CASE REPORT: Multiple cervical and lumbar disc herniations and ligamentous injury, post MVA treated successfully with conservative chiropractic treatment
Dennis Mutell D.C.
Abstract: This case report demonstrates the use of conservative chiropractic care in the treatment of cervical and lumbar disc injuries as well as ligamentous instability in the cervical and lumbar spine of a person injured in a double impact automobile collision.
Diagnostic studies include complete case history, physical examination, including orthopedic and neurological exams, radiographic examination, including flexion extension views of the cervical and lumbar spine and MRI of the cervical and lumbar spine.
Introduction: The patient, a 48-year-old male who reports he was a passenger in a hotel shuttle van which was struck on the passenger side by another automobile, followed by a full-frontal impact of the shuttle van hitting a pole. The patient was wearing a seatbelt. From the scene of the accident, he was transported by ambulance to a local hospital emergency department where he had x-rays and a CT scan of the head taken. He received contusions to the chest, legs and shin. He was released with prescription medication and told to follow up with his doctor when he got home if he continued to have problems.
Patient complaints were as follows: At the time of the accident, the patient noted he was dizzy and had tingling and numbness in the extremities. He complained of generalized ache, pain and stiffness in the neck and back. He also suffered from confusion.
At the time of his initial evaluation at my office, approximately 10 days post-accident, he complained of neck pain and stiffness which increased with physical activity and decreased with rest and medication. Neck pain was referred to the occipital region, across the shoulders and into the upper thoracic. He reported pain into the thoracic region, described as tightness and stiffness, which also increased with physical activity and improved with rest. His low back was his primary area of complaint - with the most significant and consistent pain that increased significantly with weight-bearing activity and only improved with lying down. Patient had knee stiffness and pain on the right and soreness in both knees and ankles. There was notable bruising of the chest and a contusion. Patient continued to have symptoms of mild traumatic brain injury, consisting of feeling dazed and confused with some amnesia following the accident. Patient continues to have headaches and brain fog.
Prior treatment: Patient received a prescription for anti-inflammatories and a muscle relaxer from the emergency department. He was not working and resting as much as possible and utilizing hot showers.
Past medical history: Patient reports he was involved in an automobile collision 2 to 3 years prior to this collision and received injuries to his neck and back. He had a brief course of chiropractic and physical therapy care. He was released from care without any restrictions or residual complaints. He was working without restriction since being released from that accident and was asymptomatic prior to this accident.
Clinical findings: Patient is 48 years old, 5’11” and 235 pounds. Blood pressure is 130/80 pulse is 75. Patient exhibited no swelling or edema to the extremities. Cranial nerves were intact. Patient appeared antalgic and guarded in his movements.
Physical findings: Palpation revealed significant pain and tenderness in the suboccipital region as well as guarding spasm in the cervical, upper thoracic and lumbar region. Patient had visible restrictions of range of motion in the cervical and lumbar spine, associated with pain. Patient had a positive Foramen Compression Test and Jackson’s Compression Test bilaterally. Manual cervical traction provided some relief in the C1 occipital region, but increased pain along the side the neck and out across the top of the shoulders. Patient could not perform an Apply’s Scratch Test associated with pain in the upper thoracic region. He had a positive SOTO Halls Test for pain in the cervical region into the upper thoracic region. Straight leg raise test was restricted at 60° bilaterally for increased pain in lower back into the buttock region. Patient had a positive Kemps Test bilaterally for joint pain and muscle pain. McMurray’s Test was positive the right knee. The patient was unable to obtain full flexion of the right knee.
Due to the visual restrictions of range of motion in the cervical and lumbar spine, a dual inclinometer range of motion study was ordered and performed of the cervical and lumbar spine, demonstrating loss range of motion.
Neurological testing: Dermatome testing revealed normal sensation in the upper and lower extremity to light touch and pinwheel. Deep tendon reflexes were found to be +2 bilaterally of the upper and lower extremity, except for a diminished left bicep reflex. Manual muscle testing of the upper and lower myotomes revealed 5/5 strength bilaterally, except for 4/5 of the left deltoid muscle and diminished grip strength of the left hand.
Based on the patient’s subjective symptoms and examination findings, x-rays of the cervical and lumbar spine, including flexion extension views were ordered. I personally reviewed these images.
Cervical: Significant loss of the normal lordosis.
Retrolisthesis is noted at C-4 in relationship to C-5 on the neutral lateral view.
Flexion shows significant fixation to normal movement. C-3 demonstrates anterolisthesis in relation to C-4 and it is noted that C-4 shows realignment in relationship to C-5, which is indicative of ligamentous laxity and injury.
Extension demonstrates significant fixation to normal movement. There is further retrolisthesis of C-4 in relationship to C-5 extension.
Small osteoarthritic spur is noted on the anterior inferior aspect of C-4 and posterior disc thinning.
Lumbar: Biomechanical misalignment is noted as rotation of L1, L2 and L3 to the right. Patient has a significant external rotation to the left ilium and the right ilium appears elevated in relationship to the left.
Osteophyte is noted of the anterior superior aspect of L4 associate with significant posterior disc thinning.
Retrolisthesis of L-3 in relation to L-4 on the neutral lateral image.
Flexion reveals significant fixation to normal movement and realignment of L-3 in relation to L-4 flexion - indicating some degree of ligamentous laxity.
Number 1: Cervical neutral lateral view demonstrating retrolisthesis of C4 in respect to C5 and C5 and respect to C6, indicating ligament laxity.
Number 2: Cervical flexion view demonstrating realignment of C-4 in respect to C5 and C5 and respect to C6, indicating ligament laxity. Normal movement into cervical flexion is significantly restricted.
Number 3: Cervical extension view demonstrating retrolisthesis of C4 in respect to C5, indicating ligament laxity. Significant restriction to normal cervical extension.
Cervical MRI without contrast: Following my personal review of the MRI images, my impressions are as follows:
Cervical spinal cord appears normal in signal intensity. Generalized arthritic changes to the facet joints throughout the cervical spine.
C-2 / C-3: High intensity signal in the posterior aspect of the disc, which is visualized as a radial tear.
C-3 / C-4: Disc protrusion on the left causing stenosis of the left neural canal, resulting in contact with the C-4 nerve root.
C-4 / C-5: Disc bulge associated with marginal osteophytes resulting in mild restriction of the neural canals, bilaterally.
C-5 / C-6: Disc bulge associated with marginal osteophytes resulting in mild restriction of the neural canals, bilaterally.
C-6 / C-7: Normal appearance of the vertebral discs.
C-7 / T-1: Normal appearance of the vertebral disc.
Lumbar MRI without contrast: Following my personal review of the MRI images, my impressions are as follows:
Conus terminates at L1 and appears normal in position. Generalized arthritic changes of the lumbar facet joints and mild thickening of the ligament of flava from the mid to lower lumbar.
L-1 / L-2: Vertebral disc appears normal with no central canal or neural canal stenosis.
L-2 / L-3: Vertebral disc protrusion on the left causing mild neural canal stenosis on the left.
L-3 / L-4: Vertebral disc protrusion on the right resulting in stenosis of the right neural canal with associated high signal intensity in the posterior right disc indicative of recent trauma. Disc protrusion is superimposed upon a bulging disc resulting in some left neural canal stenosis as well.
L-4 / L-5: Left lateral disc protrusion resulting in stenosis of the left neural canal. Disc protrusion superimposed upon a bulging disc which results in mild right neural canal stenosis.
L-5 / S-1: Bulging disc associated with osteophyte formation resulting in bilateral neural canal stenosis.
Number 4: Lumbar neutral lateral demonstrating loss of lumbar lordosis in the upper lumbar spine with slight retrolisthesis of L2 in relationship to L3 and L3 in relationship to L4, indicating ligament laxity.
Number 5: Cervical MRI without contrast. C2 – C3 demonstrates high intensity signal in the posterior aspect of the disc which is visualized as a radial tear on the axial view.
Number 6: Cervical MRI without contrast. Left disc protrusion causing stenosis of the left neural canal resulting in contact to the C4 nerve root.
Number 7: Lumbar MRI without contrast. Disc protrusion on the right resulting in stenosis of the right neural canal with associated high signal intensity in the posterior the right disc indicative of recent trauma.
Diagnostic impression: Considering the patient’s history, physical examination findings, x-ray findings demonstrating ligamentous laxity in both the cervical and lumbar spine, MRI findings demonstrating the vertebral disc injuries involving the cervical and lumbar spine, an initial treatment plan, consisting of conservative chiropractic treatment was initiated.
Treatment: Following review of all diagnostic imaging, there were no contraindications to cervical and lumbar spinal adjustments. Patient received chiropractic spinal adjustments to the cervical and lumbar spine in association with at home and work recommendations, as well as instructions for the utilization of ice, TENS and an at home exercise program to improve flexibility and strength.
Patient was referred to an interventional pain management medical doctor for evaluation and possible recommendations. The medical doctor initially recommended epidural steroid injections and possible consideration for facet joint ablation in both the cervical and lumbar spine. Due to the patient finding some relief with initial chiropractic care, the patient elected to continue with chiropractic care without receiving the injections. At the six week follow up with the pain management doctor, the patient experienced enough improvement and symptomatic relief that the pain management doctor recommended he continue with conservative chiropractic care.
Discussion: Doctor of Chiropractic trained in MRI spine interpretation, spinal biomechanics, and qualified as primary spine care physicians, are capable to triage patients involved in automobile collisions resulting in injury. Through proper identification of the injuries, establishing a diagnosis and a treatment plan to address the injuries and evaluate for the need of co-management with medical providers a traumatically injured patient has the best chance for a return to function.