Title: Conservative care and axial distraction therapy for the management of cervical and lumbar disc herniations and ligament laxity post motor vehicle collision.
Dr. Alex Jimenez, doctor of chiropractic, focuses on the diagnosis, treatment and prevention of a variety of injuries and conditions associated with the musculoskeletal and nervous systems, utilizing several chiropractic methods and techniques. The following procedures may be similar to his own but can differ according to the specific issue and complications by which the individual is diagnosed.
Abstract: This middle-aged female was injured in a vehicle collision causing her to sustain disc and additional ligament injuries in the cervical and lumbar spine. Diagnostic studies included physical examination, orthopedic and neurological testing, lumbar MRI, multiple cervical MRI’s, CRMA with motion cervical radiographs and EMG studies. Typically, conservative care is initiated prior to interventional procedures, and this case study seeks to explore the usage of passive therapy for mechanical spine pain and noted anatomic disc lesions after failure of interventional procedures. She reported both short term and long term success regarding pain reduction along with improvement in her activities of daily living after initiating conservative care, and continued to report further reductions in pain with periodic pain management using conservative care.
Introduction: The 49-year-old married female (Spanish speaking patient) reported that on March 4th, 2014 she was the seat-belted driver of a truck that was struck by a much larger fuel truck changing lines, hitting her vehicle at the front passenger side (far side, side impact). The force of the impact caused her truck to be lifted up and the right wheel popped off. Her head hit the window after impact and the spinal pain and complaints started approximately 24 hours later. Two days after the crash she went to the emergency department. Occupant pictures were taken describing an out of position occupant injury. She did not report any additional significant trauma after the collision.
Initial Diagnosis and Treatment for Disc Herniations
Prior to her evaluation at our clinic, she utilized multiple providers for diagnosis and treatment over the course of 11 months. She went to the emergency department, utilized 3 pain management medical doctors, neuropsychologist and a cognitive rehabilitation therapist. Imaging included radiographs and MRI of the right shoulder revealing rotator cuff tear; radiographs of the lumbar and thoracic spine, and left hand; CT of the head and cervical spine were performed; MRI cervical (3) and lumbar spine. Medications prescribed included Fentanyl, Percocet, Naprosyn, Cyclobenzaprine, Norco, Hydrocodone-acetaminophen, Soma, and Carisoprodol. Physical therapy was provided for spinal injuries and she did not respond to treatment. The neurosurgeon recommended epidural steroid injections and facet blocks. Cervical nerve blocks and cervical trigger point injections, cervical and lumbar epidural steroid injections (ESI), lateral epicondyle steroid injections were performed, none of which were palliative. Post-concussion disorder and PTSD with major depressive disorder were diagnosed.
On February 12th, 2015, she presented to our office with neck pain (average 6/10 VAS) that affected her vision, with paresthesia’s in both upper extremities radiating to the hands with numbness. She had low back pain (average 6/10 VAS), and she additionally reported paresthesia at the plantar surface of feet bilaterally. She had left elbow pain, right shoulder pain, knee pain, headaches and “anxiety” along with anterior sternal pain.
Her injuries were causing significant problems with her activities of daily living. Summarily she had increased pain with lifting, increased pain and restricted movement with bending, walking and carrying. She had been unable to perform any significant physical activity from the time of the crash in March 2014 until March 2015. Her right hand was always hurting and her forearms. She was not able to clean windows or do laundry, difficulty using stairs, problems with mopping, ironing and cleaning. She had to limit her walking and jogging primarily due to neck pain and right arm pain. She was not able to sit for long periods of time and sleeping was disrupted due to numbness in her hands. She was only able to walk on a treadmill for 10 minutes before having to stop due to pain, prior to the crash she would exercise for an hour.
Prior History: No significant prior musculoskeletal or contributory medical history was reported.
Research Study Conclusions
Clinical Findings (2/12/15): She had a height of 5’2”, measured weight of 127 lbs.
Visual analysis of the cervical spine revealed pain in multiple ranges of motion including flexion, extension, bilateral rotation and bilateral side bending. On extension pain was noted in the upper back, on rotation pain was noted in the posterior neck, and on lateral flexion pain was noted contralaterally.
Visual analysis of the lumbar spine revealed pain in the low back on all active ranges of motion, including flexion, extension and side bending, pain primarily at L5/S1.
Dual inclinometer testing was ordered based on visual active range of motion limitations with pain.
Sensory testing was performed of the extremities, C5-T1 and L4-S1. No neurological deficits other than right sided C5 hypoesthesia.
Foraminal compression test produced pain in the cervical spine. Foraminal distraction test caused an increase in pain in the neck. Jackson’s test on the right produced pain bilaterally in the neck. Straight leg raise bilaterally produced low back pain, double Straight leg raise produce pain at L5/S1 at 30 degrees.
Muscle testing of the upper extremities was tested at a 5/5 with the exception of deltoid bilaterally tested at a 4/5. The patient’s deep tendon reflexes of the upper and lower extremities were tested including Triceps, Biceps, Brachioradialis, Patella, Achilles: all were tested at 2+ bilaterally, equal and reactive. No evidence of clonus of the feet and Hoffman’s test was unremarkable.
C3-C5 right sided segmental dysfunction was noted on palpation. T5-T12 spinous process tenderness on palpation. Low back pain on palpation, particularly L5/S1.
I reviewed the cervical MRI images taken May 2014 with the following conclusions (images attached):
- Dramatic reversal of the normal cervical curvature, apex C5/6.
- C5/6 herniation, indentation of the spinal cord anteriorly. High signal posterior on STIR.
- Due to the angular kyphosis of the cervical spine and axial slices performed, C6/7 slices did not render a pure diagnostic image for disc disruption.
Fig. 1 (A) T2 Axial C5/6, 2 months post injury Fig. 1 (B) Sag T2 C5/6
I reviewed cervical MRI images taken September 17th, 2014 approximately 6-months post injury, and rendered the following conclusions:
- Reversal of the normal cervical lordosis.
- C5/C6 herniation (extrusion type) with indentation of spinal cord, appropriate CSF noted posteriorly.
I reviewed the cervical MRI dated October 24th, 2015 (images attached):
- C4/5 herniation, extrusion type, left oriented into the lateral recess and neural canal causing moderate neural canal stenosis
- C5/C6 disc protrusion, anterior cord abutment, thecal sac involvement.
- C6/7 herniation with early spondylosis changes