I recently had this case:

Subjective: 44 y/o female presents with neck pain.  It started coming on a few weeks ago (no known reason) but really got really bad yesterday (again no known reason).  She sought PCP office for a consult, who did x-ray (she is unsure results yet) and prescribed Prednisone & Skelaxin (but says no relief).  The pain was so bad last night that she went to the ER, but was in too much pain to wait long enough to be seen.  She cannot sleep at all in last 2 nights and unable to lie down. **I performed subjective history while patient stood as she could not sit down**

Location of Neck Pain: Right peri-scapula symptoms radiating posteriorly to elbow. Pain is aggravated with the following activities or positions: almost all activities right now. She is out of work for a few days as a full time nurse. Pain Quality: Weakness in right hand.  Constant pain in areas described above.

Pain rating: Currently: 9/10, Best: 5/10 (with ibuprofen a few days ago but nothing helps now), Worse: 10/10 (just happens).

Objective:

Cervical AROM sitting: Rrot: 60, Lrot: 60, Ext: 20, Flex: 40 all with local pain at CTJ.  No referral symptoms with AROM.  Could not perform overpressure secondary to guarding.

MMT: Grip 90/90: R: 15#, L: 30#. C8-T1 myotomes: 4-/5, All other myotomes: 5/5 but pain with shoulder testing.

Neurological screen: DTRs: 2+ B C5-C7. Intact sensation to light touch and sharp prick to involved areas.

Palpation: Notable hyperalgesia TTP centrally C6-T1 to SP and interspinous space.  Satellite MTrPs peri-scapula region.

Treatment:

This lady was hurting! As you can tell from irritability status from pain rating, inability to sit to perform history, pain with all movements and inability to perform a thorough exam.  Therefore, I decided to proceed with a treatment of repeated movements vs manual.

1. Repeated cervico-thoracic extension in chair, first patient-directed then OP by me at the CTJ.  Why did I choose this?  EBP: Experience: I have seen it work in the past for presentation as described above.  I decided not to beat around the bush too much as her symptoms were hot.

Result was basically what you want: Centralization of all symptoms from arm and peri-scapula region.  Grip normalized to 35# bilaterally (was 10#) initially.

However, symptoms only stayed centralized for a few minutes.  Therefore, the procedure was performed again with higher repetitions.  Again, only 5-10 minutes of relief by testing just sitting.

Therefore, mechanical cervical traction was performed at 20# for 15 minutes.  Why?  Minimal carry-over within session as describe above.  Also, read here.  She had no symptoms upon rest for ~10 minutes and departed from clinic.

Impression:

I told her I was concerned that her grip was that weak initially but considering it normalized after sensory symptoms centralized, that this was a very good sign and she is showing a mechanical response.   Also, on a positive note; her reflexes and sensory exam to sharp was intact showing possibly a more central sensitization / facilitated segment vs a herniated disc.

I scheduled her for the next day due to irritability.  On 2nd day, she came in with same complaints but continues to have centralization with exercise program, prescribed every hour.  Same treatment was performed with addition of supine CTJ extension over a foam roll (for HEP) and mid and high dog thoracic HVLAT.  Similar response as initial evaluation.

She called back and cancelled the following week’s appointment as she saw a neurosurgeon and he said she had a herniated disc requiring surgery.

So my question to you is:

Do you think she should continue conservative care or pursue surgery?  What implications in exam and results would lead you one way or the other? We can continue discussion on this case in comments.

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9 comments

  1. She obviously should continue conservative treatment for now because in my experience it should improve with time alone and it is showing some signs of improvement with therapy albeit, short term. The neurosurgeon obviously got her in prime condition which is an extremely vulnerable condition and desperate. I don’t blame the patient but she most likely isn’t informed that it has a good chance of doing just as well without surgery plus she is probably going to miss more time from work having surgery than not having surgery. I think her being a nurse also played into “pulling the trigger” on having the surgery based on my experience

  2. if pt can demonstrate centralization of symptoms, there is good likelihood she will respond well to PT.
    here’s some applicable research on your pt:

    Murphy DR, Beres JL; Is treatment in extension contraindicated in the presence of cervical spinal cord compression without myelopathy? A case report Manual Therapy; 13.468-472, 2008.

    Case report of patient with neck pain and peripheral numbness who lastingly abolished symptoms with cervical extension exercises despite MRI evidence of disc protrusions.

    Spanos G, Zounis M, Natsika M, May S.; The application of Mechanical Diagnosis and Therapy and changes on MRI findings in a patient with cervical radiculopathy Manual Therapy; In Press, 2012.

    Case report of woman with signs and symptoms of cervical radiculopathy and MRI showing a large disc herniation at the relevant level who was successfully treated with retraction extension exercises until she was symptom free. Shortly after this a repeat MRI showed a 56% reduction in the size of the herniation.

    There’s a lot we can educate the patient on about their herniation. shameless plug, I just wrote about this yesterday…http://www.directppt.com/2014/10/an-important-conversation-on-mris.html
    But a herniation on the MRI doesn’t tell us much.

    To play devil’s advocate, we don’t know if a sequestration or smorl’s node was seen in which case surgery may actually be applicable. However this I unlikely.

    ok my next pt is here…always a good read dude.

    1. Thanks for the references Jake. I’ll check them out. I am well aware of the imaging results with lumbar herniations, but always heard cervical findings don’t have as much false-positives.

      I’ll have to follow up with this case and let you know.
      Great MRI read by the way…I want to be able to get this on paper to show patients in a formal document. I think that will really help with patient education.
      Hv

    2. Jake,
      I just read over this case report:
      http://sandbox.skinandallergynews.com/fileadmin/qhi/ajo/pdfs/ajo04307E140.pdf

      Pretty cool results. I have heard mixed results on “resorption” of discs but this study is nice to share with patients, especially if they are stuck on “disc”.

      I have heard that discs are not the cause of symptoms over the age of ~60 y/o. This guy was in his 70’s. Not sure what your thoughts were and even though clinical exam matched his location of symptoms on MRI, I am not convinced that it was the cause.

      H

  3. Sometimes when we do everything correctly the patient still doesn’t respond as they wish. Who knows how this was effecting her work, home, social life. Based on centralization, she should’ve stuck with it. Did you give her a lumbar roll as well?

    1. Yeh exactly. This is where science and results don’t always go in your direction.

      This is an example where paternalistic attitude as a PT could pay off in your favor…I tried my best.

      And yes, she got a foam roll for home.

  4. I’ve had so many cases that present with similar symptoms and have complete abolishment of symptoms within a few weeks. Shame you didn’t get a chance to try conservative treatment longer as symptoms were responding. It doesn’t sound like an irreducible derangement as the symptom relief lasted for ten minutes. I’m interested to hear the response to surgery. Also if she gets a fusion or disc removal. I hate to think about the consequences of a fusion at 44yo.

    I always make a point to educate the patient that research shows results between conservative treatment and surgery are very similar and lean more to the side of conservative treatment. MDT courses have provided plenty of evidence that through my course work.

    1. Hey Stephen,
      Thanks for the response man and I agree. I even called her to discuss the case more and encouraged her to continue with HEP.
      One thing that has sparked me is that how QUICK surgery was planned? I saw her one day then the next she went to a neurosurgeon and surgery planned for 6 days later. I can tell you after 6 yrs…it has never been this quick!

      Lots of factors going into this case.

      I have never heard about the “10 minute symptom relief rule”. You got any more info on that?

      H

      1. http://scottsevinsky.tripod.com/pt/reference/spine/lumbar/spine_centralization_prognostic_value.pdf

        http://rosephysicaltherapy.com/ppts/BrianBobWebinar.ppt

        Here are a few good site that reference a huge amount of research. There is no “ten minute rule”, however irreducible Derangements have been found to peripheralize with weight bearing within a minute. If the does not occur then you stand a good chance that the derangement can be reduced. You may just need more frequency, reps or force to centralize the derangement.

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