Case reportCox Decompression Manipulation and Guided Rehabilitation of a Patient With a Post Surgical C6-C7 Fusion With Spondylotic Myelopathy and Concurrent L5-S1 Radiculopathy
Introduction
Patients commonly present with concurrent back and neck symptoms to conservative spine care practitioners. With numerous structures possibly responsible for symptomatology, identifying the pain generator is a daunting task. Even if the cause seems to be clinically certain, open debate is still possible. Lower extremity findings may be related to or caused by cervical injuries.
Cervical spondolytic myelopathy is the most common disorder in the United States causing dysfunction of the spinal cord.1 Cervical spondylotic myelopathy refers to impaired function of the spinal cord caused by degenerative changes of the cervical spine resulting in spinal cord compression.1 Cervical myelopathy may reflect age-related changes, genetic predisposition, occupational and repetitive factors, or post-surgical changes. Treatment of patients with minor cord compression and myelopathy may occur in a chiropractic clinic, however surgery is the prevailing treatment. The prevalence of surgically treated cervical spondolytic myelopathy is estimated to be 1.6 per 100 000 inhabitants.2 However, information on conservatively treated patients is lacking, and treatment protocols are not well identified. It has been reported that conservative treatment of cervical spine disc herniation patients without myelopathy respond better than surgically treated patients.3 However, no large-scale studies have been completed on conservative treatment of patients with myelopathy.
Manipulation is often utilized in conservative care of spine conditions and manual therapy has been used to treat both neck pain and back pain.4 Conservative treatment in spine care varies widely and there is little agreement on what defines conservative care, except for the absence of surgical intervention. Some suggest that conservative care may be a better and that surgery was no better than non-surgical patients.5 Another stated there was no clinical outcome difference between conservative and surgical treatment for cervical spondolytic myelopathy in a 64-patient randomized study over 10 years.6 Currently there is no evidence that outcome after surgery is better than the natural history or conservative therapy.
Radiographic or advanced imaging evidence of cord impingement or compression may be seen in asymptomatic people, thus it is unclear who may develop symptoms. There are no clear guides to the selection of patients who may benefit from the operation and there has been no standardization of preoperative evaluation, trials of conservative therapy, ascertainment of progressive disability, or assessment of outcome.7 These quandaries beg for further investigation.
There is little in the literature that describes the chiropractic care of patients who have previously had spine fusion. The purpose of this case study is to describe the conservative treatment of a post-surgical fusion with myelopathy and concurrent right L5-S1 radiculopathy utilizing Cox technique and rehabilitation.
Section snippets
Case Report
A 38-year-old male presented to a chiropractic clinic with neck pain and a history of an anterior cervical spine plate fusion at C6-7 after a work related accident 4 years earlier. He was referred from a physical medicine doctor who was his physician case manager. The patient had neck, middle, and lower back pain of 4 years duration following working as a driver for a trucking company and while unloading boxes he was hit in the left neck and shoulder with 2 80-lb boxes. The impact knocked him
Physical Evaluations
His appearance was a large-framed individual, with height of 6 ft 1 in, and weight of 260 lb. His coordination was poor, as he walked with a cane and wore a knee brace on the right side to prevent hyperextension. Upper extremity neurological signs included a positive Hoffman sign, which suggests an upper motor neuron lesion from cord compression. Reflex testing of the biceps, brachioradialis, and triceps was within normal limits. Light touch, sharp/dull, vibration, and hot/cold were all normal.
Imaging
CT of the cervical spine performed prior to presenting to the clinic demonstrated an intact C6-C7 anterior cervical spine fusion with anatomic alignment and no evidence of hardware failure. Mild to moderate marginal osteophytes were identified at the C67 level posteriorly which results in mild to moderate central canal stenosis and mild to moderate bilateral neuroforaminal stenosis (Fig 1A-C). No imaging of the lumbar spine was obtained, as no red flags were present in the presentation of low
Diagnosis
Post-surgical continued pain of a C6-C7cervical fusion with spondylotic myelopathy, C2 through C5 degenerative disc disease, presumed L5-S1 disc lesion with associated sciatic radiculopathy, facet dysfunctions and myofascial pain.
Patient Management
The chiropractic manipulative treatment was delivered on a Cox Model 7 adjusting table. (Fig 2) Both cervical and lumbar flexion distraction techniques were utilized. Careful tolerance testing was applied in the cervical spine and lumbar spine prior to treatment and the patient tolerated both central and lateral tolerance testing procedures well. The contact in the cervical spine was on the C4 vertebrae, as to influence motion above and below the fusion. The bilateral numbness of the fourth and
Discussion
This patient was treated with Cox decompression manipulation in addition to other therapies. In the lumbar spine, ligament loads are below tolerance failure to the spinal ligaments when the forces of 2° to 3° of downward table distraction are applied. The intervertebral disc space increases by 2 to 3 mm during this application.13 Cox manipulation physiological properties aim to open and separate the body disc body complex, decrease the intradiscal pressure to between − 39 and − 192 mm Hg,14
Limitations
The limitations of this case report include that this report is for only 1 patient. The results of this study may not necessarily be transferrable to other patients. The study data had been only short term, so the long-term lasting benefits of treatment are not clear. It is possible that the patient may have improved in spite of care. Additionally, it is not certain that the patient's relief of symptomatology will be ongoing if he does not continue to perform regimented rehabilitation.
Conclusion
This combined treatment protocol of rehabilitation and Cox distraction manipulation demonstrated beneficial results for a patient with spine pain and post-surgical C6-7 fusion with myelopathy and concurrent L5-S1 radiculopathy. This patient was treated 12 times over a 3-month time period, showing substantial clinical improvement with no reported adverse effects.
Funding Sources and Potential Conflicts of Interest
No funding sources or conflicts of interest were reported for this study.
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Cited by (1)
Chiropractic Management of a 67-Year-Old Veteran With Chronic Low Back Pain Utilizing Low-Velocity Flexion-Distraction: A Case Report
2023, Journal of Chiropractic Medicine