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Chiropractic care of a patient with vertebral subluxations and unsuccessful surgery of the cervical spine
Journal of Manipulative and Physiological Therapeutics Volume 24 • Number 7 • September 2001 0161-4754/2001/$35.00 + 0 76/1/117084 © 2001 JMPT
Chiropractic Care of a Patient with Vertebral Subluxations and Unsuccessful Surgery of the Cervical Spine Joel Alcantara, DC,a Gregory Plaugher, DC,b Richard E. Thornton, DC,c and Chris Salem, DCd
ABSTRACT Objective: The chiropractic care of a patient with vertebral subluxations, neck pain, and cervical radiculopathy after a cervical diskectomy is described. Clinical Features: A 55-year-old man had neck pain and left upper extremity radiculopathy after unsuccessful cervical spine surgery. Intervention and Outcome: Contact-specific, highvelocity, low-amplitude adjustments (ie, Gonstead technique) were applied to sites of vertebral subluxations. Rehabilitation exercises were also used as adjunct to care. The patient reported a decrease in neck pain and left arm pain after chiropractic intervention. The patient also demonstrated a
marked increase in range of motion (ROM) of the left glenohumeral articulation. Conclusion: The chiropractic care of a patient with neck pain and left upper extremity radiculopathy after cervical diskectomy is presented. Marked resolution of the patient’s symptoms was obtained concomitant with a reduction in subluxation findings at multiple levels despite the complicating history of an unsuccessful cervical spine surgery. This is the first report in the indexed literature of chiropractic care after an unsuccessful cervical spine surgery. (J Manipulative Physiol Ther 2001;24:477-82) Key Indexing Terms: Cervical Spine; Surgery; Chiropractic
INTRODUCTION
CASE REPORT
Neck pain with upper extremity involvement is considered common in the general population. Epidemiological studies based on surveys of the Scandinavian general population place neck and shoulder pain at 16% to 18% for a 1year prevalence.1,2 One aspect of neck pain with upper extremity involvement may be attributed to cervical radiculopathy. This diagnosis is the result of mechanical and biochemical irritation of the spinal nerve root(s) in the cervical spine caused by cervical disk herniation, spondylosis, and subluxation. Differential diagnostic considerations include extraspinal or intraspinal tumors, upper extremity nerve entrapment, brachial plexus disorders, neuropathies, and infections. We discuss the chiropractic management of a patient with subluxations and complaints of neck pain with upper extremity involvement.
Patient History
a Assistant Professor, Life Chiropractic College West, Wayward, Calif. b Director of Research, Life Chiropractic College West, Hayward, Calif. c Private Practice of Chiropractic, Auburn, Calif. d Private Practice of Chiropractic, San Jose, Calif. This study was funded by Life Chiropractic College West, Hayward, Calif, Gonstead Clinical Studies Society, Mount Horeb, Wis, and Palmer College of Chiropractic West, San Jose, Calif. Submit reprint requests to: Joel Alcantara, DC, Research Department, Life Chiropractic College West, 25001 Industrial Blvd, Hayward, CA 94545. E-mail: [email protected]. Paper submitted August 9, 2000.
doi:10.1067/mmt.2001.117084
The patient was a 55-year-old highway patrolman treated by one of us (RET) for complaints of neck pain, bilateral upper extremity pain, paresthesia, and weakness. He related the following history leading to his condition. While responding to an auto accident during an ice storm, the patrolman slipped getting out of his car and fell backward, landing on his upper back and neck. A few days later, he began to experience an unusual pain in his neck. Two months after the accident, he consulted a medical doctor, who subsequently referred him to a neurologist. During the neurologic examination, the patient experienced a seizure that eventually led to a diagnosis of pheochromocytoma, a tumor of the adrenal gland. Several weeks later, the patient had surgery to excise the tumor, resulting in temporary relief of the neck pain. After returning to work 6 weeks after surgery, the patient progressively began to experience neck pain again, which he described as “sharp,” along with pain, numbness, and tingling in both arms. The patient continued to work for about 6 to 7 months, but his condition worsened, and he was was referred to a neurosurgeon. According to his medical report, the patient experienced pain in his right arm. Magnetic resonance imaging (not available) showed disk bulging or herniation, or both, at the C4-5, C5-6, and C6-7 vertebral levels. According to his medical doctor, it was impossible to determine the involved spinal level that was causing his right-arm pain until weakness in his right triceps and a decreased triceps reflex developed, indicating C6-7 intervertebral disk
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Subluxation and Unsuccessful Cervical Spine Surgery • Alcantara et al
Fig 1. Oblique radiograph showing severe spinal stenosis of the IVF at C4-C5 and C5-C6.
involvement. The patient consented to surgery, and an anterior cervical diskectomy was performed in April of 1992. The sharp neck pain disappeared after spinal surgery, but the patient still experienced tingling in the arms along with weakness (greater on the left than the right). Four to 6 weeks after surgery, the patient’s neck pain returned, now described as a “burning intense pain.” When he returned to the surgeon for a postsurgery check-up and had continuing complaints, he asked when the surgeon wanted to see him again. The answer was, “I never want to see you again.” This was devastating for the patient, and he assumed that he was destined to live with these problems for life. The postoperative diagnosis by the medical doctor remained as right C6-7 radiculopathy. For the next 2 to 3 years the patient’s left arm became weak to the point of being unable to perform adduction and forward flexion. He was unable to use his left arm to remove his wallet from the left hip pocket or loop a belt through his pants. A second neurologic consult resulted in longitudinal traction treatment for approximately 2 months, which the patient felt was not very successful. His condition continued to deteriorate.
Chiropractic Examination Approximately 31⁄2 years after surgery, the patient consulted one of us (RET) for chiropractic care. Physical examination of the patient showed the following notable findings. On palpation, there was marked point tenderness at the C5 spinous process, slightly less at C6, and minimal at T6. In addition, the C5 spinous region was edematous. Motion palpation of the cervical spine was performed at the atlanto-occipital and atlas-axis articulation as well as the rest of the cervical motion segments. Palpation findings confirmed the presence of fused segments in the lower cervical spine. The C5 spinous process was restricted
on left rotation (+θY), and there was a noticeable limited cervical ROM on left lateral flexion. Nervoscope instrumentation3 showed moderate readings at T1 to the right (needle deflection =15 points), a very minimal reading at C5, and an approximate 10-point needle deflection at T6. Subluxation findings at the left sacroiliac (SI) joint and the lumbar spine were also found as evidenced by static palpation, motion palpation, nervoscope instrumentation, and radiographic findings. Radiographic analysis confirmed the diskectomy at the C6-C7 functional spinal unit. Oblique views (left posterior) of the right intervertebral foramen (Fig 1) showed decreased diameters, particularly at the C5-6 motion segment. The patient’s original symptoms were of the right upper extremity. After surgery and during the chiropractor’s examination, the symptomatology was bilateral with more severity on the left extremity. The right posterior oblique view to demonstrate the left intervertebral foramen was unavailable. On the lateral view (Fig 2), the fifth cervical vertebral body was displaced posterior and inferior with respect to C6. The cervical spine was hypolordotic/mild kyphotic and classified as a D4 disk.4 Comparative lateral radiographs were obtained at approximately 1 month (Fig 3) and 10 months (Fig 4) after initiating chiropractic care. The anteroposterior radiograph is shown in Fig 5. Full-spine radiographs (not pictured) showed a level pelvis with slight posterior rotation of the right innominate. The lateral lumbar view (not shown) demonstrated severe exostosis at the anterior body of L3 and the intervertebral disk at L3-L4 rated as a D5.5 Subluxation findings are summarized as follows: C5 PLI [–Z, –θY, –θZ], T1 PRS [–Z, +θY, –θZ], T3 PRS [–Z, +θY, –θZ], T6 PRS [–Z, +θY, –θZ], and PI [–Z, –θX] of the right innominate. Neurologic testing showed normal deep tendon reflexes of +2 at C5-7 and T1, bilaterally. However, the patient was unable to perform left arm abduction. Specifically, he could not raise his arm more than 5 to 6 inches from his side. In terms of functionality, the patient was unable to loop his belt through his pants because he could not extend his left arm posteriorly more than a few inches. He was also unable to reach for his wallet from the left hip pocket. His left arm measured 121⁄2 inches in diameter at mid humerus; his right arm, 131⁄2 inches. The patient indicated that he had been in this condition for about 3 years and was slowly deteriorating.
Chiropractic Care A specific contact, high-velocity, low-amplitude adjustment was applied by using the Gonstead Technique.6 The adjustment was a PL-inf [–Z,–θX,–θY] of the fifth cervical vertebra with a spinous contact in the seated position. Because the fifth spinous process was inferior [–θX] and very close to the C6 spinous process, it was necessary to flex the patient’s head foreward to get a good posterior-to-anterior line of correction during the setting. He was also adjusted at the third and sixth thoracic vertebrae, and at the first thoracic level at a different visit. The T1 was adjusted in the cervical chair (ie, Gonstead); and the T3 and T6, with the patient in the prone position. The patient’s right ilium was adjusted as a PI [–Z, –θX] listing (on 2 visits) in the side posture position.
Journal of Manipulative and Physiological Therapeutics Volume 24 • Number 7 • September 2001
Subluxation and Unsuccessful Cervical Spine Surgery • Alcantara et al
Fig 2. Lateral cervical radiograph showing hypolordosis of upper cervical spine combined with mild kyphosis at C3-C5. There is retrolisthesis present at C4 and C5. Diskectomy is noted at C6-C7.
Fig 3. Comparative cervical lateral radiograph taken 1 month after initial chiropractic care showing a slight improvement in the cervical lordosis of upper cervical segments.
The chiropractic care began on August 14, 1996, and was repeated on the 16th, 18th, and 21st. After receiving the first set of adjustments, the patient indicated that his ability to raise his left arm had increased by 50% and that his neck pain and arm complaints were also relieved. Sometimes there was no pain during the 2-hour drive home after treatment. The patient was very astonished and excited by the results of the care he received. By August 28th, 1996, he was able to fully abduct his left arm and to loop his belt to his pants. The patient received further care as a result of recurring weakness and pain in the left arm. However, he never lost the range of motion gained in the first 2 weeks of care. In 1996, the patient made a total of 16 visits. On 2 of these occasions, he required no treatment. In 1997, he was seen a total of 11 times; and in 1998, 8 times. The patient has been very active on his small ranch performing various odd jobs and has, on occasion, had some exacerbations because of overactivity. He has been given arm exercises, (ie, the use of free weights for biceps flexion, triceps extension, and deltoid adduction) and low back exercises. On last measurement (approximately 1 year follow-up) his left arm had gained a half inch in diameter at mid-humerus. The patient was last seen on December 1, 1998, and only had complaints of mild low back pain and mild neck pain with occasional left-hand numbness.
scientifically proven in a randomized controlled clinical trial; however, it is thought to be effective, particularly in the treatment of neck pain and associated radicular symptoms.7,8 According to Grob,9 70% to 80% of cases of cervical radiculopathy symptoms could be treated by conservative means. These include the use of oral medications, soft collars, cervical traction, and other physical therapy modalities. Patients with associated radiculopathy might also achieve relief of neck pain with the use of corticosteroids. Failure of the above conservative approaches may result in cervical diskectomy and fusion for the patient. As such, spine surgery ranks as one of the most common inpatient surgical procedures in the United States.10-14 In considering only spinal fusions, there was a 310% increase from 36,000 in 1985 to 111,400 in 1996. In 1996, 48% of the spinal fusions involved the cervical spine, and in 97% of these the indication was because of degenerative changes.15 Despite the frequency of spinal fusions, there does not seem to exist a standard outcome tool for measuring clinical success after surgery. Using the status of the arthrodesis as an outcome assessment is of great controversy among surgeons, particularly when this measure of outcome does not necessarily correlate with clinical measures of success.16,17 Reliable outcome measures remain to be developed, and the effects of fusion on any functional spinal unit continue to be studied.18 One of the supporting ideas behind this intervention is that the achievement of fusion results in the prevention of spondylotic spurs, the offending entity, whereas existing spurs regress because of the stability of the fused segments. However, degenerative joint disease, as evidenced on radi-
DISCUSSION The medical treatment of musculoskeletal neck pain, conservative or surgical, remains largely based on empirical evidence. For example, the efficacy of traction has not been
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Fig 4. Comparative cervical lateral radiograph obtained 10 months after initial chiropractic care showing slight improvement of the lordosis of the upper cervical segments and reduction of the anterior carriage of patient’s head.
ographic studies, has been found within the fused spinal segments. In addition, the segments above and, to a lesser extent, in the segments below also demonstrate degenerative joint changes.19-22 A recent descriptive paper by Klein et al23 examined the health outcomes of 28 patients before and after cervical diskectomy and fusion for radiculopathy. They concluded that this procedure may improve a patient’s self-reported health assessment, especially for pain and physical function. Other studies also report positive outcomes from similar surgical intervention.24 However, cervical spine surgery in general may lead to such complications as bone graft failure, cerebrospinal fluid leak, recurrent laryngeal nerve injury, nerve root injury, quadriplegia, and death.25 For the patient presented in this case report, based on Odom’s criteria, the surgical outcome can be described as poor.26 The patient’s signs and symptoms remained unchanged after surgery and eventually worsened.
Chiropractic Care This is the first description in the indexed literature of the chiropractic care of a patient with vertebral and sacroiliac subluxations with a history of unsuccessful cervical diskectomy of the cervical spine. In our experience, allopathic practitioners usually do not offer patients the option of chiropractic care before surgery. Perhaps more rarely is chiropractic care considered a viable option in instances of unsuccessful surgical care. Since chiropractic’s inception, chiropractors have for the most part performed their clinical activities based on the detection and removal of a patient’s vertebral subluxa-
Fig 5. Anteroposterior radiograph of cervical spine showing fusion at C6-C7. There is global inclination of cervical spine to the right. tions.27 Subluxation is defined as a partial dislocation, a sprain.28 Historically, chiropractors have described kinesiologic, neurologic, and histologic manifestations of this injury. The term vertebral subluxation complex (VSC) is used to highlight the diverse tissues that are involved and the impact of the lesion on the individual’s ability to maintain homeostasis. Several mechanisms and models have since been proposed24,29-31 reflective of the state of knowledge encompassing the biopsychosocial sciences. For the purpose of this writing, mechanical and neurologic components of subluxation will provide the theoretical framework from which we will discuss this case. The patient consulted one of us for chiropractic care approximately 3 years after surgical diskectomy. From a biomechanical point of view, the cervical spine of this patient had been compromised. Schulte et al32 studied the kinematics of the cervical spine after diskectomy and stabilization and found that there were significant reductions in mobility at fused segments. Motion palpation of the patient’s neck exhibited decreased left lateral flexion and decreased spinous process rotation at the C5 vertebral level in addition to the fused segments at C6-7. Early studies have demonstrated a decrease in motion at the fused segments with concomitant increase in motion segments above or below the site(s) of cervical fusion.33 This abnormal pattern of movement (ie, hypomobility) at one or several functional spinal units (including global and intersegmental malposition) is referred to as kinesiopathology. A possible consequence of this may be an increased rate of degenerative changes.19-21 As previously described, degenerative joint disease was visible on the radiographs in the segments above the cervi-
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cal fusion; particularly with the presence of anterior osteophytes, which are more frequent in anterior cervical fusions.34 In addition to compromising activities of daily living and contributing to the persistence of pain, the presence of a cervical kyphosis after anterior cervical diskectomy/fusion is correlated with a less successful outcome.35 This patient had a mild cervical kyphosis, most apparent in the mid to lower cervical spine. This is associated with anterior carriage of a patient’s head, which may lead to further compromise of osseous and soft tissue structures. The neuropathologic component of the VSC involves nerve root compression/irritation interfering with normal nerve root function resulting in pain or other clinical pathologies. The oblique views clearly demonstrated a decrease in diameter at the C5-C6 left intervertebral foramen (see Fig 1). Compressive radiculopathies are the result of pressure on the spinal nerve roots caused by protrusion of the intervertebral disk; retrolisthesis or Y-axis rotation of the segment; spondylotic spurring of the vertebral body, the uncovertebral joints, or the facet joints; or combinations thereof. For example, at the most medial aspect of the nerve root, osteophytic projections from the lateral aspects of the vertebral body end plates can compress the nerve root without resulting in clinical evidence of spinal cord compression. The patient discussed in this case report did not have spinal cord compression. Mechanical compression combined with chemical mediators of inflammation likely produced the neck pain and radiculopathy experienced by the patient. Of interest in this case report is the immediate relief of neck pain and radiculopathy and the improved shoulder range of motion after adjustments at the sites of vertebral subluxations. The comparative radiographs (Fig 4) showed only minimal improvements in the patient’s posture, most notably in the upper cervical spine. A comparative oblique radiograph was not obtained on this patient. In our opinion, the intervertebral foramen (IVF) would not likely have demonstrated an increased diameter of the structure given the amount of retrolisthesis at C5 on the comparative lateral radiographs. Radiographs may not be sensitive to small changes in IVF size or changes in the patient’s outcome as a reflection of the changes in the IVF. It is important to remember that functional characterisitics of nerve root compression are dependent, not only on the patency of the IVF, but also on the presence or absence of inflammatory products such as edema, interneural edema, and connective tissue fibrosis/scarring. The fact that the nerve root must telescope within the IVF during neck and arm movements may play a role in its susceptibility to compression. If nerve root adhesions are present, this may increase susceptibility. Theoretically, an adjustment could alter the mobility of an individual motion segment, the mobility of the nerve root within the IVF, or both. This may provide a possible explanation as to why functional improvements in the patient were obtained despite minimal changes to IVF architecture. The patient’s cervical curve became mildly more lordotic in the upper portions of the
neck. It is well recognized that alterations in cervical lordosis can alter the function and/or circulation of the spinal cord and nerve roots.36 We acknowledge the speculative nature of what putatively happened to this patient from a histologic standpoint. There is a considerable body of literature that demonstrates that patients who undergo spinal adjustments experience relief of pain. According to Vernon,37 hypoalgesia may possibly be achieved through central facilitation from the stimulation of spinal structures through a spinal adjustment. This may result in changes of cutaneous and muscular pain thresholds and the release of endorphins. In a pilot study, Cassidy et al38 examined the effects of spinal manipulation on pain and range of motion in the cervical spine. They found a significant relationship between a decrease in pain and an increase in cervical range of motion. In a further study, Cassidy et al39 found that both mobilization and manipulation increased range of motion; however, manipulation was more effective in decreasing pain. Hurwitz et al40 performed a systematic review of the literature on manipulation and mobilization of the cervical spine and found that manipulation and mobilization provided short-term benefits for some patients with neck pain and headaches. The improvement in the patient’s shoulder range of motion may be attributed to the reduction of the components of subluxations in the cervical spine, because the glenohumeral articulation did not receive an adjustment. The mechanism by which this occurred remains to be elucidated. Concomitantly, the patient’s complaints of myopathology (muscle weakness and atrophy) were also alleviated. This could be attributed generally to positive changes in nervous system function associated with removal of subluxations. In addition to spinal adjusting to sites of subluxations, the patient was provided with arm exercises to increase his shoulder range of motion, muscle strength, and muscle hypertrophy. These adjunctive procedures played an important role in ameliorating the muscle weakness and atrophy. Many clinicians support the use of ancillary therapies to improve the effect of the adjustment; however, scientific evidence of any putative effect is lacking.41
CONCLUSION We presented the chiropractic care of a patient with neck pain and cervical radiculopathy after an unsuccessful surgical diskectomy. This unusual case may challenge the conventional allopathic clinical care pathways, as well as opinions within some chiropractic circles about the appropriateness of chiropractic care of patients with cervical radiculopathy or unsuccessful cervical surgery.
REFERENCES 1. Klaukka T, Sievers K, Takala J. Epidemiology of rheumatic diseases in Finland in 1964-76. Scand J Rheumatol Suppl 1982; 47:5-13. 2. Westerling D, Jonsson BG. Pain from the neck-shoulder region and sick leave. Scand J Soc Med 1980;8:131-6. 3. Plaugher G, Lopes MA, Melch PE, Cremata EE. The inter- and
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intraexaminer reliability of a paraspinal skin temperature differential instrument. J Manipulative Physiol Ther 1991;14:361-7. 4. Plaugher G, Doble RW, Lopes MA. Lower cervical spine. In: Plaugher G, editor. Textbook of clinical chiropractic: a specific biomechanical approach. Baltimore: Williams & Wilkins; 1993. p. 287. 5. Plaugher G, Lopes MA. Clinical anatomy and biomechanics of the spine. In: Plaugher G, editor. Textbook of clinical chiropractic: a specific biomechanical approach. Baltimore: Williams & Wilkins; 1993. p. 30. 6. Plaugher G, Lopes MA. Clinical anatomy and biomechanics of the spine. In: Plaugher G, editor. Textbook of clinical chiropractic: a specific biomechanical approach. Baltimore: Williams & Wilkins; 1993. p. 295-9. 7. van der Heijden GJ, Beurskens AJ, Koes BW, Assendelft WJ, de Vet HC, Bouter LM. The efficacy of traction for back and neck pain: a systematic, blinded review of randomized clinical trial methods. Phys Ther 1995;75:93-104. 8. Kjellman GV, Skargren EI, Oberg BE. A critical analysis of randomized clinical trials on neck pain and treatment efficacy. A review of the literature. Scand J Rehabil Med 1999;31: 139-52. 9. Grob D. Surgery in the degenerative cervical spine. Spine 1998; 23:2674-83. 10. Graves EJ. National hospital discharge survey: annual summary, 1987, 1988, 1990. National Center for Health Statistics. Vital Health Stat Series 1989. p. 13,99,106,112,1989. 11. Graves EJ. National hospital discharge survey: annual summary, 1987, 1988, 1990. National Center for Health Statistics. Vital Health Stat Series 1991. p. 1,40-41. 12. Graves EJ. National hospital discharge survey: annual summary, 1987, 1988, 1990. National Center for Health Statistics. Vital Health Stat Series 1992. p. 38-39,44. 13. Graves EJ. National hospital discharge survey: annual summary, 1987, 1988, 1990. National Center for Health Statistics. Vital Health Stat Series 1991. p. 1,38-39. 14. Graves EJ. National hospital discharge survey : annual summary, 1987, 1988, 1990. National Center for Health Statistics. Vital Health Stat Series 1992. p. 1,8,44-45,51. 15. Abraham DJ, Herkowitz HN. Indications and trends in cervical spinal fusions. Orthop Clin North Am 1998;29:731-44. 16. Dowd GC, Wirth FP. Anterior cervical discectomy: is fusion necessary? J Neurosurg 1999;90(Suppl):8-12. 17. Beatty RA. Is fusion necessary? J Neurosurg 1999;91:354. 18. Liew SM, Simmons ED. Cervical deformity. Orthop Clin North Am 1998;29:779-86. 19. Hunter LY, Braunstein EM, Bailey RW. Radiographic changes following anterior cervical fusion. Spine 1980;5:399-401. 20. Cherubino P, Benazzo F, Borromeo U, Perle S. Degenerative arthritis of the adjacent spinal joints following anterior cervical spinal fusion: clinicoradiologic and statistical correlations. Ital J Orthop Traumatol 1990;16:533-43. 21. Braunstein EM, Hunter LY, Bailey RW. Long-term radiographic changes following anterior cervical fusion. Clin Radiol 1980; 31:201-3. 22. Hunter LY, Braunstein EM, Bailey RW. Radiographic changes following anterior cervical fusion. Spine 1980;5:399-401.
23. Klein GR, Vaccaro AR, Albert TJ. Health outcome assessment before and after anterior cervical discectomy and fusion for radiculopathy. Spine 2000;25:801-3. 24. Palit M, Schofferman J, Reynolds J, Kerner M, Keaney D, Lawrence-Miyasaki L. Anterior discectomy and fusion for the management of neck pain. Spine 1999;24:2224-8. 25. Zeidman SM, Ducker TB, Raycroft J. Trends and complications of cervical spine surgery: 1989-1993. J Spinal Disord 1997;10:523-6. 26. Odom GL, Finney W. Cervical disc lesions. JAMA 1958;166:23-8. 27. Walker BF, Buchbinder R. Most commonly used methods of detecting spinal subluxation and the preferred term for its description: a survey of chiropractors in Victoria, Australia. J Manipulative Physiol Ther 1997;20:583-9. 28. Simpson JA, Weiner ESC. The Oxford English dictionary, 2nd ed. Volume XVII. Oxford: Clarendon Press; 1989. p. 42. 29. Dishman RW. Static and dynamic components of the chiropractic subluxation complex: a literature review. J Manipulative Physiol Ther 1988;11:98-107. 30. Alcantara J, Plaugher G, Lopes MA, Cichy DL. Spinal Subluxation. In: Anrig C, Plaugher G, editors. Pediatric chiropractic. Baltimore (MD): Williams & Wilkins; 1997. 31. Gatterman M, editor. Foundations of chiropractic: subluxation. St. Louis (MO): Mosby; 1995. 32. Schulte K, Clark CR, Goel VK. Kinematics of the cervical spine following discectomy and stabilization. Spine 1989; 14:1116-21. 33. Fuller DA, Kirkpatrick JS, Emery SE, Wilber RG, Davy DT. A kinematic study of the cervical spine before and after segmental arthrodesis. Spine 1998;23:1649-56. 34. Gore DR, Gardner GM, Sepic SB, Murray MP. Roentgenometric findings following anterior cervical fusions. Skeletal Radiol 1986;15:556-9. 35. Jenkins LA, Capen DA, Zigler JE, Nelson RW, Nagelberg S. Cervical spine fusions for trauma. A long-term radiographic and clinical evaluation. Orthop Rev 1994;(Suppl 1):13-19. 36. Harrison DE, Cailliet R, Harrison DD, Troyanovich SJ, Harrison SO. A review of biomechanics of the central nervous system—part II: spinal cord strains from postural loads. J Manipulative Physiol Ther 1999;22:322-32. 37. Vernon H. Qualitative review of studies of manipulation induced hypoalgesia. Plenary paper for the 1999 World Chiropractic Congress. J Manipulative Physiol Ther 2000;23:137-42. 38. Cassidy JD, Quon JA, LaFrance LJ, Yong-Hing K. The effect of manipulation on pain and range of motion in the cervical spine: a pilot study. J Manipulative Physiol Ther 1992;15: 495-500. 39. Cassidy JD, Lopes AA, Yong-Hing K. The immediate effect of manipulation versus mobilization on pain and range of motion in the cervical spine: a randomized controlled trial. J Manipulative Physiol Ther 1992;15:570-5. 40. Hurwitz EL, Aker PD, Adams AH, Meeker WC, Shekelle PG. Manipulation and mobilization of the cervical spine. A systematic review of the literature. Spine 1996;21:1746-59. 41. Gross AR, Aker PD, Goldsmith CH, Peloso P. Physical medicine modalities for mechanical neck disorders. Cochrane Database Syst Rev 2000;2:CD000961.
Chiropractic Care of a Patient with Vertebral Subluxations and Unsuccessful Surgery of the Cervical Spine Joel Alcantara, DC,a Gregory Plaugher, DC,b Richard E. Thornton, DC,c and Chris Salem, DCd
ABSTRACT Objective: The chiropractic care of a patient with vertebral subluxations, neck pain, and cervical radiculopathy after a cervical diskectomy is described. Clinical Features: A 55-year-old man had neck pain and left upper extremity radiculopathy after unsuccessful cervical spine surgery. Intervention and Outcome: Contact-specific, highvelocity, low-amplitude adjustments (ie, Gonstead technique) were applied to sites of vertebral subluxations. Rehabilitation exercises were also used as adjunct to care. The patient reported a decrease in neck pain and left arm pain after chiropractic intervention. The patient also demonstrated a
marked increase in range of motion (ROM) of the left glenohumeral articulation. Conclusion: The chiropractic care of a patient with neck pain and left upper extremity radiculopathy after cervical diskectomy is presented. Marked resolution of the patient’s symptoms was obtained concomitant with a reduction in subluxation findings at multiple levels despite the complicating history of an unsuccessful cervical spine surgery. This is the first report in the indexed literature of chiropractic care after an unsuccessful cervical spine surgery. (J Manipulative Physiol Ther 2001;24:477-82) Key Indexing Terms: Cervical Spine; Surgery; Chiropractic
INTRODUCTION
CASE REPORT
Neck pain with upper extremity involvement is considered common in the general population. Epidemiological studies based on surveys of the Scandinavian general population place neck and shoulder pain at 16% to 18% for a 1year prevalence.1,2 One aspect of neck pain with upper extremity involvement may be attributed to cervical radiculopathy. This diagnosis is the result of mechanical and biochemical irritation of the spinal nerve root(s) in the cervical spine caused by cervical disk herniation, spondylosis, and subluxation. Differential diagnostic considerations include extraspinal or intraspinal tumors, upper extremity nerve entrapment, brachial plexus disorders, neuropathies, and infections. We discuss the chiropractic management of a patient with subluxations and complaints of neck pain with upper extremity involvement.
Patient History
a Assistant Professor, Life Chiropractic College West, Wayward, Calif. b Director of Research, Life Chiropractic College West, Hayward, Calif. c Private Practice of Chiropractic, Auburn, Calif. d Private Practice of Chiropractic, San Jose, Calif. This study was funded by Life Chiropractic College West, Hayward, Calif, Gonstead Clinical Studies Society, Mount Horeb, Wis, and Palmer College of Chiropractic West, San Jose, Calif. Submit reprint requests to: Joel Alcantara, DC, Research Department, Life Chiropractic College West, 25001 Industrial Blvd, Hayward, CA 94545. E-mail: [email protected]. Paper submitted August 9, 2000.
doi:10.1067/mmt.2001.117084
The patient was a 55-year-old highway patrolman treated by one of us (RET) for complaints of neck pain, bilateral upper extremity pain, paresthesia, and weakness. He related the following history leading to his condition. While responding to an auto accident during an ice storm, the patrolman slipped getting out of his car and fell backward, landing on his upper back and neck. A few days later, he began to experience an unusual pain in his neck. Two months after the accident, he consulted a medical doctor, who subsequently referred him to a neurologist. During the neurologic examination, the patient experienced a seizure that eventually led to a diagnosis of pheochromocytoma, a tumor of the adrenal gland. Several weeks later, the patient had surgery to excise the tumor, resulting in temporary relief of the neck pain. After returning to work 6 weeks after surgery, the patient progressively began to experience neck pain again, which he described as “sharp,” along with pain, numbness, and tingling in both arms. The patient continued to work for about 6 to 7 months, but his condition worsened, and he was was referred to a neurosurgeon. According to his medical report, the patient experienced pain in his right arm. Magnetic resonance imaging (not available) showed disk bulging or herniation, or both, at the C4-5, C5-6, and C6-7 vertebral levels. According to his medical doctor, it was impossible to determine the involved spinal level that was causing his right-arm pain until weakness in his right triceps and a decreased triceps reflex developed, indicating C6-7 intervertebral disk
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Fig 1. Oblique radiograph showing severe spinal stenosis of the IVF at C4-C5 and C5-C6.
involvement. The patient consented to surgery, and an anterior cervical diskectomy was performed in April of 1992. The sharp neck pain disappeared after spinal surgery, but the patient still experienced tingling in the arms along with weakness (greater on the left than the right). Four to 6 weeks after surgery, the patient’s neck pain returned, now described as a “burning intense pain.” When he returned to the surgeon for a postsurgery check-up and had continuing complaints, he asked when the surgeon wanted to see him again. The answer was, “I never want to see you again.” This was devastating for the patient, and he assumed that he was destined to live with these problems for life. The postoperative diagnosis by the medical doctor remained as right C6-7 radiculopathy. For the next 2 to 3 years the patient’s left arm became weak to the point of being unable to perform adduction and forward flexion. He was unable to use his left arm to remove his wallet from the left hip pocket or loop a belt through his pants. A second neurologic consult resulted in longitudinal traction treatment for approximately 2 months, which the patient felt was not very successful. His condition continued to deteriorate.
Chiropractic Examination Approximately 31⁄2 years after surgery, the patient consulted one of us (RET) for chiropractic care. Physical examination of the patient showed the following notable findings. On palpation, there was marked point tenderness at the C5 spinous process, slightly less at C6, and minimal at T6. In addition, the C5 spinous region was edematous. Motion palpation of the cervical spine was performed at the atlanto-occipital and atlas-axis articulation as well as the rest of the cervical motion segments. Palpation findings confirmed the presence of fused segments in the lower cervical spine. The C5 spinous process was restricted
on left rotation (+θY), and there was a noticeable limited cervical ROM on left lateral flexion. Nervoscope instrumentation3 showed moderate readings at T1 to the right (needle deflection =15 points), a very minimal reading at C5, and an approximate 10-point needle deflection at T6. Subluxation findings at the left sacroiliac (SI) joint and the lumbar spine were also found as evidenced by static palpation, motion palpation, nervoscope instrumentation, and radiographic findings. Radiographic analysis confirmed the diskectomy at the C6-C7 functional spinal unit. Oblique views (left posterior) of the right intervertebral foramen (Fig 1) showed decreased diameters, particularly at the C5-6 motion segment. The patient’s original symptoms were of the right upper extremity. After surgery and during the chiropractor’s examination, the symptomatology was bilateral with more severity on the left extremity. The right posterior oblique view to demonstrate the left intervertebral foramen was unavailable. On the lateral view (Fig 2), the fifth cervical vertebral body was displaced posterior and inferior with respect to C6. The cervical spine was hypolordotic/mild kyphotic and classified as a D4 disk.4 Comparative lateral radiographs were obtained at approximately 1 month (Fig 3) and 10 months (Fig 4) after initiating chiropractic care. The anteroposterior radiograph is shown in Fig 5. Full-spine radiographs (not pictured) showed a level pelvis with slight posterior rotation of the right innominate. The lateral lumbar view (not shown) demonstrated severe exostosis at the anterior body of L3 and the intervertebral disk at L3-L4 rated as a D5.5 Subluxation findings are summarized as follows: C5 PLI [–Z, –θY, –θZ], T1 PRS [–Z, +θY, –θZ], T3 PRS [–Z, +θY, –θZ], T6 PRS [–Z, +θY, –θZ], and PI [–Z, –θX] of the right innominate. Neurologic testing showed normal deep tendon reflexes of +2 at C5-7 and T1, bilaterally. However, the patient was unable to perform left arm abduction. Specifically, he could not raise his arm more than 5 to 6 inches from his side. In terms of functionality, the patient was unable to loop his belt through his pants because he could not extend his left arm posteriorly more than a few inches. He was also unable to reach for his wallet from the left hip pocket. His left arm measured 121⁄2 inches in diameter at mid humerus; his right arm, 131⁄2 inches. The patient indicated that he had been in this condition for about 3 years and was slowly deteriorating.
Chiropractic Care A specific contact, high-velocity, low-amplitude adjustment was applied by using the Gonstead Technique.6 The adjustment was a PL-inf [–Z,–θX,–θY] of the fifth cervical vertebra with a spinous contact in the seated position. Because the fifth spinous process was inferior [–θX] and very close to the C6 spinous process, it was necessary to flex the patient’s head foreward to get a good posterior-to-anterior line of correction during the setting. He was also adjusted at the third and sixth thoracic vertebrae, and at the first thoracic level at a different visit. The T1 was adjusted in the cervical chair (ie, Gonstead); and the T3 and T6, with the patient in the prone position. The patient’s right ilium was adjusted as a PI [–Z, –θX] listing (on 2 visits) in the side posture position.
Journal of Manipulative and Physiological Therapeutics Volume 24 • Number 7 • September 2001
Subluxation and Unsuccessful Cervical Spine Surgery • Alcantara et al
Fig 2. Lateral cervical radiograph showing hypolordosis of upper cervical spine combined with mild kyphosis at C3-C5. There is retrolisthesis present at C4 and C5. Diskectomy is noted at C6-C7.
Fig 3. Comparative cervical lateral radiograph taken 1 month after initial chiropractic care showing a slight improvement in the cervical lordosis of upper cervical segments.
The chiropractic care began on August 14, 1996, and was repeated on the 16th, 18th, and 21st. After receiving the first set of adjustments, the patient indicated that his ability to raise his left arm had increased by 50% and that his neck pain and arm complaints were also relieved. Sometimes there was no pain during the 2-hour drive home after treatment. The patient was very astonished and excited by the results of the care he received. By August 28th, 1996, he was able to fully abduct his left arm and to loop his belt to his pants. The patient received further care as a result of recurring weakness and pain in the left arm. However, he never lost the range of motion gained in the first 2 weeks of care. In 1996, the patient made a total of 16 visits. On 2 of these occasions, he required no treatment. In 1997, he was seen a total of 11 times; and in 1998, 8 times. The patient has been very active on his small ranch performing various odd jobs and has, on occasion, had some exacerbations because of overactivity. He has been given arm exercises, (ie, the use of free weights for biceps flexion, triceps extension, and deltoid adduction) and low back exercises. On last measurement (approximately 1 year follow-up) his left arm had gained a half inch in diameter at mid-humerus. The patient was last seen on December 1, 1998, and only had complaints of mild low back pain and mild neck pain with occasional left-hand numbness.
scientifically proven in a randomized controlled clinical trial; however, it is thought to be effective, particularly in the treatment of neck pain and associated radicular symptoms.7,8 According to Grob,9 70% to 80% of cases of cervical radiculopathy symptoms could be treated by conservative means. These include the use of oral medications, soft collars, cervical traction, and other physical therapy modalities. Patients with associated radiculopathy might also achieve relief of neck pain with the use of corticosteroids. Failure of the above conservative approaches may result in cervical diskectomy and fusion for the patient. As such, spine surgery ranks as one of the most common inpatient surgical procedures in the United States.10-14 In considering only spinal fusions, there was a 310% increase from 36,000 in 1985 to 111,400 in 1996. In 1996, 48% of the spinal fusions involved the cervical spine, and in 97% of these the indication was because of degenerative changes.15 Despite the frequency of spinal fusions, there does not seem to exist a standard outcome tool for measuring clinical success after surgery. Using the status of the arthrodesis as an outcome assessment is of great controversy among surgeons, particularly when this measure of outcome does not necessarily correlate with clinical measures of success.16,17 Reliable outcome measures remain to be developed, and the effects of fusion on any functional spinal unit continue to be studied.18 One of the supporting ideas behind this intervention is that the achievement of fusion results in the prevention of spondylotic spurs, the offending entity, whereas existing spurs regress because of the stability of the fused segments. However, degenerative joint disease, as evidenced on radi-
DISCUSSION The medical treatment of musculoskeletal neck pain, conservative or surgical, remains largely based on empirical evidence. For example, the efficacy of traction has not been
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Fig 4. Comparative cervical lateral radiograph obtained 10 months after initial chiropractic care showing slight improvement of the lordosis of the upper cervical segments and reduction of the anterior carriage of patient’s head.
ographic studies, has been found within the fused spinal segments. In addition, the segments above and, to a lesser extent, in the segments below also demonstrate degenerative joint changes.19-22 A recent descriptive paper by Klein et al23 examined the health outcomes of 28 patients before and after cervical diskectomy and fusion for radiculopathy. They concluded that this procedure may improve a patient’s self-reported health assessment, especially for pain and physical function. Other studies also report positive outcomes from similar surgical intervention.24 However, cervical spine surgery in general may lead to such complications as bone graft failure, cerebrospinal fluid leak, recurrent laryngeal nerve injury, nerve root injury, quadriplegia, and death.25 For the patient presented in this case report, based on Odom’s criteria, the surgical outcome can be described as poor.26 The patient’s signs and symptoms remained unchanged after surgery and eventually worsened.
Chiropractic Care This is the first description in the indexed literature of the chiropractic care of a patient with vertebral and sacroiliac subluxations with a history of unsuccessful cervical diskectomy of the cervical spine. In our experience, allopathic practitioners usually do not offer patients the option of chiropractic care before surgery. Perhaps more rarely is chiropractic care considered a viable option in instances of unsuccessful surgical care. Since chiropractic’s inception, chiropractors have for the most part performed their clinical activities based on the detection and removal of a patient’s vertebral subluxa-
Fig 5. Anteroposterior radiograph of cervical spine showing fusion at C6-C7. There is global inclination of cervical spine to the right. tions.27 Subluxation is defined as a partial dislocation, a sprain.28 Historically, chiropractors have described kinesiologic, neurologic, and histologic manifestations of this injury. The term vertebral subluxation complex (VSC) is used to highlight the diverse tissues that are involved and the impact of the lesion on the individual’s ability to maintain homeostasis. Several mechanisms and models have since been proposed24,29-31 reflective of the state of knowledge encompassing the biopsychosocial sciences. For the purpose of this writing, mechanical and neurologic components of subluxation will provide the theoretical framework from which we will discuss this case. The patient consulted one of us for chiropractic care approximately 3 years after surgical diskectomy. From a biomechanical point of view, the cervical spine of this patient had been compromised. Schulte et al32 studied the kinematics of the cervical spine after diskectomy and stabilization and found that there were significant reductions in mobility at fused segments. Motion palpation of the patient’s neck exhibited decreased left lateral flexion and decreased spinous process rotation at the C5 vertebral level in addition to the fused segments at C6-7. Early studies have demonstrated a decrease in motion at the fused segments with concomitant increase in motion segments above or below the site(s) of cervical fusion.33 This abnormal pattern of movement (ie, hypomobility) at one or several functional spinal units (including global and intersegmental malposition) is referred to as kinesiopathology. A possible consequence of this may be an increased rate of degenerative changes.19-21 As previously described, degenerative joint disease was visible on the radiographs in the segments above the cervi-
Journal of Manipulative and Physiological Therapeutics Volume 24 • Number 7 • September 2001
Subluxation and Unsuccessful Cervical Spine Surgery • Alcantara et al
cal fusion; particularly with the presence of anterior osteophytes, which are more frequent in anterior cervical fusions.34 In addition to compromising activities of daily living and contributing to the persistence of pain, the presence of a cervical kyphosis after anterior cervical diskectomy/fusion is correlated with a less successful outcome.35 This patient had a mild cervical kyphosis, most apparent in the mid to lower cervical spine. This is associated with anterior carriage of a patient’s head, which may lead to further compromise of osseous and soft tissue structures. The neuropathologic component of the VSC involves nerve root compression/irritation interfering with normal nerve root function resulting in pain or other clinical pathologies. The oblique views clearly demonstrated a decrease in diameter at the C5-C6 left intervertebral foramen (see Fig 1). Compressive radiculopathies are the result of pressure on the spinal nerve roots caused by protrusion of the intervertebral disk; retrolisthesis or Y-axis rotation of the segment; spondylotic spurring of the vertebral body, the uncovertebral joints, or the facet joints; or combinations thereof. For example, at the most medial aspect of the nerve root, osteophytic projections from the lateral aspects of the vertebral body end plates can compress the nerve root without resulting in clinical evidence of spinal cord compression. The patient discussed in this case report did not have spinal cord compression. Mechanical compression combined with chemical mediators of inflammation likely produced the neck pain and radiculopathy experienced by the patient. Of interest in this case report is the immediate relief of neck pain and radiculopathy and the improved shoulder range of motion after adjustments at the sites of vertebral subluxations. The comparative radiographs (Fig 4) showed only minimal improvements in the patient’s posture, most notably in the upper cervical spine. A comparative oblique radiograph was not obtained on this patient. In our opinion, the intervertebral foramen (IVF) would not likely have demonstrated an increased diameter of the structure given the amount of retrolisthesis at C5 on the comparative lateral radiographs. Radiographs may not be sensitive to small changes in IVF size or changes in the patient’s outcome as a reflection of the changes in the IVF. It is important to remember that functional characterisitics of nerve root compression are dependent, not only on the patency of the IVF, but also on the presence or absence of inflammatory products such as edema, interneural edema, and connective tissue fibrosis/scarring. The fact that the nerve root must telescope within the IVF during neck and arm movements may play a role in its susceptibility to compression. If nerve root adhesions are present, this may increase susceptibility. Theoretically, an adjustment could alter the mobility of an individual motion segment, the mobility of the nerve root within the IVF, or both. This may provide a possible explanation as to why functional improvements in the patient were obtained despite minimal changes to IVF architecture. The patient’s cervical curve became mildly more lordotic in the upper portions of the
neck. It is well recognized that alterations in cervical lordosis can alter the function and/or circulation of the spinal cord and nerve roots.36 We acknowledge the speculative nature of what putatively happened to this patient from a histologic standpoint. There is a considerable body of literature that demonstrates that patients who undergo spinal adjustments experience relief of pain. According to Vernon,37 hypoalgesia may possibly be achieved through central facilitation from the stimulation of spinal structures through a spinal adjustment. This may result in changes of cutaneous and muscular pain thresholds and the release of endorphins. In a pilot study, Cassidy et al38 examined the effects of spinal manipulation on pain and range of motion in the cervical spine. They found a significant relationship between a decrease in pain and an increase in cervical range of motion. In a further study, Cassidy et al39 found that both mobilization and manipulation increased range of motion; however, manipulation was more effective in decreasing pain. Hurwitz et al40 performed a systematic review of the literature on manipulation and mobilization of the cervical spine and found that manipulation and mobilization provided short-term benefits for some patients with neck pain and headaches. The improvement in the patient’s shoulder range of motion may be attributed to the reduction of the components of subluxations in the cervical spine, because the glenohumeral articulation did not receive an adjustment. The mechanism by which this occurred remains to be elucidated. Concomitantly, the patient’s complaints of myopathology (muscle weakness and atrophy) were also alleviated. This could be attributed generally to positive changes in nervous system function associated with removal of subluxations. In addition to spinal adjusting to sites of subluxations, the patient was provided with arm exercises to increase his shoulder range of motion, muscle strength, and muscle hypertrophy. These adjunctive procedures played an important role in ameliorating the muscle weakness and atrophy. Many clinicians support the use of ancillary therapies to improve the effect of the adjustment; however, scientific evidence of any putative effect is lacking.41
CONCLUSION We presented the chiropractic care of a patient with neck pain and cervical radiculopathy after an unsuccessful surgical diskectomy. This unusual case may challenge the conventional allopathic clinical care pathways, as well as opinions within some chiropractic circles about the appropriateness of chiropractic care of patients with cervical radiculopathy or unsuccessful cervical surgery.
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