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Case Report
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.
© 2018 Indian Journal of Pain | Published by Wolters Kluwer - Medknow 197
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the legs along with an inability to walk at a brisk pace of cervical spine reported a prominent central extrusion
and reported multiple falls due to balance-related issues. component with inferior migration to the C6-7 interspace,
She started using a walker since last 4 months. She never which was abutting and flattening the ventral cord surface
received any chronic pain injections or had any previous [Figure 1]. The MRI also reported a mild diffuse disk
spine surgeries. Her medical history was significant for osteophyte complex at C5-6, asymmetric to the right,
hypertension, hypercholesterolemia, chronic bronchitis, which led to mild-to-moderate foraminal narrowing
and gastroesophageal reflux disease. She worked as a [Figure 2]. The patient underwent emergent anterior
housekeeper but could not keep up with the demands of cervical discectomy at C5-6, C6-7, with C6 corpectomy
her job due to her symptoms. On examination, the pain and plating. During the surgery, a large sequestered
was localized to the cervical paraspinal muscles, anterior fragment leading to severe compression of thecal sac was
shoulder with “numbness” in the axilla; medial upper seen behind the C6 body. The fragment was retrieved
arm; lateral forearm; and third, fourth, and fifth digits. and adequate decompression of thecal sac was done all
There was wasting of intrinsic muscles in both hands and the way laterally. After an uneventful hospital course, the
decreased sensation to light and sharp touch bilaterally in patient was discharged on the fifth postoperative day with
the upper extremities in a nondermatomal pattern. She a Miami J collar and a wheeled walker and a grade 5 motor
had 3/5 strength in C5-T1 distribution with decreased power in all myotomes. Three weeks after the surgery, the
pinch and grip strength and 4/5 strength in L2-S1. The neck collar was removed and patient reported significant
cervical compression test (Spurling’s test) was positive improvement in the neck and arm symptoms. The X-ray of
for reproduction of arm pain bilaterally. The Hoffmann’s the neck spine confirmed satisfactory hardware placement
test and scapulohumeral reflexes were positive. The biceps [Figure 3]. The patient was ambulating with a cane for
and supinator reflexes (C5 and C6) were absent, with a up to 30-min intervals and continued to have narrow-
brisk triceps reflex (C7). The knee and ankle reflexes were based gait and slow velocity. She had 5/5 motor strength
accentuated (hyperreflexia), and Babinski reflex with ankle in C5-T1 and L2-S1 bilaterally, and her reflexes were 2+
clonus was present bilaterally. She had a positive Romberg throughout. Her only complaints were infrequent neck
sway along with compromised coordination as evidenced spasms and minimal residual paresthesias in the hands.
by difficulty walking and placing one foot in front of the The patient was able to actively participate in physical
other (tandem walking). She was graded as a 4 on the therapy for gait training. At 6 months after the discharge,
Nurick scale [Table 1] and 3 on the Cooper myelopathy she was undergoing physiatrist evaluation for specialized
scale [Table 2]. The magnetic resonance imaging (MRI) rehabilitation to determine if she could return to work.
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 difficulty in walking
Grade 2 Slight difficulty in walking that did not prevent full-time employment
Grade 3 Difficulty 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 deficit 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 flicker 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.
198 198 Indian Journal of Pain ¦ Volume 31 ¦ Issue 3 ¦ September-December 2017
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clinching the diagnosis of myelopathy and delineating the modalities such as neck manipulation should be practiced
underlying pathomechanics of the acute process.[7] keeping in mind the potential of pathology to progress
to catastrophic complication such as myelopathy. There
This report is an important addition to recent publications
is a consensus that the causal relationship between
reporting cases that were described as postmanipulative
manipulation and the subsequent appearance of
complications.[8-10] In this case, there was a lag of 10 months
symptoms should not be assumed. Following neck
between the neck manipulation and evaluation by a pain
manipulation, cervical myelopathy may be clinically silent
specialist; furthermore, the symptoms worsened in the
for a long duration or coexist with radiculopathy before
last 6 months. In light of this evidence, the worsening
becoming clinically evident. It is critical to recognize and
of the symptoms of the patient was attributed to the
institute timely intervention for cervical myelopathy. It is
natural progression of the disease. Neck manipulation can
of paramount importance to adequately counsel, reassure,
accentuate the dynamic pathway of myelopathy, but it can
and explain to the patient about this phenomenon as this
also be coincidental. The flexion of the neck can cause the
can place the physician at legal risk.
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 Financial support and sponsorship
cord causing pressure-induced injury.[11] Malone et al.[12] Nil.
in their retrospective review of neurosurgical patients
commented that they cannot establish a causal relationship Conflicts of interest
between cervical manipulation and progression of disk None.
herniation to myelopathy. Oppenheim et al.[13] reported 18
patients who had received spinal manipulation and whose References
neurological condition immediately worsened. Injuries 1. Baron EM, Young WF. Cervical spondylotic myelopathy: a brief
were sustained to the cervical, thoracic, and lumbar spine review of its pathophysiology, clinical course, and diagnosis.
and resulted, variously, in myelopathy, paraparesis, cauda Neurosurgery 2007;60:S35-41.
2. Baptiste DC, Fehlings MG. Pathophysiology of cervical myelopathy.
equina syndrome, and radiculopathy. They concluded that Spine J 2006;6:190S-7S.
spinal manipulation may be associated with significant 3. Voorhies RM. Cervical spondylosis: recognition, differential
complications in patients with disk herniation, and diagnosis, and management. Ochsner J 2001;3:78-84.
imaging can be done before manipulation to identify 4. Dolan RT, Butler JS, O’Byrne JM, Poynton AR. Mechanical and
cellular processes driving cervical myelopathy. World J Orthop
patients with significant risk factors, such as substantial 2016;7:20-9.
disk herniations or occult malignancies. Leboeuf-Yde 5. Emery SE. Cervical spondylotic myelopathy: diagnosis and
et al.[14] reported six cases in whom complications treatment. J Am Acad Orthop Surg 2001;9:376-88.
developed before manipulation. They further commented 6. Vitzthum HE, Dalitz K. Analysis of five specific scores for cervical
spondylogenic myelopathy. Eur Spine J 2007;16:2096-103.
that had any intervention been provided in these cases, the 7. Taylor JA, Bussieres A. Diagnostic imaging for spinal disorders in
intervention could have been implicated in the incident, the elderly: a narrative review. Chiropr Man Therap 2012;20:16.
when it evidently would have occurred anyway. All the 8. Destee A, Lesoin F, Di Paola F, Warot P. Intradural herniated
authors have unanimously echoed that a cause–effect cervical disc associated with chiropractic spinal manipulation. J
Neurol Neurosurg Psychiatry 1989;52:1113.
relationship between the neck manipulation and cervical 9. Tseng SH, Chen Y, Lin SM, Wang CH. Cervical epidural
myelopathy is ambiguous at its best. Disk herniation can hematoma after spinal manipulation therapy: case report. J Trauma
progress to myelopathy without provocation, and there are 2002;52:585-6.
10. Tseng SH, Lin SM, Chen Y, Wang CH. Ruptured cervical disc after
no objective measures to predict the same.[8-13]
spinal manipulation therapy: report of two cases. Spine (Phila Pa
1976) 2002;27:E80-2.
Conclusion 11. Lebl DR, Hughes A, Cammisa FP Jr, O’Leary PF. Cervical
spondylotic myelopathy: pathophysiology, clinical presentation, and
This case report emphasizes the fact that a careful treatment. HSS J 2011;7:170-8.
interpretation of evidence on hand for any kind of 12. Malone DG, Baldwin NG, Tomecek FJ, Boxell CM, Gaede SE,
Covington CG, et al. Complications of cervical spine manipulation
posttreatment complications, in patients with disk
therapy: 5-year retrospective study in a single-group practice.
herniation, should be done considering the progression Neurosurg Focus 2002;13:ecp1.
due to the natural history of the disease independent 13. Leboeuf-Yde C, Rasmussen LR, Klougart N. The risk of over-
of the manipulative treatment, as a differential. It is reporting spinal manipulative therapy-induced injuries: a description
of some cases that failed to burden the statistics. J Manipulative
important to be aware of the possibility, in patients with Physiol Ther 1996;19:536-8.
disk herniation with or without radiculopathy, to develop 14. Oppenheim JS, Spitzer DE, Segal DH. Nonvascular complications
cervical myelopathy. The conservative management following spinal manipulation. Spine J 2005;5:660-6; discussion 6-7.
200 200 Indian Journal of Pain ¦ Volume 31 ¦ Issue 3 ¦ September-December 2017