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Original Article 1

back to March 2011 issue

C5-C6 and C6-C7 Disc Herniation with Stenosis Causing Nerve Root Impingement

James R. Brandt DC, MPS, FACO 1

1 Chiropractic Private Practice, Coons Rapids, MN, USA

Published:
Journal of the Academy of Chiropractic Orthopedists
March 2011, Volume 8, Issue 1
Received: September, 2010
Accepted: September, 2010

This is an Open Access article which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The article copyright belongs to the author and the Academy of Chiropractic Orthopedists and is available at: http://www.dcorthoacademy.com.
© 2011 Brandt and the Academy of Chiropractic Orthopedists.

Abstract

Objective:  Demonstrate how conservative management using flexion- distraction to multiple causes of neck complaints can successfully be treated with co-management and cooperation between healing disciplines. 

Clinical Features:  A 43 year old male patient returned to the clinic with left side neck pain, left arm numbness and numbness in the left thumb, index and middle finger.  Imaging revealed  a "C5-C6 broad based 1-2 mm AP 1-2mm left posterolateral foramina and mostly foraminal protrusion, superimposed upon an uncinate osteophyte, impinging upon the exiting left C6 nerve root in the severely stenotic left neural foramen. This is superimposed on an annular bulge-osteophyte that produces mild central canal stenosis to 10mm AP midline dimension, with no cord impingement.  Left uncinate osteophyte and a 2mm soft herniation at the left foraminal entrance zone, with impingement upon the left C7 root, entering within the moderately stenotic left foramen. Mild right foraminal stenosis".

Outcome:  The patient had been treated for neck pain in the past. Nevertheless he was counseled about the presenting complaints and findings. Different chiropractic and medical treatment protocols were outlined for this condition. The treatment for these presenting complaints and findings included a course of flexion-distraction and a surgical consultation. The patient responded favorably and was dismissed from active care after 14 in office sessions.  When the surgical consultation occurred, the patient had been responding to care and a "wait-and-see" strategy was employed by the orthopedic surgeon about the need for more aggressive treatment.

Conclusion:  Cox© flexion-distraction provided a conservative treatment plan for a difficult case to manage.  Referral for a surgical consultation was appropriate noting the extensive changes. Working with a surgeon who understands the flexion-distraction protocols was helpful in this case.  The treating clinician was able to reduce patient anxiety about their condition by the patient understanding the team approach to care. 

Case Study

The patient presented to the office with an insidious onset of neck pain on the left with discomfort and numbness into his thumb, index and middle finger.  The discomfort also went into the upper back adjacent to the left scapula. He could not relate any one incident that brought on the current complaints.  The patient was last seen in the office 3 years prior with a history of neck pain. He was treated then for two sessions and was able to go deer hunting. He had not been seen by any clinician for neck pain after that treatment.  He was employed as a carpenter. Concern was expressed as it was starting to affect his activities of daily living (ADL).  There is a sense of weakness in the left arm and his dexterity with the hand seemed less.  He was a non-smoker. The pain was with him constantly and his Visual Analog Scale (VAS) was 5 out of 10.  His cervical Oswestry index was 11 out of 50 or 22%.  There was a family history of cancer.  Over -the -counter (OTC) pain medication was being taken that included 400 mg of an Ibuprofen product.

On examination, he was noted to be a 43 year old Caucasian male with a height of 70 inches and a weight of 210 lbs.  He is afebrile with a pulse rate of 86 per minute and a respiration rate of 16 per minute.  The blood pressure on the left was 136/84 and on the right 132/82 at 1700 hours.  A review of the HEENT was unremarkable and no lympyhadenopathy was noted.  Palpation produced +2 pain (0/+4 scale) on the left side C5-C7.  Cervical distraction gave his neck relief.  It also eased, but did not eliminate discomfort into the left arm.  Cervical flexion (90) 55 degrees, extension (70) 45 degrees, left lateral bending (45) 20 degrees, right lateral bending 10 degrees, left rotation (90) 70 degrees and right rotation 75 degrees.  Muscle stretch reflexes were +2/+2 with hypoesthesia noted in the C6 dermatome. It appeared to be include the area of the 7th as well.  To try and circumduct the neck was quite painful to him and he commented that looking up while working bothers him the most.  Grip strength was slightly less on the left, but he is right hand dominate.  He had a positive Bakody sign on the left and Spurling's was positive with pain into the left upper arm.  In-office imaging studies were deferred with prospects of advanced imaging if he does not respond quickly.

Diagnosis and Treatment

The working diagnosis was cervical radiculopathy, rule out cervical discopathy
He was started on a course of Cox© cervical-flexion-distraction following the protocol for radiculopathy. The pre-test was done without the use of the cervical restraint straps.  He tolerated the pre-test well and gentle long-y- axis distraction followed by unrestrained flexion manipulation was performed.  Pulsed (50%) ultrasound 1.25W for 6 minutes was applied to the C6 nerve root area followed by interferential current 4000Hz 10 minutes to the mid-cervical paraspinals (2 electrode pads) and at the wrist (2 electrodes pads).  Cryotherapy was instructed q.i.d daily.  He was instructed to remain off work for 5 days to start aggressive, non-surgical care.  This care is supported by Simotas in Spine 2000;25(2) where he found non operative aggressive treatment for lumbar stenosis is reasonable.  In that study he found 40 of 49 patients were treated non-surgically: 23 improved, 12 no change and 5 progressively go worse.(1)

After the first treatment, he felt better the remainder of the day.  After the 2nd visit he noticed that the discomfort in the hand was less. When he completed the 3rd office session, the treatment had remained the same for the exception that the EMS electrodes were moved to just below the elbow because he had virtually no hand symptoms. I began the use of the cervical spine restraint straps on the 3rd session as he was progressing and had not adverse signs to treatment.  It was my opinion that he was approaching 50% improvement. I switched to Cox© protocol 2 for this technique.

When he returned to see me for his 4th session he was markedly worse. ROM had decreased and he had numbness back in the hand and fingers.  His neck pain had increased to 5-6/10.  He had increased his ibuprofen to 800 mg q.i.d over the last 24 hours.  I learned that he was an avid spear fishing participant and had been been spearing in northern Minnesota.  The sudden action of throwing the spear and pulling in the big fish had aggravated his symptoms.
He was scheduled for advanced imaging and the MRI scan was read by a chiropractic radiologist. See Figures 1 and 2.

Figure 1. C5-C6 broad based 1-2mm AP left posterolateral and mostly foraminal protrusion, superimposed on uncinate osteophyte, impinging upon the exiting left C6 root in the severely stenotic left neural foramen.  This is superimposed on annular bulge-osteophyte, with mild central stenosis to 10mm AP midline dimension, abutting the cord on the left, without deformation.  Moderate right foraminal stenosis from uncinate osteophyte.  No facet arthropathy.

Figure 2. Annular bulge-osteophyte produces mild central canal stenosis to 10 mm AP midline dimension, with no cord impingement.

The radiologist reported further: Left uncinate osteophyte and a 2 mm soft herniation at the left foraminal entrance zone, with impingement upon the left C7 root, entering/within the moderately stenotic left foramen.  Mild right foraminal stenosis. The average sagittal diameter of the cervical spinal cord ranges from 5-11.5mm (mean 10mm) as demonstrated on computed tomography (CT) and myelography. The average canal sagittal diameter of the canal from C3 to C7 ranges from 15 to 25mm (mean 17mm).

Debate exists regarding the absolute canal diameter that constitutes cervical stenosis. Absolute stenosis has been defined as a cervical sagittal canal diameter of less than 10mm, as seen on a lateral cervical spine radiograph. A canal of 10-13mm is considered to be relatively stenotic (6)

The patient was set up for a surgical consultation noting the increase in his symptoms.  I have found co-management of potentially difficult cases eases the anxiety of the patient. Treatment in our office resumed and he was returned to the same acute care protocol that began the treatment of his condition. (Cox© Technique Protocol 1 for radicular patients). He did see the surgeon a few days later and he had two treatments within the interval from the flare-up to seeing the surgeon. I did talk to the surgeon regarding the recommendation of continuing chiropractic treatment.  I met with him and had information with me that explained the treatment that was used in this case and data that supports the use of the modalities.

The surgeon's report stated: "It does appear likely that his symptoms are stemming from the disc herniation and stenosis at C5-C7. He has marked improvement of his neck pain and triceps pain. He has only intermittent tingling in his hand at this time. We would recommend careful observation at this time and also use of good body mechanics. He can continue with chiropractic treatments but should avoid neck adjustments.”

The patient was treated a total of 9 more sessions with the flexion-distraction adjustments.  His neck was restrained each session. The patient continued improving with treatment and by the time he saw the surgeon he had accomplished 50% improvement of his flare-up. He had been given isometric exercises for the cervical spine after session 3 and was instructed to do these t.i.d (three times a day) daily.  Cryotherapy was discontinued after his 6th session. He was prescribed an over-the-door traction unit beginning at 10 lbs. traction 5 minutes 3 times per day. The weight was gradually increased and by the last two sessions he was at 18 lbs. once daily.

Four weeks after the start of treatment, the flare-up, advanced imaging and surgical consultation, he was 80% improved. He had returned to work after missing 7 days and he also returned to spear fishing at this time.  The patient had 3 more sessions of flexion-distraction in the clinic over the next 4 weeks and was dismissed with only fleeting tingling in the left thumb.  He was performing his ADL without any encumbrances.

He is now nearly 10 months post treatment and in recent conversation with him, he has not had any increase in symptoms.

Discussion
This case of cervical spondylosis and cervical disc herniation was followed conservatively for a two month period of time.  He was told of symptoms or activities causing him problems with the neck and arms that would necessitate a follow up visit. Cervical spondylotic myelopathy (CSM) is the most common progressive spinal cord disorder in patients more than 55 years old.  This disease is also the most common cause of acquired spasticity in later life and may lead to progressive spasticity and neurologic decline.   More than 50% of middle-aged patients show radiographic evidence of cervical disease, but only 10% have clinically significant root or cord compression. CSM is also the most common cause of acquired spasticity in later life and may lead to progressive spasticity and neurologic decline. (2,3,5)  There are multiple symptoms of myelopathy, including motor and sensory disturbances, but the onset is usually insidious. Symptoms can include gait abnormalities, loss of coordination, upper and lower neuron signs and symptoms in the upper and lower extremities, bowel and bladder difficulties and the classic abnormalities of hand function.  However, the symptoms can be much more subtle and may involve axial neck pain, scapular pain or a progressive broad-based gait. (4,5)

The history of CSM is not well known. There are static mechanical factors contributing to cervical spondylosis and CSM. These include the following (3):

  • Acquired spinal stenosis and disc degeneration -  The chemical composition of the nucleus pulposus and annular fibers deteriorate over time. During the aging process of the spine, the disc cannot bear or transfer load due to ongoing dehydration.  With increased load, the uncovertebral processes become flattened, which alters the load bearing function of the intervertebral joint.  Osteophytic spurs develop  at the margins of the end plates.  Osteophytes stabilize adjacent vertebrae whose hypermobility is caused by the degeneration of the disc. The disc further calcifies, stabilizing the vertebrae and the osteophytes increase the weight bearing surface of the endplates, which decreases the effective force being placed upon them. Osteophyte over growth and ligamentum flavum buckling can cause direct compression of the spinal cord. Such a transformation can lead to compression of the spinal nerve and the vertebral artery.  These are generators of chronic pain, as well as demyelination of ascending and descending spinal cord pathways.
  • Ossification of the posterior longitudinal ligament (OPLL): - Ossification of the OPLL is a common multifactorial disease.  This disorder can result in progressive myelopathy caused by compression of the spinal cord from ectopic ossification of spinal ligaments. The natural course of OPLL suggests progression with age, implying the contribution of environmental factors such as accumulate mechanical stress on the spine, and genetic factors.
  • Ossification of the ligamentum flavum (OLF):  - More frequently diagnosed in the thoracic and lumbar spine. Most common symptoms associated with OLF are neck pain and arm weakness.
  • Congenital spinal stenosis: -  A narrowed spinal canal is thought to cause the compression. A number of authors have identified the normal sagittal diameter of the spinal canal is approximately 17-18 mm between C3 and C7 variations 15-25 mm (6).
  • Stenosis vs. dynamic mechanical factors: - Translation and angulations between vertebral bodies in flexion and extension can also transiently narrow the canal.  Flexion and extension MRI can visualize this translation.
  • Ischemia: - Considerable evidence exists to support ischemia as a major underlying pathologic event, which contributes to the etiology of myelopathy.

Past treatment for CSM has been primarily surgical intervention.  Traction and soft collars have not been shown to alter the course of this disease. The success of non-operative modalities in altering the natural history of cervical myelopathy is largely unknown. (7) There have been several studies of patients treated conservatively and with laminectomy versus non-operative care, 67% of patients may deteriorate neurologically over time. (2)  The conservative management consisted of a soft collar, nonsteroidal anti-inflammatory drugs (NSAIDS), and discouragement from high-risk activities. (6)  The literature supports conservative management of mild CSM. (1) Manipulation and traction in extension (underline by the author) is contraindicated as it closes the foramina and decreases the size of the cervical canal. (7) Recognizing the signs and symptoms of myelopathy and referral for a surgical consultation is critical for patient care. The literature regarding flexion-distraction manipulation and its effectiveness is currently  limited.  This may be due to multiple factors, which include a lack of proper training and knowledge in the use of the treatment.  Cervical flexion-distraction therapy is a relatively new procedure. (8)

Conclusion
Cox© cervical flexion-distraction adjustment was an effective treatment for cervical disc and stenosis. It should be considered prior to cervical spine surgery for disc herniation or stenosis without myelopathy.  Like all treatments, it is not the answer for all disc and stenotic problems, but there is clinical evidence that it can be effective. (9)  Further research is needed in the area of flexion-distraction treatment of cervical spine injury and presenting complaints.

Competing Interests
The author does not have any conflicting or competing interests.

References
1. Simotas AC: Non-operative treatment for lumbar spinal stenosis: clinical and outcome results and a 3 year survivorship analysis.  Spine 2000,25:197-204.
2. Vigna FE, Tortolani PJ: Cervical myelopathy: differential diagnosis, Seminars in Spine Surgery 2004, 16:228-233.
3.  Baptiste DC, Fehlings MG: Pathophysiology of cervical myelopathy. The Spine Journal 2006,6:S190-S197.
4.  Rumi MN and Yoon ST: Cervical myelopathy history and physical examination. Seminars in Spine Surgery 2004,(16)4:234-240.
5. Lavelle WF and Bell GR: Cervical myelopathy: history and physical examination. Seminars in Spine Surgery 2007,(19)1:6-11.
6.  Dean CL, Lee MJ and Cassinelli EH: Incidence of cervical stenosis: radiographic and anatomic.  Seminars in Spine Surgery 2007, (19)1:12-17.
7. Edwards CE, Riew KD,  Anderson PA, Hillbrand AS, Vaccaro AF: Cervical myelopathy current diagnostic and treatment strategies. The Spine Journal 2003, (3)1:68-81.
8. Cox JM: Neck, Shoulder and Arm Pain (3rd ed). Ft. Wayne, Indiana: Chiro-Manis, Inc.; 2004.
9. Hurwitz EL, Morgenstern H, Vassilaki M, Chiang L: Adverse reactions to chiropractic treatment and their effects on satisfaction and clinical outcomes among patients enrolled n the UCLA neck pain study. Journal of Manipulative and Physiological Therapeutics 2004, 27(1):16-25.