Wednesday, 19 August 2015 15:28

CASE REPORT: Spinal Adjustments are Safe in the Presence of Herniated disc with the Absence of Cord Compression

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Case Report

 

By: Karen M. Callaghan, DC

Title: Spinal Adjustments are Safe in the Presence of Herniated disc with the Absence of Cord Compression

Abstract: The objective was to explore the use of MRI to increase the efficacy and safeness of adjusting the cervical spine in the presence of a disc herniation when there is no evidence of cord compression on MRI.

Key Words: Chiropractic, spinal adjustment, MRI, herniation

Introduction:  A 30 year old male patient presented to the office on 1/8/14 with injuries from a motor vehicle accident.  The motor vehicle accident had occurred 3 weeks prior to his first visit.  The patient was the restrained front seat passenger.  The car he was travelling in struck another car and the patient’s car was flipped over onto its roof.  While the car remained on its roof the patient was able to crawl out and awaited medical attention.  The patient was taken by ambulance to the hospital where he was examined and testing was ordered.  The patient had multiple CT scans of the head and X-rays of the cervical and lumbar.  The CT of the head revealed a nasal fracture and the patient underwent immediate surgery to repair his broken nose. 

The patient presented three weeks post-accident with persistent and progressive daily occipital headaches, neck pain into the shoulders bilaterally, upper back pain and lower back pain that radiates into the legs and down into the feet bilaterally. He has swelling at the left anterior knee and bandages around the right elbow and two black eyes. 

The patient states that he was having difficulty with regular activities of daily living including walking for more than 15-20 minutes, long periods of standing, more than an hour of sitting, any bending or lifting and any regular daily chores.  The patient also states he was having difficulty getting a restful night’s sleep due to the pain.  The patient’s visual analog scale rating was 10 out of 10.

History: The patient denied any prior history of neck or back pain.  No reported prior injuries or traumas.

Objective Findings:  An examination was performed and revealed the following:

            Range of Motion: 

Cervical Motion Studies:

Flexion: Normal=60                      Exam-   25 with pain  with spasm 

Extension: Normal=50                  Exam-   20 with pain  with spasm

Left Rotation: Normal=80             Exam-   35 with pain  with spasm

Right Rotation: Normal=80           Exam-   35 with pain  with spasm

Left Lat. Flex: Norma=-40             Exam-   15 with pain  with spasm

Right Lat. Flex: Normal=40           Exam-   15 with pain  with spasm

 

Dorsal-Lumbar Motion Studies:

Flexion: Normal=90                  Exam-   35 with pain   with spasm

Extension: Normal=30              Exam-   10 with pain  with spasm 

Left Rotation: Normal=30         Exam-   10 with pain  with spasm

Right Rotation: Normal=30       Exam-   5 with pain  with spasm 

Left Lat. Flex: Normal=20         Exam-   5 with pain  with spasm 

Right Lat. Flex: Normal=20       Exam-   5 with pain  with spasm 

 

               

Orthopedic Testing

The orthopedic testing revealed the following positive orthopedic tests in the cervical spine: Valsalva’s indicating the presence of a disc at L4-S1 and the lower cervical region, foraminal compression indicating radicular pain in the lower cervical region, Jackson’s compression , shoulder depressor and cervical distraction all indicating pain in the lower cervical region.  The lumbar testing revealed a positive Soto-Hall with pain at the L4-S1 level, Kemps positive with pain from L4-S1, Straight Leg raiser with pain at 60 degrees, Milgram’s with pain at the L5-S1 level, Lewin’s with pain at L5-S1, and Nachlas eliciting pain in the L5-S1 region.

 

Neurological Testing

The neurological exam revealed bilateral upper extremity tingling and numbness into the shoulder on the left and down the right arm into the hand. The lower extremity revealed tingling and numbness into the gluteal’s bilaterally with left sided radicular pain in to the leg into left foot.  The pinwheel revealed hypoesthesia at C7 bilaterally and L5 bilaterally dermatome level. The patient was unable to perform the heel-toe walk

The chiropractic motion palpation and static palpation exam revealed findings  at C 1,2 , 5, 6, 7 and T 2,3,4,9, 10  and L 3,4,5 as well as the sacrum.

X Ray  Studies:

The hospital had cervical x-rays and a CT of the head on the day of the accident. Thoracic and lumbar studies were needed as a result of the positive testing and the patients history and complaints The x-ray studies revealed a reversed cervical curve and misalignment of the C1,2,5,6,7 and the lumbar studies revealed a mild IVF encroachment at L5-S1 with rotations at L3,4,5.

The results of the exam were reviewed.  The patient’s positive orthopedic testing, neurological deficits coupled with the decreased range of motion and positive chiropractic motion and static palpation indicated the necessity to order both cervical[1]and lumbar[2]  MRI’s4.

 MRI results

The MRI images were personally reviewed.  The cervical MRI revealed a right paracentral disc herniation at the level of C5-6 with impingement on the anterior thecal sac.  There is also a C6-7 disc bulge impinging on the anterior thecal sac. The lumbar MRI revealed an L5-S1 disc herniation.  There are disc bulges at from L2-L4.

                  CERVICAL MRI STUDIES

LUMBAR MRI IMAGES

Treatment Plan:

After reviewing the history, examination, prior testing, x-rays, MRI’s and DOBI care paths3 it was determined that chiropractic adjustments6  wereclinically indicated

The patient was placed on a treatment plan of spinal manipulation with modalities including intersegmental traction, electric muscle stimulation and moist heat.  Diversified technique was used to adjust the subluxation diagnosed levels of C1,2,5,6,7 and L3,4,5.  Although there were herniated and bulging discs present in the cervical and lumbar spine there was no cord compression. Therefore; there was no contraindication to performing a spinal adjustment.  As long as there is enough space between the cord and the herniation or bulge then it is generally safe to adjust.5

The patient responded quite favorably to the spinal adjustments and therapies over the course of 6 months of treatments.  Initially, the patient was seen three times a week for the first 90 days.  The patient demonstrated subjective and objective improvement and his care plan was adjusted accordingly and reduced to two visits per week for the next 90 days of care.  His range of motion returned to 90% of normal:

Range of Motion: 

Cervical Motion Studies:

Flexion: Normal=60                      Exam-   55 with no pain 

Extension: Normal=50                  Exam-   40 with mild tenderness

Left Rotation: Normal=80             Exam-   75 with mild tenderness

Right Rotation: Normal=80           Exam-   75 with mild tenderness

Left Lat. Flex: Norma=-40             Exam-   35 with no pain 

Right Lat. Flex: Normal=40           Exam-   35 with no pain

 

Dorsal-Lumbar Motion Studies:

Flexion: Normal=90                  Exam-   80 with tenderness

Extension: Normal=30              Exam-   25 with tenderness 

Left Rotation: Normal=30         Exam-   25 with no pain

Right Rotation: Normal=30       Exam-   25 with no pain

Left Lat. Flex: Normal=20         Exam-   20 with no pain 

Right Lat. Flex: Normal=20       Exam-   20 with no pain

 

The patient had decreased spasm, decreased pain, increased ability to perform ADL’s and his sleep had returned to normal. The patient states that he was no longer having the same difficulties with regular activities of daily living.  He was now able to walk for 45 minutes to 1 hour before the lower back pain flared up, he is able to stand for 1-2 hours before the lower back pain begins, he is able to sit for an hour or more before the lower back pain flares up. When the patient bends or lifts he has learned to use his core and lifts less than 20-30 pounds to avoid exacerbating his low back.  The patient also states he was no longer having difficulty getting a restful night’s sleep.  The patient’s visual analog scale rating was 3 out of 10.

Conclusion:

The patient presented 3 weeks post trauma with cervical and lumbar pain as well as headaches.  The symptoms were progressing and the pain was radiating into the upper and lower extremities.  The history and exam indicated the presence of a herniated disc in the lower lumbar and cervical region.  Cervical and lumbar MRI’s were ordered to identify the presence of the herniated disc as well as to determine whether or not the patient should be adjusted.  The MRI results of both the cervical and lumbar MRI revealed herniated discs, however, because these discs were not causing cord compression it was safe to adjust the cervical and lumbar spine5.

Competing Interests:  There are no competing interests in the writing of this case report.

 

De-Identification: All of the patient’s data has been removed from this case.

 

References

  1. New England Journal of Medicine; Cervical MRI, July 28, 2005, Carette S. and Fehlings M.G.,N Engl J Med 2005; 353:392-399MRI for the lumbar disc, March 14  2013, el Barzouhi A., Vleggeert-Lankamp C.L.A.M., Lycklama à Nijeholt G.J., et al., N Engl J Med 2013; 368:999-1000 http://www.state.nj.us/dobi/pipinfo/carepat1.htm -16.7KB
  2. New England Journal of Medicine; Cervical-Disk HerniationN Engl J Med 1998; 339:852-853September 17, 1998DOI: 10.1056/NEJM199809173391219
  3. Is It Safe to Adjust the Cervical Spine in the Presence of a Herniated Disc? By Donald Murphy, DC, DACAN, Dynamic Chiropractic, June 12, 2000, Vol. 18, Issue 13
  4. Treatment Options for a Herniated Disc;  Spine-Health, Article written by:John P. Revord, MD

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