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Neck pain, headaches, and plain film

Exit forum ID Forum Discussion Neck pain, headaches, and plain film

This topic contains 12 replies, has 7 voices, and was last updated by   William Brady, DC August 9, 2016 at 9:44 am.

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    Brandon Cohen DC, CSCS

      Buckle up, its a little long.

      34 year old female presented with middle thoracic spine achy pain which began a couple of days prior. She has previously had this type of pain years before and would roll on a foam roller and get some crunching and feel better. This has not been helpful this episode.

      No Neurological symptoms. Provocative factors are sitting upright with “good posture,” upper extremity movement, and exercise class. Deep inspiration is not provocative. Accountant, sits for 9 hours for work, rides horses for 1 hr/day, and group exercise class 3 days a week.

      She also reports some cervical spine tension with this condition, beginning after thoracic spine pain, no headaches.

      Exam: UCF: 27 degrees with no pain. CF: chin overshoots the SC joints with lower cervical spine tension. CTF: 75 degrees with lower thoracic spine tension. CR: not tested. TF: full and pain free. TR: 35 degrees bilaterally with central thoracic spine pain when performed bilaterally.

      DX: Acute exacerbation of chronic mechanical thoracic spine pain with associated soft tissue adhesions in the thoracic rotatores. Adhesions in the cervical spine.

      Priority was set to address thoracic rotation first due to symptoms and decreased motion. Then to address UCF and other cervical spine motions.

      Treatment for 3 visits to the thoracic spine with improved motions and decreased symptoms. She “sleeps awkwardly” and begins to have increased cervical spine pain. I check ranges of motion of the cervical spine and UCF is the same as the first visit, but now produces suboccipital tension. When asked about the thoracic spine pain, she reports that the cervical spine pain is so bad that she cannot tell where the thoracic spine symptoms are. I suspect cervical disc irritation.

      I worked RCP major and minor and SO. ROM improves post treatment, and symptoms decrease for a day, the day following we have a suboccipital headache. 2 days later she has more pain than before and decreased range of motion of UCF to 23 degrees (suboccipital spine pain). CF is also worse 3 fingers to the SC joint (lower cervical spine pain). I treat RCP major and minor, SO. UCF and CF improve. I also treat nuchal ligament, and levator scapula to help unload the cervical discs, and symptoms are worse. I explain how unloading the disc too much can create an increase in symptoms and that she will be sore.

      She misses her next appointment and comes in 1 week later. Pain is worse (8/10), and headaches constant for 2 days. No neurological symptoms. I want to get a cervical spine MRI to see what is going on as I still suspect a disc injury. Her insurance is weird and fighting, so I order a plain film to get the process started.

      Findings: Mild c3-4 osseous neural foraminal narrowing, right greater than left. Mild atlantoaxial degenerative changes.

      Are these findings helpful? What might cause the atlantoaxial changes?

      Help. And…..go. Thanks for the input.


      Carl Nottoli, DC

        Assuming all other load factors between the visit are the same I would also be suspicious of underlying disc pathology.

        The plain film findings are relevant as she has diminished capacity in the degenerative changes of the spine. She is likely also very weak and imbalanced from years of postural abuse and adhesion formation. After removing adhesion that quickly, her symptom threshold tanked and now she is left with the more relevant degeneration, likely disc pathology, and weakness. Extremely low capacity in a high load environment with very low symptom threshold.

        Draw this on the whiteboard and it should become pretty clear to her. You can never predict how cases will unfold, but she is still getting the correct treatment and finally addressing her whole problem.

        A couple things that seem to be outliers is that she is pretty young so genetic durability may also be a factor. If she’s had any high stress events happen recently this may also be relevant. Prolonged head forward posture could conceivably cause C1/C2 degenerative changes, or any past cervical spine trauma. There are some other metabolic diseases that attack the C1/C2 joint as well so if you suspect anything wrong there you could ask her if she has had any blood work done recently. I’m curious how Dr. Brady will see this case and respond.



        Eric Lambert, DC

          I agree with Carl on this one.  Looks like underlying cervical disc issue.  I’ve had the same issue twice this year unloading someone too fast and having their disc get worse briefly and cause more symptoms.  It’s hard, especially when you’re all doing the right things.

          Has she stopped/slowed down riding the horse while you’re treating her?  I would think that if you unloading the area that fast and she is still riding a horse as much as before it may have given her neck more range than she was used too and the jarring from riding the horse is aggravating it too.  Load management issue there.

          I’ll be interested to see what Dr. Brady thinks as well.



          Brandon Cohen DC, CSCS

            Thanks. Pain has been so severe that all activity other than work has ceased. I believe it’s been just over two weeks.


            William Brady, DC

              Interesting case. Really good answers from Carl and Eric. To drill down on the details… What concerns me the most is the atlantoaxial degeneration. Is this due to a prior trauma? (Ask her if she ever hit her head hard- MVA, fall from horse etc.) She is flaring up with treatment to this region. I would think this is the pain generator more likely than a typical lower cervical disc. While she has lots of pain the headaches are the worst not neck and back pain (lower cervical discs won’t do this).

              We definitely need a MRI. This will help rule out disc and rule in atlantoaxial involvement. Is there inflammation? Are the ligaments intact? Is the joint unstable?

              In the meantime, stop upper cervical treatment. Based on her response to treatment this is a bad idea. Shift to treatment that won’t irritate/involve the upper cervical spine.

              Also, keep in mind that treating rectus capitis major and minor with SO, nuchal ligament and levator…. and all of that bilateral is a TON of treatment.

              If rectus major and minor are bad. Stop after treating these.

              If rectus major and minor are improving and near finished go ahead and add superior oblique.

              If a disc is so bad you can’t treat rectus and SO then only treat nuchal lig and levator.

              Dose of treatment is very important, particularly in cases of sensitivity and flaring.


              Brandon Cohen DC, CSCS

                Thanks for all the input. Definitely will scale back treatment, and avoid the upper cervical stuff for now. We are moving forward on the MRI, and will hopefully have some more answers soon.



                  Any update on this case Brandon?? Looking forward to seeing how this played out for you and the patient.


                  Brandon Cohen DC, CSCS

                    We got the MRI done late last week.
                    She has small disc bulges at C4-5 and C5-6 (that were reported as normal on the report), and some minor degeneration at C1-2. I spoke with a radiologist about her symptoms and history and he confirmed no annular tearing, or anything suspicious looking with C1-2. He suggested flexion/extension films if instability is suspected.

                    I treated the patient once more before the MRI. She was still in a lot of pain and had severely limited ranges of motion.

                    UCF was very limited, but I did not measure it because I was waiting to see the results of the MRI before resuming treatment there.

                    CF: 4 fingers to the SC joint with pain in the middle and upper cervical spine bilaterally.

                    I did check her thoracic motions and flexion was full, and rotation was 35 degrees bilaterally.

                    We treated nuchal ligament and levator scapula to unload the cranky discs, and CF improved to 1 finger to SC joints. We stopped treatment, and I explained how that much of a change could exacerbate things again.

                    The patient went to her PCP the day before the MR to get pain medication, and I spoke with her that day before that appointment, and she reported some relief from pain, but still limited ranges of motion.

                    I called her yesterday after reviewing the report and images, but have not been able to talk with her. I will try again today.

                    What is the likelihood that there is some issue throughout the thoracic spine that is producing this symptom? Maybe a thoracic disc? I haven’t seen this presentation before. Could the comparatively good ROM of the thoracic spine be hiding something? I need to speak with her and see where she is, but I’m concerned that she’s not going to answer my calls.


                    Brandon Cohen DC, CSCS

                      This post is like exercises. I don’t prescribe them for no reason. Because I went through this case, I imagine there are others who have had or will have similar experiences.

                      I spoke with her the day after the last post, and we reviewed the results of the MRI.

                      She had already been to her primary, who gave her a prescription for some muscle relaxers and pain medication which (surprise!) did not affect her symptoms. She was diagnoses with spasms. She was also referred to physical therapy, and by the time I spoke with her had done her consult and a treatment (1 of 6) and was feeling worse. (A little more background, she was referred to me by her sister who is away at PT school). She didn’t want to come in for treatment because PT is going to help.

                      So, in the communication department, we talked about how disc pain works, and why she had the pain in the first place. She wanted to go through with physical therapy, and that we should touch base after that trial and figure out the next step for her. I don’t expect to see her again as she self discharged after 5 visits for the original complaint and 3 to the cervical spine when exacerbated.

                      I have run over the situation in my head and learned some valuable lessons. While I am disappointed by the current status of the case, I’m over it and moved on. I think we all want everyone to get better as soon as possible. Everyone wants to be better yesterday, for free. I am the same way as a provider. I want to be right every time, and do everything right all the time. The times when things don’t go as planned are very frustrating, but I’ve tried to use them as learning points. I talked with Dr. Brady about this very issue and we discussed looking at this as education, and while expensive the information learned is invaluable.

                      So, here’s the take home I found from this case. Most of you already know all these things!

                      1. Communication is important. Patients are dumb and don’t know what you know.  They do not know your thought process, you have to tell them what is happening, and why its happening.

                      2. Be present and on point each visit with each patient. I rushed through one appointment with her because I was behind on my schedule, and that was a crucial visit where more communication was needed.

                      3. Flaring up with treatment is a bad thing. I know that and you know that, but the patient needs to know that. Getting ahead of this could have changed this case from a communication stand point.

                      4. Don’t do too much. She came in with a lot of cervical spine pain and ROM limitation (which I didn’t expect), and I slipped back into my former ART mode of trying to fix the whole thing in one visit. I did too much treatment that visit and while the ranges of motion massively improved after 10 minutes of treatment, she had a major flare a couple hours later. On that note

                      5. Respect the pathology, and for crying out loud respect the body. Protective tension is an important thing and has a job to do. Don’t try and over ride it, because the chance of getting better is much less than the chance of a flare. I was lazy and stupid. Don’t do that. (On a related note, I had a guy come in 2 days ago with a major lumbar disc issue for 3 days, super antalgic, and QLF extended from 1-5″. First treatment we did just supraspinous ligament and he improved to extended from 1-3″ and flat from 3-5″. Some relief and a lot of pain. He returned two days later with minimal antalgia and QLF flat from 1-4″, because I didn’t do too much. He is better off because of what I didn’t do.)

                      6. When you screw up, admit it, analyze it, and move on. Dwelling on mistakes without learning from them is the worst. You can bet your bippy I won’t make all these mistakes again. Ain’t nobody got time for that.



                      Cody Scharf, DC

                        Great takeaways, Brandon! We have all been there, we have all done something similar. Learn and move on, just as you are doing! Thanks for sharing this case with us!

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