Chiropractic Clinical Reasoning in a Patient with Cervical Radiculopathy: A Case Report

Original Article

Chiropractic Clinical Reasoning in a Patient with Cervical Radiculopathy: A Case Report  

Kenneth P. May, DC 1, Matthew F. Funk, DC2

1 Private Practice, Warrenton, VA

2 Associate Professor of Clinical Services at University of Bridgeport, College of Chiropractic

[email protected]

Published: August 2020
Journal of the International Academy of Neuromusculoskeletal Medicine
August 2020, Volume 17, Issue 1

The original article copyright belongs to the original publisher. This review is available from: http://ianmmedicine.org ©2020 May/Funk and the International Academy of Neuromusculoskeletal Medicine. This is an Open Access article which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Objective

This case presents the successful evidence-based diagnosis and treatment of a patient with cervical radiculopathy in a chiropractic setting.

Clinical Features

Cervical radiculopathy is a common and sometimes severe neuromusculoskeletal condition that is reported to affect about 2 out of every 1000 individuals and is most commonly diagnosed during the 4th and 5th decades of life. A 33-year-old male presented with persistent neck and left arm pain over the last 2 months. He had consulted with an orthopedic surgeon who recommended immediate surgical intervention.  

Interventions

The patient elected to exhaust conservative measures prior to pursuing surgery.  History and examination were consistent with cervical radiculopathy. Red flags were ruled out and there were no neurologic deficits other than those associated with cervical radiculopathy.  A trial of chiropractic care was provided and included: manual traction of the cervical spine, pin and stretch, trigger point therapy, home strengthening and stretching activities, and low-level-laser therapy.

Outcome:  The patient reported moderate relief immediately following the first visit; after a total of 5 visits over 3 weeks the patient rated his pain at 0/10 on an 11-point numeric rating scale and reported feeling “normal”.  A three year follow up revealed that the patient has been able to successfully adhere to his home exercise plan and has not needed further medical care for his condition.  

Indexing Terms

Chiropractic; Manipulation, Chiropractic; Radiculopathy; Case Report; Neck; Neck Injuries; Spine; Conservative Treatment; Orthopedics; Intervertebral Disc

Introduction

The human neck is an intricate structure built for mobility and strength. It houses many delicate nervous system structures including spinal nerves, the irritation of which can cause cervical radiculopathy.  Cervical radiculopathy is a complex and painful medical condition that affects about 1 out of 500 people in their lifetime. It occurs most commonly during the 4th and 5th decades of life [1]. Neck pain is a common cause of disability worldwide and 19% of people suffering from neck pain are found to suffer from cervical radiculopathy [2].  Risk factors that have been associated with cervical radiculopathy include cigarette smoking, being Caucasian and having a history of cervical/lumbar radiculopathy [1]. Cervical radiculopathy is most commonly attributed to mechanical compression or chemical irritation of the spinal nerve roots.  Intervertebral disc degeneration can result in neuroforaminal stenosis, predisposing nerve roots to compression. Trauma, infection and tumors can also result in cervical radiculopathy [3]. The most common features associated with cervical radiculopathy are neck pain and arm pain that manifests with a gradual onset.  The quality of pain reported with cervical radiculopathy may range from mild discomfort to sharp shooting pain. This pain presentation often begins in the midline of the neck and radiates into the shoulder and/or upper extremity. As the radiculopathy progresses, the pain often peripheralizes to the more distal aspects of the involved upper extremity.  Individuals with cervical radiculopathy may also experience sensory changes along the dermatome associated with the compressed nerve root, or motor weakness within the corresponding myotome [4]. Cervical radiculopathy can be caused by acute trauma or insidious degeneration leading to the injury [4].  

No single test or procedure can establish a diagnosis of cervical radiculopathy. Instead, elements of the history and a comprehensive exam lead a clinician to a diagnosis of cervical radiculopathy [2].  Electromyography (EMG) can help assess the function of a specific nerve root in suspected cases of cervical radiculopathy [3]. Advanced imaging such as a cervical magnetic resonance imaging (MRI) or computed tomography (CT) provide visualization of structures that may contribute to the cause of cervical radiculopathy [3].  This report presents a case of cervical radiculopathy that responded favorably to a short course of chiropractic care. Written informed consent was obtained from the patient for the publication of this case report. A copy of the written consent is available for review by the Editor-In-Chief of this journal.

Case Report

A 33-year-old male presented with a chief complaint of neck and arm pain and a recent diagnosis of cervical radiculopathy from an orthopedic surgeon.  The pain originated in the left side of his neck and “shoots” down his left arm into his thumb, pointer and index fingers. The patient also described an achy pain in his left shoulder region.  The pain was rated 8/10 and described as sharp and shooting. Any amount of physical activity intensified the pain. Specific provocative actions included turning his head to the left, coughing and sneezing.  The onset was two months prior to his presentation to our office. The patient stated that he had never experienced this type of pain before. He sought evaluation by an orthopedic surgeon prior to seeking chiropractic care and was offered surgery to minimize the likelihood of further injury and disability.  The patient had undergone bilateral transverse carpal ligament release 4 years earlier to address carpal tunnel syndrome and appreciated only modest improvement. He was not eager to undergo another surgical procedure. Further, he was alarmed by the language used surrounding disability and elected to delay surgery, instead seeking an opinion from a provider of conservative care. 

The patient was a manual laborer and performed tasks specific to landscaping (operating heavy machinery, lifting large and/or heavy objects and using bulky motorized tools for various tasks).  Upon presentation he had been unable to perform such work-related tasks for 2 months. The patient was not restricted with respect to activities of daily living (ADLs), but was in severe pain when performing them.  Lying in supine with his left arm raised above his head was palliative. This pain-relieving position is known as “Bakody’s sign” and is suggestive of cervical radiculopathy. The patient reported previous treatment for this condition including acupuncture and over the counter NSAIDs, both of which provided modest temporary relief. The patient was adamantly opposed to using opioid medications as their use would preclude him from operating heavy machinery. He also communicated concern for the highly addictive nature of opioid medications.

Physical Examination

A detailed physical examination was performed.  The first step in the physical examination was to rule out serious or emergent pathologies by assessing for “red flags”. [2] During the history the patient intimated elevations of stress and anxiety related to major work and life events which he felt impacted his ability to cope with his medical condition.  After the history, a neurological exam was performed. Cerebral, cerebellar, cranial, and peripheral nerve examinations were all unremarkable. The head & neck, eyes, ears, nose, throat examination were unremarkable. Heart, lung, and circulatory examination were unremarkable. Orthopedic testing reproduced the patient’s chief complaint with neutral cervical compression, left lateral flexion cervical compression test, shoulder depression test, and upper limb median nerve tension test.  A detailed chiropractic evaluation was performed on the patient to assess his neuromusculoskeletal system with an emphasis on biomechanics. Passive range of motion testing revealed that cervical extension, left lateral flexion, and left rotation were all decreased and reproduced the patient’s chief complaint. When performing flexion of the patient’s cervical spine, a “stretching” sensation was elicited within the musculature of the posterior cervical spine. Posterior to anterior springing of the C3-C7 spinal segments was tender to palpation, bilaterally over the articular pillars.  Painful myofascial trigger points were detected, bilaterally, within the cervical paraspinal muscles, left levator scapulae, left upper trapezius, and left posterior scalene muscles. Anterior head carriage and scapular protraction were also noted and were consistent with the postural features of upper crossed syndrome. This is significant as this type of postural abnormality leads to increased forces through the lower cervical spine and the affected cervical intervertebral disc.  

The patient produced a copy of a cervical MRI from 2 months prior which revealed a large posterolateral broad-based disc protrusion that was causing moderate-to-severe left neuroforaminal canal stenosis at the C5-C6 level.  

MRI Findings

C3-C4

C4-C5

C5-C6

C6-C7

C7-T1

Size of Disc Protrusion

None

Small

Large

Small

Small

Type of Disc Protrusion

None

Posterocentral

Posterolateral

Posterocentral

Posterocentral

Direction of Disc Protrusion

None

Central

Left

Central

Central

Intervertebral Canal Stenosis

Absent

Absent

Present

Absent

Absent

Severity of Protrusion

None

Mild

Moderate to Severe

Mild to Moderate

Mild

These radiographic findings correlated with the orthopedic testing further verifying our working diagnosis of cervical radiculopathy.  

We implemented several outcome measures to quantify and track the patient’s progress.  We assessed pain severity using an 11-point numeric rating scale or NRS. The patient rated his level of discomfort as 8/10 on his initial visit and 0/10 by the end of care.  We assess functional impact using the Neck Disability Index at initial evaluation, during his reevaluation roughly halfway through care and upon discharge.  

Treatment/ Management

Current Evidence gives the following practice recommendations: [1] [4]

Treatment

Level of Supportive Evidence

Manual or Mechanical Intermittent Traction

Moderate Level of Evidence

Ancillary Treatments (Passive Modalities)

Moderate Level of Evidence

Surgical Intervention (Cervical Discectomy)

Moderate Level of Evidence

Epidural Steroid injection/ Nerve Block

Mild Level of Evidence

Multimodal Multidisciplinary Care

Mild Level of Evidence

Current literature suggests the natural course of cervical radiculopathy is usually favorable and self-limited, with 75%–90% of patients experiencing symptomatic improvement with conservative treatment [1]

A multimodal treatment plan was applied including manual therapies and a home exercise program (HEP). Manual Intermittent Traction was applied to the cervical spine.  [5] [6] [7] Chiropractic manipulation was applied to the thoracic spine. [11] [12] Pin and stretch and manual trigger point pressure release (also known as ischemic compression) was applied to the upper trapezius, sternocleidomastoid, splenius capitus, splenius cervicis, anterior scalene, middle scalene, posterior scalene, semi spinalis capitis, suboccipitals, and levator scapulae bilaterally. [8] A HEP was provided and consisted of self-stretch for the parascapular and cervical paraspinal musculature as well as directional preference movements and nerve mobility exercises. [9] We also implemented FDA approved low level laser therapy for accelerated recovery of the same myofascial structures that were treated with manual therapy and at the level of the disc protrusion. [10]   

Outcomes

The patient underwent treatment twice per week for the first 4 weeks, once per week for the next 2 weeks, and once every 2 weeks over the next 4 weeks, for a total of 12 treatments.  He reported a reduction in pain from 8/10 to 4/10 on the NRS following initial treatment. After the 4th treatment he reported feeling “normal” with resolution of sharp shooting pains down his arm.  By the end of the 5th treatment his pain level was rated 0/10.

From the 8th visit on the patient’s primary complaint was neck stiffness, thought to be related to suboptimal posture and stress.  NRS was again measured at 0/10. The patient’s NDI score decreased significantly, consistent with his report of having returned to normal work duties.  Peripheral nerve examination (e.g., dermatome, myotome, and myotatic reflex) and cervical orthopedic tests were repeated weekly to assess for progressive neurologic deficit. A three year follow up revealed that the patient has been able to successfully adhere to his home exercise plan and had not required further medical care regarding neck pain.  

Discussion

This case report is an example of the conservative rehabilitation and management of a patient with cervical radiculopathy. The patient demonstrated consistent and steady improvement with the proposed plan of care. Improvement was seen in range of motion, pain intensity, muscular endurance, ability to perform ADL’s and psychosocial aspects.

There is a growing body of research supporting conservative therapies for the treatment of patients with cervical radiculopathy. We based much of our clinical reasoning on the collective research on evaluation and treatment of cervical radiculopathy in this case. [5 – 12] The author carefully considered available options and chose a multimodal treatment plan that included various forms of manual therapy, passive modalities and a home exercise plan.

Manual intermittent traction of the cervical spine was performed for axial decompression of the involved structures. Depending on the clinical setting, tools available, provider preference, and patient preference either mechanical traction or manual traction could be performed. In our case both the provider and the patient preferred manual traction over mechanical traction and thus it was selected as one modality of care. [5-7]

Chiropractic manipulation of the thoracic spine was performed to normalize regional and segmental range of motion and decrease regional muscle spasm thus increasing mobility in the affected area. Studies have demonstrated that impairments of the upper thoracic spine can cause problems in the cervical spine and many of the muscles of the cervical spine attach and act on the upper thoracic region making them closely interconnected. The patient was comfortable and able to tolerate lying in a prone position when the therapy was administered, and increased ROM was noted after the procedure was performed. [11-12]

Pin and stretch and ischemic compression were selected to address the myofascial components of his complaint. Either therapy type could be performed with the patient supine or seated depending on the patient’s preference. This was important to consider initially when the patient was quite uncomfortable and unable to tolerate comfortably prior to therapy with our clinic. The muscles treated with manual therapy were the upper trapezius, sternocleidomastoid, splenius capitus, splenius cervicis, anterior scalene, middle scalene, posterior scalene, semi spinalis capitis, suboccipitals, and levator scapulae bilaterally. [8]

FDA approved low level laser therapy was applied throughout the course of care. The intention of using this modality was to increase the rate of recovery of the involved myofascial tissues. The laser was applied both centrally and laterally over the level of the disc protrusion in the cervical spine. The laser was also applied over the muscles that were treated with manual therapies via pin and stretch or ischemic compression. When one suffers from a painful spinal condition with aspects of their social life impacted, it is important to be effective and efficient in their recovery to help get them back to their normal life to avoid increased odds of long term disability. [10]

A home exercise plan was provided along with education regarding the importance of self-efficacy. Elements of the program were aimed at improving neurodynamic function, thereby decreasing pain related to the radiculopathy and increasing the patient’s level of confidence and comfort. Other exercises were aimed at normalizing the patient’s posture by stretching or strengthening involved musculature. [9]

Though the patient described in this case responded exceedingly well, the treatment approach and positive outcome may not be generalizable to others. Evidence-based care was provided by consulting the available research, bringing to bear the author’s clinical expertise, and considering – at every step – patient preference. It is worth noting that the patient’s condition may have improved with other combinations or in absence of treatment, as the natural history of cervical radiculopathy is such that many people improve without intervention. It is the author’s judgment that, given the patient’s anxiety about possible disability and surgery, professional guidance and reassurance, at the very least, were indicated. At 3-year-follow-up the patient had not experienced recurrence of neck or upper extremity pain. In addition, he endorsed greater confidence in his body’s resilience and ability to recover from injury. It is important to consider the impact of radicular pain on quality of life and to mitigate distress not only through treatment but also through careful education.

Conclusion

This case describes the successful management of a patient with cervical radiculopathy using conservative, patient centered, evidence-based treatment in an outpatient setting. 

Limiting Factors

The greatest limitation of this case is that this only pertains to one patient rather than multiple patients with the same diagnosis.  Due to this the findings might not be reproducible in others with similar circumstances and the findings should be interpreted as such.  Many individuals with cervical radiculopathy improve without intervention, so natural history must be considered.   

Competing Interests

The authors declare that there were no conflicts of interest in the making of this study.  

References

1.  Woods BI, Hilibrand AS. Cervical Radiculopathy. Journal of Spinal Disorders & Techniques 2015;28(5).

2.  Murphy D, Hurwitz EL. Application of a diagnosis-based clinical decision guide in patients with neck pain. Chiropractic & Manual Therapies Chiropr Man Therap 2011;19(1):19.

3.  Murphy D. A Clinical Model for the Diagnosis and Management of Patients with Cervical Spine Syndromes. Austrailasian Chiropractic & Osteopathy 2004;12(2).

4.  Bono CM, Ghiselli G, Gilbert TJ, et al. An evidence-based clinical guideline for the diagnosis and treatment of cervical radiculopathy from degenerative disorders.The Spine Journal 2011;11(1):64–72.

5.  Young IA, Michener LA, Cleland JA, Aguilera AJ, Snyder AR. Manual Therapy, Exercise, and Traction for Patients with Cervical Radiculopathy: A Randomized Clinical Trial. Physical Therapy 2009;89(7):632–642.

6.  Gudavalli MR, Potluri T, Carandang G, et al. Intradiscal Pressure Changes during Manual Cervical Distraction: A Cadaveric Study.Evidence-Based Complementary and Alternative Medicine2013;2013:1–10.

7.  Jellad A, Salah ZB, Boudokhane S, Migaou H, Bahri I, Rejeb N. The value of intermittent cervical traction in recent cervical radiculopathy.Annals of Physical and Rehabilitation Medicine 2009;52(9):638–652.

8.  Salt E, Wright C, Kelly S, Dean A. A systematic literature review on the effectiveness of non-invasive therapy for cervicobrachial pain. Manual Therapy 2011;16(1):53–65.

9.  Savva C, Giakas G. The effect of cervical traction combined with neural mobilization on pain and disability in cervical radiculopathy. A case report. Manual Therapy 2013;18(5):443–446.

10.  Konstantinovic LM, Cutovic MR, Milovanovic AN, et al. Low-Level Laser Therapy for Acute Neck Pain with Radiculopathy: A Double-Blind Placebo-Controlled Randomized Study. Pain Med Pain Medicine 2010;11(8):1169–1178.

11. Norlander S, Aste-Norlander U, Nordgren B, Sahlstedt B. Mobility in the cervico-thoracic motion segment: An indicative factor of musculo-skeletal neck-shoulder pain. Scand J Rehabil Med. 1996;28:183–192.

12. 34. Cleland JA, Childs JD, McRae M, et al. Immediate effects of thoracic manipulation in patients with neck pain: A randomized clinical trial. Man Ther. 2005;10:127–135.