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36 y/o male, severe neck tension, dizziness, headache and Chiari malformation

Exit forum ID Forum Discussion 36 y/o male, severe neck tension, dizziness, headache and Chiari malformation

This topic contains 0 replies, has 1 voice, and was last updated by   Eric Lambert, DC January 17, 2018 at 1:12 pm.

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    Eric Lambert, DC
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      Been a while since I’ve asked for help on a case on a forum, so hopefully I’ve added everything to help you guys help me.

      Pain location: upper back tension and ache, neck tightness and stiffness, headaches and dizziness for 8 months

      – Age/Gender: 36, Male

      History:

      Feb 2017 playing hockey fell and landed on his left elbow and felt a jarring up into his neck and head. States he was very sore and stiff for a few days and then felt better.

      March 2017 he was sucker punched in the back of his head while playing hockey. He had a headache immediately after this and was sore and stiff again for a week and then two weeks after incident he woke up with vertigo, neck pain and headaches. Since that time the tightness and ache has migrated from his neck into his upper back. He also had left sided facial paresthesia that is no longer an issue.

      He has tried glasses, but still gets headaches and dizziness and his neck and upper back are still stiff.

      He has been on multiple medications, tried PT and finally his PCP touched his neck and noticed that he has a lot of hyper-tonicity. He wife referred him to my office as she had relief in the past.

      Aggravated: very positional: flexing neck forward and then back into extension, pressing on the muscles on left side at C2-C3, feels like a lacrosse ball inside of neck. Sleeping on his pillow at night.

      Relieved: sitting still without moving neck, medications

      EXAMINATION:

      Cervical Neutral is measured as: – 2 degrees

      Upper Cervical Flexion (UCF): 8% function

      UCF measured 2 degrees with moderate to severe stiffness and tightness in the neck and hard to perform. No pain is felt.

      Cervical Flexion (CF): 67% function

      CF measured 40 degrees with moderate to severe stiffness and tightness in the neck and upper back and hard to perform. No pain is felt.

      Cervico-Thoracic Flexion (CTF): 74% function

      CTF measured 67 degrees with mild to moderate stiffness in the neck and moderately difficult to perform. No pain is felt.

      Cervical Rotation (CR): Left 76% function Right 68% function

      Left CR measured 69 degrees with no pain felt only mild stiffness.

      Right CR measured 62 degrees with no pain felt only mild stiffness.

      Palpation:

      Palpation of the muscles revealed hypertonicity in the following areas: entire cervical spine musculature and upper thoracic musculature

      Adhesions were noted by palpation in the rectus capitus minor and major bilaterally, left superior oblique, medial cervical erector is worse on the left, levator scapulae, the upper thoracic erectors. These structures are loaded with adhesions and were almost difficult to palpate due to the hyper-tonicity involved.

      He does have a confirmed Chiari 1 malformation See the MRI report attached in picture below. His cervical spine is relatively clean minus some mild disc desiccation.

      I have treated him 4 times now and UCF has improved from 2 degrees to 9 degrees, but he is still extremely stiff and still has dizziness with neck motion, especially from flexion back to extension in his cervical spine. He can palpate his own left neck area at C2-C3 and cause dizziness to occur. His neurologist liked the idea of treating adhesions in his neck and placed him on a muscle relaxer to help his progress. The neurologist states that the Chiari malformation is mild in nature and wants to try all conservative means to help.

      My question is, how much can the Chiari malformation change the normal cervical measurements, or should I still expect the range to be closer to the normal ranges??

      Are there other tests I should be considering since he’s already had the MRI in March or is this just a treat all relevant adhesion and see what happens? The dizziness with flexion extension and palpation to the left side of the neck is what concerned me the most.

      Thanks for the help.

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