Title: The chiropractic management of cervical Myelomalacia
Abstract: To examine the diagnosis and condition of a patient suffering from neck pain and radiation of pain into arms following a motor vehicle accident. Diagnostic studies include the chiropractic orthopedic and neurological examination, digital x-rays, range of motion and cervical MRI.
Introduction: On 10/10/2016, a 38-year-old male presented to our office for injuries he had sustained in an MVA on 10/01/2016. The patient stated that he was stopped at an intersection when the pickup behind him hit him at a fast speed, pushing him through the intersection. The patient stated that he had neck pain and stiffness the radiated into the trapezius area. He also complained about “tingling” into both hands. He also complained of lower back pain that he felt more than the neck. His review of systems was benign, other than the current symptoms of neck and back pain and tingling.
The patients Social/Family Medical History included his mother having high blood pressure and Diabetes.
Clinical Findings of Chiropractic and Myelomalacia
The patient is 6’0”. The patient weighs 211 pounds. The sitting blood pressure measured was 122/74.
An evaluation and management exam was performed. The exam consisted of a visual inspection of the spinal ranges of motion, digital palpation, manual testing of muscles, deep tendon reflexes and orthopedic and neurological findings. The Cervical exam showed the following decreased motion on visual exam in flexion, extension, left rotation, right rotation, right lateral flexion and left lateral flexion. All of the above motions produced pain.
When digital palpation was performed in the cervical and thoracic spinal areas, there was moderate spasm noted bilaterally in paraspinal areas with moderate tenderness noted.
In performing the cervical orthopedic and neurological testing, positive findings were present bilaterally with Foraminal Compression and Foraminal Decompression. Soto Hall test was positive when performed in the thoracic spine area. Manual, subjectively rated muscle testing was performed on certain muscles of the upper extremities. Based on the AMA Guides to the Evaluation of Permanent Impairment, 4th Ed., 1993/5th ed. 2001, differences were noted using the rating scale of five to zero. Five is full Range of Motion/Maximum Strength, Four is Full Range of motion with Moderate Resistance, Three is Full Range of Motion/Perceptible Weakness. The Deltoids and Triceps tested normally bilaterally at 5. The Biceps, forearm muscles and the intrinsic hand muscles all tested as a four on the right and a three on the left.
Grip Strength tests the strength of the hands which indicate nerve integrity from the cervical spine. In evaluation, the normal would be for a difference of strength in the preferred hand of 10% more. More than that would be a weakness in the opposite hand, less than that would be a weakness in the preferred hand. The preferred hand for this patient is the right hand. The testing below shows a definite decrease in strength in the left hand.
|Hand tested||Rep one||Rep two||Rep three|
Deep Tendon Reflexes were performed on the patient and were noted at a plus two bilaterally.
Using a Whartenburg pinwheel, dermatomes showed normal findings except for C8, which was hyposensitive on the left.
A Lumbar orthopedic and neurological exam was then performed. Upon visual examination, there was decreased motion in flexion, extension. right and left lateral flexion with pain present on all of the motions.
Lasegue’s Straight Leg Raising test was performed and was negative with 80 degree movement. Braggards test was performed and was negative bilaterally.
Kemps was done with the patient on both sides and was noted as negative. Ely test was noted as negative.
Digital palpation was performed and there was severe tenderness and spasm bilaterally in the lumbar paraspinal muscles.
Manual, subjectively rated muscle testing was performed on certain muscles of the lower extremities. Based on the AMA Guides to the Evaluation of Permanent Impairment, 4th Ed., 1993/5th ed. 2001, differences were noted using the rating scale of five to zero. Five is full Range of Motion/Maximum Strength, Four is Full Range of motion with Moderate Resistance, Three is Full Range of Motion/Perceptible Weakness. Muscle testing was done bilaterally in the Quadriceps, Hamstrings, Calf Muscles and Extensor Hallicus Longus and showed Full ROM and Strength.
Deep Tendon Reflexes were performed. They negative in the Achilles bilaterally, but +3 in the Patella bilaterally.
Based on the ortho/neuro findings and the history, the following x-rays were ordered:
AP/Lat/Flex/Ext/Bilateral Oblique’s/ APOM of the cervical spine, AP/Lat Thoracic
AP/Lat/Lateral Flexion/Oblique Lumbar’s. The x-rays were read and the Lumbar spine showed the discs were of a normal height and Georges line was un-interrupted. There the Lumbar curve appeared to be hypolordotic. On visual inspection, there was a decrease in the lateral bending bilaterally.
The Cervical spine showed that there was anterior spurring present in the C5/6 region of the cervical spine. In the lateral view, the normal curvature of the spine was no longer lordotic, but noted as a “Military Neck.” There was decreased range of motion noted in the flexion as well as the extension views. Also, noted on flexion and extension was paradoxical motion present at C1. Disc spaces were normal throughout the spine, except for narrowing of the disc space at C5/6, as well as spurring noted in the anterior part of the vertebral body.
Due to the injuries, orthopedic and neurological and x-ray findings, a cervical MRI was ordered. I recommended that the patient receive palliative therapy until a Cervical MRI could be obtained.
The MRI was obtained and personally reviewed. The Cervical MRI performed on 10/14/2016 revealed that C1/2 was unremarkable. There was a mild disc bulge at C2/3 and a moderate disc bulge which abuts the ventral cord and results in mild spinal canal stenosis at C3/4. There is also bilateral uncovertebral hypertrophy with moderate bilateral neural foraminal narrowing noted at C3/4. At C4/5, There is a mild disc bulge which abuts the ventral cord. There is a mild spinal canal stenosis. There is a bilateral uncovertebral hypertrophy with moderate bilateral neural foraminal narrowing. At C5/6, There is a moderate disc bulge which indents the ventral cord and results in severe spinal canal stenosis. There is a resultant T2 weighted hyperintense (high) signal abnormality in the spinal cord at this level. This may represent edema or myelomalacia. C6/7 shows that there is a mild disc bulge which abuts the ventral cord and results in mild spinal canal stenosis. There is bilateral uncovertebral hypertrophy with moderate bilateral neural foraminal narrowing. C7/T1 presents as unremarkable.
Test Study Treatment Impressions
At C5/6, there is a moderate disc bulge which indents the ventral cord and results in severe spine canal stenosis. There is resultant abnormal signal in the spinal cord at C5/6, which may represent myelomalacia or edema.
An alert was placed on this study.
Fig.1 (A) Sagittal T2 MRI of Cervical Spine
(B) Axial T2 MRI of the Cervical Spine.