Uneventful upper cervical manipulation in the presence of a damaged vertebral artery

OBJECTIVE: To discuss a case in which a patient with a previously injured vertebral artery underwent manipulation in the upper cervical spine without alteration of her symptom pattern. The literature concerning the relative safety of specific upper cervical manipulative techniques is reviewed. CLINICAL FEATURES: A 42-year-old woman had a 3-week history of unilateral suboccipital pain that she related to a sudden twisting of her head and neck that occurred while she was putting sheets of drywall on top of her car. Subsequent examination by a neurologist 2 weeks later was unremarkable, and a tension-type headache was diagnosed. Approximately 10 days later (3 weeks after injury), a single high-velocity upper-cervical manipulation (incorporating slight rotation and full lateral flexion) was performed with no change in her symptom pattern. Two weeks after that, the patient had development of a lateral medullary syndrome (also known as Wallenberg syndrome) after she briefly extended and rotated her upper cervical spine while painting a ceiling. INTERVENTION AND OUTCOME: The patient was treated with anticoagulant therapy, and the lateral medullary infarct healed without incident. The spinocerebellar and subtle motor symptoms also resolved, but the ipsilateral suboccipital headache and the loss of temperature sensation associated with the spinothalamic tract lesion were still present 9 months later. CONCLUSION: This case report demonstrates that vigorous manipulation of the upper cervical spine is possible without injuring an already damaged vertebral artery. It is suggested that the line of drive used during the single manipulation, almost pure lateral flexion with slight rotation, was responsible for the apparent innocuous response. Guidelines for the evaluation and management of vertebral artery dissection are reviewed. Because it is currently impossible to identify patients at risk of having a dissected vertebral artery with standard in-office examination procedures, rotational manipulation of the upper cervical spine should be abandoned by all practitioners, and schools should remove such techniques from their curriculums.     

A preschool-age child with first-time seizure and ataxia

We present a case of a 4-year-old previously healthy child who had a possible first-time seizure at home, and upon a second Emergency Department evaluation was found to have gross cerebellar ataxia suggestive of acute stroke. Initial computed tomography scan and metabolic work-up were unrevealing. Subsequent neuroimaging demonstrated stroke in the left medulla and cerebellum secondary to left vertebral artery dissection. Cervical artery dissection may cause up to 20% of strokes in childhood and adolescence. Unlike typical adult presentations, antecedent or concurrent head and neck pain occurs less often in pediatric dissections. Symptoms of posterior circulation ischemia resulting from vertebral artery dissection may include vertigo, vomiting, ataxia, dysarthria, and seizure. Willingness to utilize newer, non-invasive imaging modalities may lead to earlier recognition of cervical artery dissection when patients have prodromal symptoms or episodes of transient ischemia. Vertebral artery dissection should be included in the differential diagnosis when evaluating children with first time seizure, headache, or neck pain.     

Left vertebral artery dissection causing bilateral internuclear ophthalmoplegia

A 21-year-old woman presented to the emergency department 1 day after a fall. On the day of presentation, she awoke with horizontal diplopia and posterior neck pain. Based on clinical findings, she was diagnosed with bilateral internuclear ophthalmoplegia. A conventional angiogram identified a left vertebral artery dissection. She was started on anticoagulant therapy, with gradual improvement of her diplopia over several months. Diplopia is frequently seen in the emergency department. Internuclear ophthalmoplegia is a cause of binocular diplopia and is important to recognize because it indicates a brainstem lesion requiring neurologic evaluation.     

Headache and Neck Pain: The Warning Symptoms of Vertebral Artery Dissection

SYNOPSIS
The clinical features of headache and neck pain in 14 patients with extracranial vertebral artery dissection proven by angiography or magnetic resonance imaging are reported. Pain was always located on the side of the dissected vertebral artery. Whereas eleven patients had head and posterior neck pain, the others had either only posterior neck pain, no change of a chronic pre-existing headache or no pain at all. Pain started suddenly, was of sharp quality and severe intensity, different from any previously experienced headache. Following acute onset, the time course of pain was monophasic with gradual remission of a persistent headache lasting one to three weeks. A delay between onset of head or posterior neck pain and onset of neurologic dysfunction was noted in 12 patients and was less than one day and between one day and three weeks in six each. Report of this distinct type of pain, although non-specific as an isolated symptom, should raise suspicion of an underlying vertebral artery dissection. Early confirmation of this diagnosis and subsequent anticoagulation if dissection does not extend intracranially may help prevent vertebro-basilar ischemic deficits.     

头颈部血管超声在评估突发性聋合并颈椎病中的应用

目的探讨头颈部血管超声在评估突发性聋合并颈椎病中的应用。 方法前瞻性选取2016年8月至2017年8月于首都医科大学附属北京朝阳医院耳鼻喉科确诊为伴有椎动脉型颈椎病的突发性聋患者58例设为A组,无颈椎病的突发性聋患者58例设为B组;另收集同期确诊为椎动脉型颈椎病而无突发性聋的患者58例设为C组。患者取平卧位和坐位+头部屈位40°体位,行颈部血管超声检查;患者取俯卧位行经颅多普勒超声检查,并进行转颈试验。记录双侧颈内动脉、双侧椎动脉、基底动脉的平均血流速度,同一血管血流速度不同体位前后比较采用配对t检验,多组血管间血流速度比较采用方差分析。 结果坐位+低头40°体位颈部血管超声检查发现,与平卧位检查相比,双侧颈内动脉流速3组均出现不同程度减低。其中存在椎动脉型颈椎病的2组双侧颈内动脉流速变化差异有统计学意义（A组左侧颈内动脉P=0.004,右侧颈内动脉P=0.011;C组双侧颈内动脉P=0.000）;无颈椎病突发性聋组双侧颈内动脉流速变化差异无统计学意义（B组双侧颈内动脉P均＞0.05）。俯卧位经颅多普勒超声检查结果显示,3组间基底动脉、双侧椎动脉流速比较,差异均有统计学意义（P均=0.000）。在转颈试验中,3组的基底动脉和双侧椎动脉流速与俯卧位相比,均有不同程度减低,其中伴有椎动脉型颈椎病的2组基底动脉和双侧椎动脉流速,转颈试验前后比较差异均有统计学意义（A组基底动脉P=0.039,双侧椎动脉P=0.001;C组基底动脉P=0.042,右侧椎动脉P=0.000,左侧椎动脉P=0.011）;无颈椎病突发性聋组基底动脉和双侧椎动脉流速变化差异无统计学意义（B组P均＞0.05）。 结论头颈部血管超声结合患者体位变化可以较好地反映颈内动脉以及椎动脉、基底动脉流速变化情况,从而为明确突发性聋患者是否存在椎动脉型颈椎病提供诊断依据。     

Emergency repair of aortic dissection in a 37-week parturient: a case report

Aortic dissection is a life-threatening condition with a 50% mortality rate in the first 48 hours and a 3-month mortality rate of 90% in untreated patients. Aortic dissection is a rare complication of pregnancy, but there is significant morbidity and mortality for the mother and infant. A 43-year-old woman with a 37-week intrauterine pregnancy was admitted to the emergency department 6 hours after the onset of tightness in her throat and neck pain. She described the pain as similar to pain she experienced with a myocardial infarction 2 years previously. Other pertinent history included hypertension, gestational diabetes, coronary artery disease, and a family history of aortic dissection. The patient was initially misdiagnosed. Transthoracic echocardio-" gram and computed tomography scan revealed a type A thoracic aortic dissection extending into the abdominal aorta. An emergency aortic repair and cesarean section were successfully performed. Recognition of aortic dissection and an evidence-based, collaborative approach to optimize treatment and recovery are vital to the patient's survival. The purpose of this article is to highlight successful management of aortic dissection in a parturient and to broaden the body of literature on the topic.     

Ischemic stroke with left hemiparesis or shock should be evaluated by computed tomography for aortic dissection

An 82-year-old woman with consciousness disturbance, left hemeparesis, and dysarthria was discovered at home by her family and was transported to a hospital. On arrival, she remained in a sleepy and disorientated and shock state. She complained of nausea but no chest or back pain. She obtained stable circulation after infusion. Her chest roentgen results showed widening of the mediastinum and the existence of a separation of the intimal calcification from the outer aortic soft tissue border, thus suggesting a Stanford A–type aortic dissection. Her head computed tomography depicted no signs of cerebral infarction. Because she did not complain of any pain, the possibility of acute phase aortic dissection was rejected. A permissive hypertensive therapy was initiated. Next day, she suddenly died. We diagnosed that she had died of a Stanford A–type aortic dissection based on the following facts: (1) patients presenting with stroke due to a Stanford A–type aortic dissection tend to have left hemiparesis because of malcirculation of the innominate artery and (2) a patient presenting with stroke by aortic dissection may have hypotension, which is unusual in standard stoke cases. Ischemic stroke induced by aortic dissection is not common among the patients with aortic dissection. However, given the high morbidity and mortality after misdiagnosis of aortic dissection, patients with ischemic stroke with left hemiparesis or shock should be evaluated by enhanced truncal computed tomography.     

Cervical Spondylodiscitis,Osteomyelitis, and Epidural Abscess Mimicking a Vertebral Fracture

Background: Spinal vertebral fractures are common in elderly patients, especially after a significant fall. Neck tenderness or neurologic deficits after a fall should increase the suspicion of cervical spinal fracture. Case Report: A 75-year-old woman complained of 2 weeks of gradually increasing neck and right shoulder pain after a fall. She had an X-ray study that appeared to show an unstable C6–C7 fracture. A computed tomography scan of the neck revealed no fracture and was consistent with spondylodiscitis and osteomyelitis of C6 and C7, with an adjacent epidural abscess and mild cord compression. Conclusion: It is important to consider this diagnosis in patients with a history of infective endocarditis who develop back pain, to minimize morbidity associated with this disorder.     

Tortuosity of the vertebral artery resulting in vertebral erosion

OBJECTIVE: To discuss the case of a patient with unilateral vertebral artery tortuosity and dilatation resulting in vertebral body and transverse foramen erosion. An emphasis is placed on diagnostic imaging. CLINICAL FEATURES: A 45-year-old man had a frozen shoulder and headaches. Previous arm pain, numbness, and a cold extremity were the result of occlusion of the subclavian artery and had been treated with a subclavian-carotid bypass procedure. INTERVENTION AND OUTCOME: As a result of the angiographic detection of the left vertebral artery dilatation and tortuosity and the concomitant hypoplastic right vertebral artery, high-velocity, low-amplitude manipulation of the cervical spine was contraindicated. However, the patient's symptoms were not related to these findings. Alternatively, low-force manipulation of the cervical spine, shoulder range of motion and muscle techniques were used, and the patient's symptoms diminished significantly with improved shoulder range of motion. CONCLUSION: Clinicians need to be alert to clinical presentations and appropriate imaging protocols in cases of suggested vertebral artery anomaly.     

Spinal cord injury associated with thoracic osteoporotic fracture

This report details a case of sudden neurologic deficit attributable to acute thoracic fractures associated with senile osteoporosis. A 73-yr-old female patient with a history of occasional back pain during the past 4 mos had sudden thoracic vertebral fracture with spinal cord injury. The patient, who had a benign past medical history, had not been evaluated for osteoporosis. Thoracic spine radiographs showed a compression fracture at T8. Thoracic magnetic resonance imaging exposed a compression fracture at T7-T8. She was treated operatively. She was found to have spinal cord injury with American Spinal Injury Association classification C (T7), and she had poor sitting balance. She was discharged in a wheelchair and was administered clean intermittent catheterization every 6 hrs. Six months after discharge, she ambulated with a walker and had spontaneous micturition. Vertebral fractures are a common presentation of senile osteoporosis. The risk of neurologic impairment attributable to vertebral fracture is a rare but potentially severe complication. Besides medical therapy and suitable rehabilitation programs, surgical treatment is an integral part of the management of patients with osteoporotic vertebral fractures.     

Isolated unilateral hypoglossal nerve palsy due to vertebral artery dissection

We report the case of a patient with unilateral tongue weakness secondary to an isolated lower motor neuron hypoglossal nerve palsy that was caused by a right vertebral artery dissection in the lower neck. The patient had a boggy tongue with a deviation to the right side but an otherwise normal neurological examination. Magnetic resonance angiography showed a narrow lumen of the right vertebral artery in the neck. After initially treating the patient with aspirin in the emergency room and later with warfarin for three months, there was complete recanalization of the right vertebral artery. Only one other case of vertebral artery dissection and twelfth nerve palsy has been reported before.     

Cervical manipulation to a patient with a history of traumatically induced dissection of the internal carotid artery: a case report and review of the literature on recurrent dissections.

OBJECTIVE: To describe the use of rotational cervical manipulation in treating a patient who had undergone a traumatically induced dissection of the internal carotid artery and to review the literature on recurrent cervical artery dissections. CLINICAL FEATURES: A 21-year-old woman with hemiparesis from an internal carotid artery dissection that occurred as the result of a motor vehicle accident had neck pain and headaches. Moderate range of motion restrictions in the neck were present along with articular restrictions to movement palpation. INTERVENTION AND OUTCOME: After a year of soft-tissue treatment, we obtained detailed, informed consent from the patient to attempt diversified manipulation to the neck. The patient described greater and more immediate relief and longer pain-free periods than could be achieved by soft-tissue treatment alone. CONCLUSION: Patients with previous cervical artery dissections may present with unrelated neck pain and headaches and request treatment. In selected cases, with complete informed consent, manipulation of the neck may relieve these symptoms. A review of published case reports on recurrent dissections suggests that trauma is not a significant factor in the second dissection. Care must be taken in extrapolating the results from this case to any other patient with a history of cervical artery dissection.     

Diagnosis of intermittent vascular claudication in a patient with a diagnosis of sciatica.

BACKGROUND AND PURPOSE: The purpose of this case report is to illustrate the importance of medical screening to rule out medical problems that may mimic musculoskeletal symptoms. CASE DESCRIPTION: This case report describes a woman who was referred with a diagnosis of sciatica but who had signs and symptoms consistent with vascular stenosis. The patient complained of bilateral lower-extremity weakness with her pain intensity at a minimal level in the region of the left sacroiliac joint and left buttock. She also reported numbness in her left leg after walking, sensations of cold and then heat during walking, and cramps in her right calf muscle. She did not report any leg pain. A medical screening questionnaire revealed an extensive family history of heart disease. Examination of the lumbar spine and nervous system was negative. A diminished dorsalis pedis pulse was noted on the left side. Stationary cycling in lumbar flexion reproduced the patient's complaints of lower-extremity weakness and temporarily abolished her dorsalis pedis pulse on the left side. OUTCOMES: She was referred back to her physician with a request to rule out vascular disease. The patient was subsequently diagnosed, by a vascular specialist, with a "high-grade circumferential stenosis of the distal-most aorta at its bifurcation." DISCUSSION: This case report points out the importance of a thorough history, a medical screening questionnaire, and a comprehensive examination during the evaluation process to rule out medical problems that might mimic musculoskeletal symptoms.     

Anomalous left anterior descending artery diagnosed on pulmonary artery computed tomography

Typically, the left anterior descending artery (LAD) and left circumflex artery (LCX) arise from the left main coronary artery.However, uncommon coronary anomalies may be found in clinical practice. This case presents with a rare finding where the LAD originates from the right coronary artery (RCA) separately from the LCX and takes an interarterial pathway to reach its perfusion territory.A 49-year-old Hispanic female with hypertension and diabetes mellitus presented to the emergency department with a 7-day history of chest pain. She denied nausea, diaphoresis, syncope, or other symptoms. A grade 3 out of 6 systolic murmur was noted on physical examination. Computed tomography of the pulmonary arteries (CTPA) revealed that the patient had no left main coronary artery. The patient's LAD arose from the proximal RCA and took an inter-arterial course. Subsequent coronary catheterization showed no stenosis of the coronary arterial system. The patient's chest pain subsided during the course of her admission and she was deemed stable for discharge with close cardiology follow up.In general, coronary artery anomalies are an uncommon finding in clinical practice. However, it is important to realize the different pathways of coronary artery anomalies because those with the inter-arterial subtype, such as our patient, may result in sudden cardiac death. All cases of clinically suspected inter-arterial coronary artery anomalies are recommended to undergo imaging studies to help visualize anatomic features as a guide for further management. This case represents the first reported diagnosis of this type of anomalous coronary artery on CTPA.     

Arteriovenous fistula between the left vertebral artery and the inferior thyroid vein: a case report

Arteriovenous fistula between the left vertebral artery and the inferior thyroid vein is a rare entity. This condition can change the blood supply of the basilar artery system, and then lead to an abnormal blood supply of the vertebral body. Therefore, this rare condition may be misdiagnosed in the clinic. We report an arteriovenous fistula between the left vertebral artery, which was found during an interventional operation of a 49-year-old Asian man. He was non-diabetic and an ex-smoker, and presented with a 1-month history of pain in the neck, shoulder, waist, back, and right lower limb. Vascular angiography showed an arteriovenous fistula, and coils were placed in the fistula. In this setting, coil embolization was effective, and a 1-year follow-up suggested that a good long-term result was likely.     

Neck pain and minor trauma: normal radiographs do not always exclude serious pathology

A 37-year-old woman presented following a trampolining accident with neck pain and paraesthesia of the left arm. Cervical spine radiographs were normal and a provisional diagnosis of whiplash was made. Three hours later she developed rotational vertigo and then cerebellar signs. Magnetic resonance angiography and magnetic resonance imaging of the brain confirmed the diagnosis of vertebral artery dissection (VAD) with cerebellar embolic infarcts. She was anticoagulated and symptoms resolved over one week. VAD is a relatively common cause of posterior circulation stroke in young people. It usually presents following (often minor) trauma, with headache, neck pain, cerebellar, sensory and cranial nerve signs. However, it remains a diagnosis that is frequently missed or misdiagnosed.     

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.     

The Use of Tissue Plasminogen Activator in the Treatment of Wallenberg Syndrome Caused by Vertebral Artery Dissection

Background

Acute cerebrovascular accident (CVA) is a devastating cause of patient morbidity and mortality. Up to 10% of acute CVAs in young patients are caused by dissection of the vertebral or carotid artery. Wallenberg syndrome results from a CVA in the vertebral or posterior inferior artery of the cerebellum and manifests as various degrees of cerebellar dysfunction. The administration of a thrombolytic medication has been recommended in the treatment of patients with stroke caused by cervical artery dissection. Surprisingly, there is scant literature on the use of this medication in the treatment of this condition.

Transcranial sonography and vertebrobasilar insufficiency

OBJECTIVE: The objective was to discuss a case illustrating the role of transcranial Doppler sonography in the screening and treatment of a patient with intermittent vertebral artery brainstem ischemia. CLINICAL FEATURES: A 28-year-old woman had neck pain, arm pain, headaches, and dizziness. Her symptoms occurred intermittently over several years. Past care had provided little relief. De Kleyn's test, transcranial Doppler sonography, and magnetic resonance imaging/magnetic resonance angiography helped establish a diagnosis of vertebrobasilar syndrome. INTERVENTION AND OUTCOME: The patient was referred for neurosurgical evaluation. She subsequently chose to be treated with spinal manipulative therapy. Her neck pain, headaches, and radicular symptoms resolved. The dizzy spells abated to a tolerable level. The neurosurgeon subsequently re-evaluated the patient and recommended that surgery not be performed. CONCLUSIONS: This illustrates a case of extra-arterial mechanical compression of the vertebral arteries documented by transcranial Doppler sonography procedures. Brainstem symptoms were correlated with a documented perfusion deficit during cervical positional testing. This case also demonstrated that spinal manipulative therapy may be safely used on patients with vertebrobasilar insufficiency when the biomechanics and related flow studies are elucidated.