This topic contains 7 replies, has 2 voices, and was last updated by Keith Puri, DC October 24, 2018 at 4:35 pm.
October 23, 2018 at 12:46 pm #4883
I had a very interesting new patient come in today. On the phone it initially sounded like a disc flare up BUT the flare up was still getting worse 10 days later. Here’s what I found:
41 yo female
Pain started 10-14 days ago 6/10 on R side of neck as an strong ache but has since moved to 9/10 pain in neck with an associated ache/sharp pain in her right lat dorsi when she bears down. She also has occasional pain and achiness into the lateral aspect of her R arm. She does not report any traumatic event causing her problems. She works a desk job and she likes to garden. Not particularly physically active but she does report getting “doored” by a car while cycling last year.
P+ ANYTHING at the moment, but especially, R rotation. Woke up at 1:30 this morning with extreme pain
P- staying still is the best.
R Arm flexion: pain/tingling in right arm
R brachioradials flexion: pain/tingling at R scalenes
R tricep extension: pain at R CT jxn
finger flexion & wrist flexion: none
Thumb to 5th digit: pain at R CT jxn
UCF: 12 degrees/6-7 pain on R side of neck
CF: too painful
CTF: too painful
L 52% 7/10 pain on R side of neck (add extension/compression: mild 3/10 pinch on left
R 33% 9/10 pain on R side of neck (add extension- 10/10 pain on R side of neck)
Nerve tension test: negative
TF: Full flexion
Considering the lack of flexion, the strength tests with pain, and referring pain to the lat, It looks to me to be a multi-level disc degeneration case at C5,6 and 7 with referring pain to the long thoracic nerve. I’m not totally sold on my diagnosis. Why doesn’t she get radiating symptoms to the forearm? Is it because she can’t rotate her neck far enough to create tension? Is an SOL a possibility? I sent her out for an MRI for more information, which will hopefully clarify her diagnosis.October 23, 2018 at 2:07 pm #4885
Adam Holen D.C.
SOL causing compressive neuropathy would be my primary diagnosis (valsalva, progressive sx intensity, pain with strength). Was her strength normal and just painful or did it cause weakness? All the positive strength tests could potentially load the neck, except thumb to index, which I’m a bit confused about. Wrist and finger flexion should slacken the nerves. My understanding is that inflammatory neuropathy is less intense neurological sx of tingling, burning, numbness while compressive is the strength, reflex, sensation. Since it’s relatively recent, it may not have progressed far enough to cause loss of sensation or reflexes, similarly, it may not have progressed past the arm into the forearm or hand yet (if my thinking is correct that this is how things progress depending on level).
So SOL compressive would be initial suspicion, but not confident in ruling out inflammatory, either way, the MRI is the best first step. Compressive is first for me because in general, the symptom intensity should match the amount of damage, dysfunction, capacity, and load. Seems like she has a high load (desk job & gardening) and lower capacity not being particularly active. Getting “doored” last year may have set the stage for her ADL’s to be enough for this to finally go (no trauma/single incident). Hope this helps, interested to see what the MRI says and what others initial thoughts are on the diagnosis.
The palliative of “staying still is the best” reminded me of Ron Swanson when he had a hernia and couldn’t move. Maybe the neck and herniations are similar.October 23, 2018 at 4:26 pm #4886
The strength tests had no weakness, just pain. It’s definitely more than a disc (or discs) being flared up but I wasn’t certain what the differentiating factors of SOL vs disc would be. I’ll keep you updated on MRI results.October 24, 2018 at 1:40 pm #4887
Carl Nottoli, DCParticipant
Based on your history and exam, the dx strongly suggests C7 disc derangement. Check out the sclerotome picture below. It basically covers the neck, arm, and lat presentation you described (assuming I’m correct on your description of the anatomy).
A disc derangement will have the same presentation as this case: severe pain after seemingly “waking up,” inability to perform level tests, severe pain with ortho tests that challenge the disc.
You aren’t getting any dermatomal patterns because there is no NR compression. However, if pissed off enough it will cause some local inflammation to the nerves into the arm.
MRI was a good call in this case.October 24, 2018 at 2:05 pm #4888
Let’s say I get the MRI results and it is C7 disc derangement. If she is still flared up, I cannot treat. Would the right move be to collaborate with an MD to get inflammation down enough to tolerate treatment?October 24, 2018 at 3:18 pm #4889
Keith Puri, DCParticipant
Outside of load management strategies, I have found an acute disc or nerve root pain that is chemically mediated is best treated with something that is chemical in nature. A Medrol dose pack seems to fit this quite well. You just have to get the PCP on board to prescribe it. Manual treatment will be most effective and tolerable once the chemical irritation is removed.October 24, 2018 at 4:09 pm #4890
Thanks Keith! She’s new to Milwaukee, so I’m not sure if she has a PCP yet but I will reach out to one I like and co-care with them.October 24, 2018 at 4:35 pm #4891
Keith Puri, DCParticipant
That is a great way to show the PCP how co-managing MSK conditions appropriately can be safe and effective.
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