|Year : 2017 | Volume
| Issue : 3 | Page : 197-200
A case report of cervical myelopathy after neck manipulation in a patient with cervical spondylosis and radiculopathy: Cause and effect or natural progression?
Gaurav Chauhan, Murali Patri, Cheryl J Mordis, Vivek Loomba
Department of Anesthesiology, Pain and Perioperative Medicine, Henry Ford Health System, Detroit, Michigan, USA
|Date of Web Publication||18-Jan-2018|
Apt 1607, 1350 W. Bethune St., Detroit, Michigan 48202
Source of Support: None, Conflict of Interest: None
A 47-year-old female, with cervical spondylosis and radiculopathy, presented with clinical features of cervical myelopathy after outpatient physical therapy. An emergent neurological surgery was scheduled after radiological evidence of cord compression. The symptoms subsided after surgery. Conservative management modalities should be practiced keeping in mind the potential of cervical spondylosis to progress to catastrophic complications such as myelopathy. It may be difficult to accurately implicate neck manipulation in the onset of the cervical myelopathy as it may be clinically silent or coexist with radiculopathy. It is vital to adequately counsel the patient, about this phenomenon to avoid legal ramifications.
|How to cite this article:|
Chauhan G, Patri M, Mordis CJ, Loomba V. A case report of cervical myelopathy after neck manipulation in a patient with cervical spondylosis and radiculopathy: Cause and effect or natural progression?. Indian J Pain 2017;31:197-200
|How to cite this URL:|
Chauhan G, Patri M, Mordis CJ, Loomba V. A case report of cervical myelopathy after neck manipulation in a patient with cervical spondylosis and radiculopathy: Cause and effect or natural progression?. Indian J Pain [serial online] 2017 [cited 2019 Jun 15];31:197-200. Available from: http://www.indianjpain.org/text.asp?2017/31/3/197/223674
| Background|| |
The progression of cervical myelopathy as a sequela of the neck manipulation or due to the natural progression of the condition is imputable. The natural history of cervical myelopathy includes static and dynamic factors., Static factors such as osteophyte formation and ligamentum flavum hypertrophy can reduce the spinal canal diameter and promote cord compression. Dynamic factors become relevant when the normal motion of cervical spine causes static components to interact in such a manner that aggravates or promotes spinal cord damage. We present a case report of a 47-year-old woman, with cervical spondylosis with radiculopathy, who presented with clinical signs and symptoms along with radiological evidence of cervical myelopathy during her follow-up visit, after the failure of outpatient physical therapy. The patient thoroughly reviewed the case report and gave written permission to the authors for publishing the report.
| Clinical Vignette|| |
A 47-year-old woman, with a history of bilateral carpal tunnel syndrome and cervical spondylosis with radiculopathy, after a motor vehicle accident 14 years ago, presented with complaints of neck pain, intermittent severe bilateral arm pain, and headaches. The patient underwent physical therapy 10 months ago and her neck pain became worse. She reported the development of intermittent electric shock-like shooting, numbing, and tingling pains starting at the anterolateral shoulder with radiation down both arms into the third, fourth, and fifth digits, especially while bending her head forward. The patient developed changes in her writing along with deterioration in fine motor activities such as sewing. She further complained of nonspecific headaches that radiated to the upper neck, shoulders, and scapular region bilaterally and interfered with her sleep. She reported gradually developing a feeling of heaviness in the legs along with an inability to walk at a brisk pace and reported multiple falls due to balance-related issues. She started using a walker since last 4 months. She never received any chronic pain injections or had any previous spine surgeries. Her medical history was significant for hypertension, hypercholesterolemia, chronic bronchitis, and gastroesophageal reflux disease. She worked as a housekeeper but could not keep up with the demands of her job due to her symptoms. On examination, the pain was localized to the cervical paraspinal muscles, anterior shoulder with “numbness” in the axilla; medial upper arm; lateral forearm; and third, fourth, and fifth digits. There was wasting of intrinsic muscles in both hands and decreased sensation to light and sharp touch bilaterally in the upper extremities in a nondermatomal pattern. She had 3/5 strength in C5-T1 distribution with decreased pinch and grip strength and 4/5 strength in L2-S1. The cervical compression test (Spurling's test) was positive for reproduction of arm pain bilaterally. The Hoffmann's test and scapulohumeral reflexes were positive. The biceps and supinator reflexes (C5 and C6) were absent, with a brisk triceps reflex (C7). The knee and ankle reflexes were accentuated (hyperreflexia), and Babinski reflex with ankle clonus was present bilaterally. She had a positive Romberg sway along with compromised coordination as evidenced by difficulty walking and placing one foot in front of the other (tandem walking). She was graded as a 4 on the Nurick scale [Table 1] and 3 on the Cooper myelopathy scale [Table 2]. The magnetic resonance imaging (MRI) of cervical spine reported a prominent central extrusion component with inferior migration to the C6-7 interspace, which was abutting and flattening the ventral cord surface [Figure 1]. The MRI also reported a mild diffuse disk osteophyte complex at C5-6, asymmetric to the right, which led to mild-to-moderate foraminal narrowing [Figure 2]. The patient underwent emergent anterior cervical discectomy at C5-6, C6-7, with C6 corpectomy and plating. During the surgery, a large sequestered fragment leading to severe compression of thecal sac was seen behind the C6 body. The fragment was retrieved and adequate decompression of thecal sac was done all the way laterally. After an uneventful hospital course, the patient was discharged on the fifth postoperative day with a Miami J collar and a wheeled walker and a grade 5 motor power in all myotomes. Three weeks after the surgery, the neck collar was removed and patient reported significant improvement in the neck and arm symptoms. The X-ray of the neck spine confirmed satisfactory hardware placement [Figure 3]. The patient was ambulating with a cane for up to 30-min intervals and continued to have narrow-based gait and slow velocity. She had 5/5 motor strength in C5-T1 and L2-S1 bilaterally, and her reflexes were 2+ throughout. Her only complaints were infrequent neck spasms and minimal residual paresthesias in the hands. The patient was able to actively participate in physical therapy for gait training. At 6 months after the discharge, she was undergoing physiatrist evaluation for specialized rehabilitation to determine if she could return to work.
|Table 1: The Nurick score—the higher the grade, the more severe the deficit|
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|Table 2: Cooper myelopathy scale—the higher the grade, the more severe the deficit|
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|Figure 1: Right foraminal stenosis at C5-6. Large disk extrusion spanning the C6 vertebral body favored to be originating from a disk osteophyte complex at C5-6, causing effacement of the CSF and mild ventral cord flattening. Mild right foraminal stenosis at C5-6|
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|Figure 3: X-ray of postsurgical neck: two-level anterior cervical discectomy and fusion (C5-6, C6-7), corporectomy of C6, and expandable cage|
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| Discussion|| |
In patients with cervical spondylosis with or without radiculopathy, cervical myelopathy may develop insidiously. Initial symptoms may be limited to a decreased range of motion along with neck stiffness. The dermatomal pattern of radiculopathy may give way to nonspecific, global pain, and paresthesia in upper extremities along with a change in intensity and character of pain., The patient may develop brachialgia, which is defined as episodes of shooting, stabbing pain in the arm, elbow, wrist, or fingers followed by dull-achy heaviness in the arm and tingling and numbness in the hands. In some subjects, radiculopathy might coexist with myelopathy creating a variable pattern on examination. Decline in fine motor control may be seen along with changes in bowel or bladder function.,, The presence of spasticity, hyperreflexia and clonus of lower extremities, areflexia or fasciculation of upper extremities along with dysesthesias, and positive Hoffman's sign should sensitize the clinician toward the presence of cord compression., In severe cases, varying degrees of unstable balance and gait due to impaired proprioception, coordination, and superficial sensory loss may lead to a functional limitation that can be graded using the Nurick score. The Cooper myelopathy scale can be used to grade both upper and lower extremity symptoms due to root compression. The differential diagnosis for acute onset myelopathy includes ossification of posterior longitudinal ligaments, spinal cord arteriovenous malformation, metastatic or primary spinal cord tumors, syringomyelia, spinal cord infarction, whiplash syndrome (hyperextension–hyperflexion injury), Brown-Sequard syndrome, and central cord syndrome., It is important to consider nonmyelopathic disorders such as amyotrophic lateral sclerosis, Guillain–Barré syndrome, shoulder amyotrophy, normal pressure hydrocephalus, traumatic or neoplastic brachial plexopathy, vitamin B12 deficiency, diabetic neuropathy, and multiple sclerosis. Along with the characteristic signs and symptoms, MRI or CT scans of the cervical spine are instrumental in clinching the diagnosis of myelopathy and delineating the underlying pathomechanics of the acute process.
This report is an important addition to recent publications reporting cases that were described as postmanipulative complications.,, In this case, there was a lag of 10 months between the neck manipulation and evaluation by a pain specialist; furthermore, the symptoms worsened in the last 6 months. In light of this evidence, the worsening of the symptoms of the patient was attributed to the natural progression of the disease. Neck manipulation can accentuate the dynamic pathway of myelopathy, but it can also be coincidental. The flexion of the neck can cause the spinal cord to stretch over ventral osteophytic ridges leading to friction-induced damage. The extension of the neck may cause buckling of the ligamentum flavum into the spinal cord causing pressure-induced injury. Malone et al. in their retrospective review of neurosurgical patients commented that they cannot establish a causal relationship between cervical manipulation and progression of disk herniation to myelopathy. Oppenheim et al. reported 18 patients who had received spinal manipulation and whose neurological condition immediately worsened. Injuries were sustained to the cervical, thoracic, and lumbar spine and resulted, variously, in myelopathy, paraparesis, cauda equina syndrome, and radiculopathy. They concluded that spinal manipulation may be associated with significant complications in patients with disk herniation, and imaging can be done before manipulation to identify patients with significant risk factors, such as substantial disk herniations or occult malignancies. Leboeuf-Yde et al. reported six cases in whom complications developed before manipulation. They further commented that had any intervention been provided in these cases, the intervention could have been implicated in the incident, when it evidently would have occurred anyway. All the authors have unanimously echoed that a cause–effect relationship between the neck manipulation and cervical myelopathy is ambiguous at its best. Disk herniation can progress to myelopathy without provocation, and there are no objective measures to predict the same.,,,,,
| Conclusion|| |
This case report emphasizes the fact that a careful interpretation of evidence on hand for any kind of posttreatment complications, in patients with disk herniation, should be done considering the progression due to the natural history of the disease independent of the manipulative treatment, as a differential. It is important to be aware of the possibility, in patients with disk herniation with or without radiculopathy, to develop cervical myelopathy. The conservative management modalities such as neck manipulation should be practiced keeping in mind the potential of pathology to progress to catastrophic complication such as myelopathy. There is a consensus that the causal relationship between manipulation and the subsequent appearance of symptoms should not be assumed. Following neck manipulation, cervical myelopathy may be clinically silent for a long duration or coexist with radiculopathy before becoming clinically evident. It is critical to recognize and institute timely intervention for cervical myelopathy. It is of paramount importance to adequately counsel, reassure, and explain to the patient about this phenomenon as this can place the physician at legal risk.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]