATURES: A 36-year-old man was seen at a chiropractic clinic 1 month after diving into the ocean and hitting his head on the ocean floor. He chipped a tooth but denied loss of consciousness. Initial medical examination in the emergency department did not include radiography, but an anti-inflammatory medication was prescribed. Radiographs taken at the chiropractic clinic 1 month later revealed an anterior compression fracture of the C7 vertebra, with migration of the fragment noted on flexion and extension views. INTERVENTION AND OUTCOME: The patient was referred back to his medical doctor for further evaluation and management.He was instructed to wear a Philadelphia collar for 4 weeks. During this time period, he reported "shooting" pain and tingling from his neck into his arms. The patient reported resolution of his neck and arm symptoms at 2.5 months after injury. Follow-up radiographs at 6 months after injury revealed fusion of the fracture fragment with mild residual deformity. At that time, the patient began a course of chiropractic treatment. CONCLUSION: After head trauma, it is essential to obtain a radiograph of the cervical spine to rule out fracture. Chiropractors should proceed with caution, regardless of any prior medical or ancillary evaluation, before commencing cervical spine manipulation after head and neck trauma.     

Epilepsy and seizure disorders: a review of literature relative to chiropractic care of children

OBJECTIVE: To review the currently available literature regarding chiropractic care relative to patients with epilepsy, particular emphasis being placed on those who have epilepsy as children. DATA SOURCES: The Index to Chiropractic Literature was searched for the years 1980 through 1998 through use of the keywords epilepsy and seizure. The MANTIS database was searched for the years 1970 through 2000 through use of the Medical Subject Heading (MeSH) keywords chiropractic, epilepsy, seizure, and child/children. In addition, a MEDLINE search of the literature was performed for the years 1966 through 2000 through use of the same subject headings. RESULTS: The present study reviews 17 reports of pediatric epileptic patients receiving chiropractic care. Fourteen of the 17 patients were receiving anticonvulsive medications, which had proven unsuccessful in the management of the condition. Upper cervical care to correct vertebral subluxation was administered to 15 patients, and all reported positive outcomes as a result of chiropractic care. CONCLUSIONS: Chiropractic care may represent a nonpharmaceutical health care approach for pediatric epileptic patients. Current anecdotal evidence suggests that correction of upper cervical vertebral subluxation complex might be most beneficial. It is suggested that chiropractic care be further investigated regarding its role in the overall health care management of pediatric epileptic patients.     

Seventh cervical rib associated with subclavian artery occlusion and multiple infarcts: case report

A cervical rib, or supernumerary (extra) rib arising from the 7th cervical vertebra, is a congenital abnormality that occurs in less than 1% of the population. Clinically, it can cause obscure nervous or vascular symptoms and be difficult to diagnose. In this rare case, a 37-year-old woman developed a subclavian artery occlusion after undergoing a chiropractic manipulation for neck, shoulder, and arm pain. The occlusion led to multiple cerebellar infarcts, frontal subarachnoid hemorrhage, myocardial infarction, and right-hand vascular compromise. The patient was subsequently diagnosed with a 7th cervical rib, which likely caused compression of the subclavian artery after a hyperextension injury sustained during the chiropractic procedure. The departments of vascular surgery, neurosurgery, cardiology, and neurology collaborated to review all elements of the patient's diagnosis and care. After the patient was stabilized, she spent 6 weeks in acute inpatient rehabilitation; upon discharge, her symptoms were greatly improved but still present. Three months later, the patient underwent a subclavian-artery-to-axillary-artery bypass with resection of the left cervical rib. She tolerated surgery well with no complications. As a result of the devastating insults sustained secondary to the presence of the 7th cervical rib and her subclavian artery occlusion, this patient faced months of recovery. Treatment involved a structured interdisciplinary plan of care.     

T2 radiculopathy: A differential screen for upper extremity radicular pain

Radicular pain in the upper extremity can have a cervical origin terminating at the cervicothoracic junction (C8, T1). Review of the literature suggests cutaneous representations of T2 nerve root to the axilla, posteromedial arm, and lateral forearm, suggesting yet another source of upper extremity radicular pain. A 53-year-old female experienced insidious right upper thoracic pain radiating into the right axilla, upper arm, and lateral forearm (10/10 numerical pain rating scale (NPRS)) of 1-week duration. Medical referral suggested cervical radiculopathy, however, cervical spine examination was unremarkable. She presented with mechanical dysfunction of C8, T1; T1, T2; and T2, T3 vertebral segments with restricted cervical extension. Firm compression over the right lateral aspect of the second and third thoracic vertebrae reproduced her symptoms markedly. There was a predominance of right axillary pain. Cervical extension reproduced local upper thoracic pain. Nine treatment visits for a period of 3 weeks addressed mechanical dysfunction at the cervicothoracic junction and upper thoracic region, comprising manual therapy, corrective exercise, and pain modalities. Reduction of local tenderness, and radiating axillary and right arm pain was observed (2/10 NPRS), with improved cervical extension. The second thoracic intercostal nerve and the adjoining intercostobrachial nerve, medial antebrachial cutaneous nerve, and the posterior brachial cutaneous branch of the radial nerve are speculated to be potential symptom mediators. They have a representation to the axilla, medial and posterior arm, and lateral forearm – a representation supporting the speculation of upper extremity radicular symptoms following mechanical dysfunction of the upper thoracic vertebrae.     

Evidence-Based Approach to the Physical Therapy Diagnosis and Management of Neck and Upper Extremity Pain using Cervical and Thoracic Spine Thrust Manipulation: A Case Report

Abstract

Neck and upper extremity pain are common medical diagnoses for patients seeking physical therapy care. The purpose of this case report is to describe an evidence-based approach to the physical therapy diagnosis and management of a 46-year-old female reporting insidious onset neck pain and bilateral upper extremity paraesthesiae of two years duration. Evaluation of examination data, based on research data with regard to diagnostic accuracy of the tests and measures used, indicated a diagnosis of cervical radiculopathy. Management was based on a treatment-based classification approach and focused on restoring mobility by way of thrust manipulations directed at the thoracic and cervical spine. At the completion of the physical therapy plan of care (8 visits), the patient rated her perceived improvement on the Global Rating of Change Scale as "a very great deal better." The Numerical Pain Rating Score improved from 6/10 to 0/10. Patient-perceived disability, as measured by the Neck Disability Index, improved from 26% to 0%, and the patient's score on the modified Oswestry Disability Index improved from 30% to 0%. Bilateral upper extremity paraesthesiae also had completely resolved. These clinically meaningful improvements in pain and perceived disability were maintained six weeks after discharge. While a cause-and-effect relationship cannot be inferred from a case report, it is plausible that an orthopaedic manual physical therapy approach in the management of patients with both neck and upper extremity pain may result in decreased pain and improved function. Further clinical trials are needed to test this hypothesis.     

Recognition of prodromal cervical spondylotic myelopathy presenting in a U.S. Veteran referred to chiropractic for acute thoracic pain: A case report

ObjectiveTo highlight a patient who was referred to a VA chiropractic clinic for thoracic pain and upon physical exam was found to be myelopathic, subsequently requiring surgery.Clinical featuresA 58-year-old male attended a telephone interview with the VA chiropractic clinic for thoracic pain of 4 months duration; he denied neck pain, upper extremity symptoms or clumsiness of the feet or hands. At his in-person visit, he acknowledged frequently dropping items. The physical examination revealed signs of myelopathy including positive Hoffman's bilaterally, 3+ brisk patellar reflexes, and 5+ beats of ankle clonus bilaterally. He also had difficulty walking heel/toe.Intervention and outcomeCervical and thoracic radiographs were ordered and a referral was placed to the Physical Medicine and Rehabilitation (PM&R) Clinic for evaluation of the abnormal neurologic exam and suspicion of cervical spondylotic myelopathy (CSM). He was treated for 2 visits in the chiropractic clinic for his thoracic pain, with resolution of thoracic symptoms. No treatment was rendered to the cervical spine.The PM&R physician ordered a cervical MRI which demonstrated severe central canal stenosis and increased T2 signal within the cord at C5–C6, representing myelopathic changes. The PM&R specialist referred him to Neurosurgery which resulted in a C5-6, C6-7 anterior cervical discectomy and fusion.ConclusionThe importance of physical examination competency and routine thoroughness cannot be overstated. Swift identification of pathologic signs by the treating chiropractor resulted in timely imaging and surgical intervention.