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© 2018 Indian Journal of Pain | Published by Wolters Kluwer - Medknow 197
Case Report
A Case Report of Cervical Myelopathy After Neck
Manipulation in a Patient with Cervical Spondylosis and
Radiculopathy: Cause and Effect or Natural Progression?
Gaurav Chauhan, Murali Patri, Cheryl J. Mordis, Vivek Loomba
Department of Anesthesiology, Pain and Perioperative Medicine, Henry Ford Health System, Detroit, Michigan, USA
Abstract
A 47-year-old female, with cervical spondylosis and radiculopathy, presented with clinical features of cervical myelopathy after
outpatient physical therapy. An emergent neurological surgery was scheduled after radiological evidence of cord compression. The
symptoms subsided after surgery. Conservative management modalities should be practiced keeping in mind the potential of cervical
spondylosis to progress to catastrophic complications such as myelopathy. It may be difficult to accurately implicate neck manipulation
in the onset of the cervical myelopathy as it may be clinically silent or coexist with radiculopathy. It is vital to adequately counsel the
patient, about this phenomenon to avoid legal ramifications.
Keywords: Cervical myelopathy, cervical spondylosis, chronic pain, neck manipulation
Background
The progression of cervical myelopathy as a sequela of the
neck manipulation or due to the natural progression of
the condition is imputable. The natural history of cervical
myelopathy includes static and dynamic factors.[1,2] Static
factors such as osteophyte formation and ligamentum
flavum hypertrophy can reduce the spinal canal diameter
and promote cord compression. Dynamic factors
become relevant when the normal motion of cervical
spine causes static components to interact in such a
manner that aggravates or promotes spinal cord damage.
We present a case report of a 47-year-old woman, with
cervical spondylosis with radiculopathy, who presented
with clinical signs and symptoms along with radiological
evidence of cervical myelopathy during her follow-up visit,
after the failure of outpatient physical therapy. The patient
thoroughly reviewed the case report and gave written
permission to the authors for publishing the report.
clinical Vignette
A 47-year-old woman, with a history of bilateral
carpal tunnel syndrome and cervical spondylosis with
radiculopathy, after a motor vehicle accident 14 years
ago, presented with complaints of neck pain, intermittent
severe bilateral arm pain, and headaches. The patient
underwent physical therapy 10months ago and her neck
pain became worse. She reported the development of
intermittent electric shock-like shooting, numbing, and
tingling pains starting at the anterolateral shoulder with
radiation down both arms into the third, fourth, and
fifth digits, especially while bending her head forward.
The patient developed changes in her writing along with
deterioration in fine motor activities such as sewing.
She further complained of nonspecific headaches that
radiated to the upper neck, shoulders, and scapular
region bilaterally and interfered with her sleep. She
reported gradually developing a feeling of heaviness in
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© 2017 Indian Journal of Pain | Published by Wolters Kluwer - Medknow2017
Address for correspondence: Gaurav Chauhan,
Apt 1607, 1350 W. Bethune St., Detroit, Michigan 48202, USA.
E-mail: Gchauha1@hfhs.org
Previous Presentation: Jan 9, 2017 for 42nd Annual Regional
Anesthesiology and Acute Pain Medicine Meeting (ASRA),
San Francisco, California, USA.
How to cite this article: Chauhan G, Patri M, Mordis CJ, Loomba V. A
case report of cervical myelopathy after neck manipulation in a patient
with cervical spondylosis and radiculopathy: cause and effect or natural
progression?. Indian J Pain 2017;31:197-200.
Access this article online
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Website:
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DOI:
10.4103/ijpn.ijpn_60_17
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Chauhan, et al.: Case report of cervical myelopathy after neck manipulation
198 198 Indian Journal of Pain ¦ Volume 31 ¦ Issue 3 ¦ September-December 2017
the legs along with an inability to walk at a brisk pace
and reported multiple falls due to balance-related issues.
She started using a walker since last 4months. She never
received any chronic pain injections or had any previous
spine surgeries. Her medical history was significant for
hypertension, hypercholesterolemia, chronic bronchitis,
and gastroesophageal reflux disease. She worked as a
housekeeper but could not keep up with the demands of
her job due to her symptoms. On examination, the pain
was localized to the cervical paraspinal muscles, anterior
shoulder with “numbness” in the axilla; medial upper
arm; lateral forearm; and third, fourth, and fifth digits.
There was wasting of intrinsic muscles in both hands and
decreased sensation to light and sharp touch bilaterally in
the upper extremities in a nondermatomal pattern. She
had 3/5 strength in C5-T1 distribution with decreased
pinch and grip strength and 4/5 strength in L2-S1. The
cervical compression test (Spurling’s test) was positive
for reproduction of arm pain bilaterally. The Hoffmann’s
test and scapulohumeral reflexes were positive. The biceps
and supinator reflexes (C5 and C6) were absent, with a
brisk triceps reflex (C7). The knee and ankle reflexes were
accentuated (hyperreflexia), and Babinski reflex with ankle
clonus was present bilaterally. She had a positive Romberg
sway along with compromised coordination as evidenced
by difficulty walking and placing one foot in front of the
other (tandem walking). She was graded as a 4 on the
Nurick scale [Table 1] and 3 on the Cooper myelopathy
scale [Table 2]. The magnetic resonance imaging (MRI)
of cervical spine reported a prominent central extrusion
component with inferior migration to the C6-7 interspace,
which was abutting and flattening the ventral cord surface
[Figure 1]. The MRI also reported a mild diffuse disk
osteophyte complex at C5-6, asymmetric to the right,
which led to mild-to-moderate foraminal narrowing
[Figure 2]. The patient underwent emergent anterior
cervical discectomy at C5-6, C6-7, with C6 corpectomy
and plating. During the surgery, a large sequestered
fragment leading to severe compression of thecal sac was
seen behind the C6 body. The fragment was retrieved
and adequate decompression of thecal sac was done all
the way laterally. After an uneventful hospital course, the
patient was discharged on the fifth postoperative day with
a Miami J collar and a wheeled walker and a grade 5 motor
power in all myotomes. Three weeks after the surgery, the
neck collar was removed and patient reported significant
improvement in the neck and arm symptoms. The X-ray of
the neck spine confirmed satisfactory hardware placement
[Figure 3]. The patient was ambulating with a cane for
up to 30-min intervals and continued to have narrow-
based gait and slow velocity. She had 5/5 motor strength
in C5-T1 and L2-S1 bilaterally, and her reflexes were 2+
throughout. Her only complaints were infrequent neck
spasms and minimal residual paresthesias in the hands.
The patient was able to actively participate in physical
therapy for gait training. At 6months after the discharge,
she was undergoing physiatrist evaluation for specialized
rehabilitation to determine if she could return towork.
Table 1: The Nurick score[6]—the higher the grade, the more severe the deficit
Grade 0 Signs or symptoms of root involvement but without evidence of spinal cord disease
Grade 1 Signs of spinal cord disease but no difculty in walking
Grade 2 Slight difculty in walking that did not prevent full-time employment
Grade 3 Difculty in walking that prevented full-time employment or the ability to perform all housework but that was not severe enough
to require someone else’s help to walk
Grade 4 Able to walk with someone else’s help or the aid of a frame
Grade 5 Chairbound or bedridden
Table 2: Cooper myelopathy scale[6]—the higher the grade, the more severe the deficit
Upper extremity function
Grade 0 Intact
Grade 1 Sensory symptoms only
Grade 2 Mild motor decit with some functional impairment
Grade 3 Major functional impairment in at least one upper extremity but upper extremities useful for simple tasks
Grade 4 No movement or icker of movement in upper extremities; no useful function
Lower extremity function
Grade 0 Intact
Grade 1 Walks independently but not normally
Grade 2 Walks but needs cane or walker
Grade 3 Stands but cannot walk
Grade 4 Slight movement but cannot walk or stand
Grade 5 Paralysis
Upper and lower extremities are analyzed separately, but the grades are not summarized.
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Chauhan, et al.: Case report of cervical myelopathy after neck manipulation
Indian Journal of Pain ¦ Volume 31 ¦ Issue 3 ¦ September-December 2017 199
discussion
In patients with cervical spondylosis with or without
radiculopathy, cervical myelopathy may develop
insidiously. Initial symptoms may be limited to a
decreased range of motion along with neck stiffness.[1]
The dermatomal pattern of radiculopathy may give way
to nonspecific, global pain, and paresthesia in upper
extremities along with a change in intensity and character
of pain.[1,2] The patient may develop brachialgia, which
is defined as episodes of shooting, stabbing pain in
the arm, elbow, wrist, or fingers followed by dull-achy
heaviness in the arm and tingling and numbness in the
hands. In some subjects, radiculopathy might coexist with
myelopathy creating a variable pattern on examination.
Decline in fine motor control may be seen along with
changes in bowel or bladder function.[3-5] The presence of
spasticity, hyperreflexia and clonus of lower extremities,
areflexia or fasciculation of upper extremities along with
dysesthesias, and positive Hoffman’s sign should sensitize
the clinician toward the presence of cord compression.[1,2]
In severe cases, varying degrees of unstable balance and
gait due to impaired proprioception, coordination, and
superficial sensory loss may lead to a functional limitation
that can be graded using the Nurick score. The Cooper
myelopathy scale can be used to grade both upper and
lower extremity symptoms due to root compression.[6] The
differential diagnosis for acute onset myelopathy includes
ossification of posterior longitudinal ligaments, spinal
cord arteriovenous malformation, metastatic or primary
spinal cord tumors, syringomyelia, spinal cord infarction,
whiplash syndrome (hyperextension–hyperflexion injury),
Brown-Sequard syndrome, and central cord syndrome.[3,4]
It is important to consider nonmyelopathic disorders such
as amyotrophic lateral sclerosis, Guillain–Barré syndrome,
shoulder amyotrophy, normal pressure hydrocephalus,
traumatic or neoplastic brachial plexopathy, vitamin B12
deficiency, diabetic neuropathy, and multiple sclerosis.
Along with the characteristic signs and symptoms, MRI
or CT scans of the cervical spine are instrumental in
Figure 1: Right foraminal stenosis at C5-6. Large disk extrusion
spanning the C6 vertebral body favored to be originating from a disk
osteophyte complex at C5-6, causing effacement of the CSF and mild
ventral cord flattening. Mild right foraminal stenosis at C5-6
Figure 2: MRI transverse section
Figure 3: X-ray of postsurgical neck: two-level anterior cervical
discectomy and fusion (C5-6, C6-7), corporectomy of C6, and
expandable cage
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Chauhan, et al.: Case report of cervical myelopathy after neck manipulation
200 200 Indian Journal of Pain ¦ Volume 31 ¦ Issue 3 ¦ September-December 2017
clinching the diagnosis of myelopathy and delineating the
underlying pathomechanics of the acute process.[7]
This report is an important addition to recent publications
reporting cases that were described as postmanipulative
complications.[8-10] In this case, there was a lag of 10months
between the neck manipulation and evaluation by a pain
specialist; furthermore, the symptoms worsened in the
last 6 months. In light of this evidence, the worsening
of the symptoms of the patient was attributed to the
natural progression of the disease. Neck manipulation can
accentuate the dynamic pathway of myelopathy, but it can
also be coincidental. The flexion of the neck can cause the
spinal cord to stretch over ventral osteophytic ridges leading
to friction-induced damage. The extension of the neck may
cause buckling of the ligamentum flavum into the spinal
cord causing pressure-induced injury.[11] Malone et al.[12]
in their retrospective review of neurosurgical patients
commented that they cannot establish a causal relationship
between cervical manipulation and progression of disk
herniation to myelopathy. Oppenheim etal.[13] reported 18
patients who had received spinal manipulation and whose
neurological condition immediately worsened. Injuries
were sustained to the cervical, thoracic, and lumbar spine
and resulted, variously, in myelopathy, paraparesis, cauda
equina syndrome, and radiculopathy. They concluded that
spinal manipulation may be associated with significant
complications in patients with disk herniation, and
imaging can be done before manipulation to identify
patients with significant risk factors, such as substantial
disk herniations or occult malignancies. Leboeuf-Yde
et al.[14] reported six cases in whom complications
developed before manipulation. They further commented
that had any intervention been provided in these cases, the
intervention could have been implicated in the incident,
when it evidently would have occurred anyway. All the
authors have unanimously echoed that a cause–effect
relationship between the neck manipulation and cervical
myelopathy is ambiguous at its best. Disk herniation can
progress to myelopathy without provocation, and there are
no objective measures to predict the same.[8-13]
conclusion
This case report emphasizes the fact that a careful
interpretation of evidence on hand for any kind of
posttreatment complications, in patients with disk
herniation, should be done considering the progression
due to the natural history of the disease independent
of the manipulative treatment, as a differential. It is
important to be aware of the possibility, in patients with
disk herniation with or without radiculopathy, to develop
cervical myelopathy. The conservative management
modalities such as neck manipulation should be practiced
keeping in mind the potential of pathology to progress
to catastrophic complication such as myelopathy. There
is a consensus that the causal relationship between
manipulation and the subsequent appearance of
symptoms should not be assumed. Following neck
manipulation, cervical myelopathy may be clinically silent
for a long duration or coexist with radiculopathy before
becoming clinically evident. It is critical to recognize and
institute timely intervention for cervical myelopathy. It is
of paramount importance to adequately counsel, reassure,
and explain to the patient about this phenomenon as this
can place the physician at legalrisk.
Financial support and sponsorship
Nil.
Conflicts of interest
None.
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