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).
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.
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.
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.