The Assessment of Traumatic Cervical Spine Injury and Utilization of Advanced Imaging in a Chiropractic Office.
Vincent M. Simokovich, D.C., Donald A. Capoferri, D.C., DAAMLP, Mark Studin DC, FASBE(C), DAAPM, DAAMLP
Abstract: the objective is to explore the standard of care regarding the assessment of cervical spine injuries in a setting of a chiropractic office. Diagnostic studies include physical examination, range of motion studies, orthopedic testing and cervical spine. MRI.
Key words: radicular pain/complaints, adjustment, extrusion, subluxation, herniation, stenosis and spinal manipulation.
Introduction: On January 30, 2017 a 49 year old female presented in my office to a second opinion examination at the request of her attorney. She had been involved in a rear-end collision on 12/12/2015. (2) She was transported to a local hospital and arrived with complaints of headaches, disorientation, right-sided neck pain and right arm pain. At the hospital emergency department CAT scan was taken of her brain, which proved to be negative. She received prescriptions of muscle relaxers and pain relievers and instructed to visit her primary care physician if her symptoms persisted.
She consulted a local Chiropractor on December 15, 2015. The initial examination included the following from my review of the doctor’s notes: Presenting complaints were right-sided neck pain that radiates to the right arm. The doctor’s records show a positive cervical compression test and a positive maximum cervical compression test. Both produced pain bilaterally worse on the right. Facet provocation tests were positive for facet disease. Right side radicular pain pattern includes the trapezius and deltoid. No x-ray studies were included in the doctor’s orders. The patient received 23 chiropractic treatments from 12/15/2015 through 4/5/2016 for a diagnosis of cervical sprain/strain. The treatments consisted of spinal manipulation and a variety of soft tissue therapies.
Around January 15, 2017 I received a phone call from a local attorney regarding this patient and asking if I would do a second opinion examination on her due to persistent neck pain and right upper extremity pain. The patient presented on January 30, 2017 for my evaluation. My clinical findings are as follows:
Vitals: Age 49, weight 170 lbs. height 5’ 8”, B.P 126/82, pulse 64, Resp. 16/min.
Appearance: in pain
Orthopedic/Range of motion: All cervical compression tests produced pain with radiation bilaterally worse on the right. Range of motion studies revealed: 40 degrees of left rotation and 32 degrees of right rotation with radiating pain produced by both motions.
Palpation: cervical spine palpation produced centralized spine pain that radiates to the right shoulder with numbness in the right arm and hand.
The patient informed me during the examination that her pain made it difficult to sleep through the night. If she was on her right side her right arm and hand would go numb immediately. A big part of this patient’s life was riding and caring for her horse and she could not do either because it resulted in severe neck and arm pain.
My recommendation to her and her attorney was to obtain a cervical spine MRI with a 1.5 Tesla machine due to the high quality images it can produce. MRI is a highly sensitive tool to evaluation of neurologic tissue including the spinal cord and nerve roots. (1) I bypassed the x-ray at this time due to the clinical presentation and 12% of spinal cord with injuries having no radiographic abnormality. (3)
Figure 1: T2 Sagittal Cervical Spine MRI
Fig 2: T2 Axial Cervical Spine with Scout line through C3/4.
Radiology Report: The report and the images demonstrated a right paracentral disc extrusion measuring 9 mm and extending 8 mm cranial/caudal causing abutment of the spinal cord. (Fig 1)(2) Additionally the diameter of the central canal was reduced to 8.1mm and projected into the right lateral recess resulting in severe stenosis of the right neural canal. (Fig 2) Additional findings not pictured: C4/5 demonstrated a 2.5 mm bulging disc with facet hypertrophy with moderate stenosis of the left neural canal and severe stenosis of the right neural canal. C5/6 demonstrated a 1.5 mm posterior subluxation narrowing the central canal to 9.1 mm with unconvertebral joint hypertrophy resulting in moderate right and severe left neural canal stenosis. C6/7 revealed a broad based disc herniation worse on the left measuring 3.6 mm resulting in severe neural canal stenosis bilaterally complicated by unconvertebral joint hypertrophy. The MRI findings correlate with the patient’s clinical presentation. (4)
Discussion: When the patient returned to a consultation on the MRI findings my recommendation was to consult a neurosurgeon. (3) Her attorney asked me if the treating doctor acted incompetently. My only response was that I would have ordered the MRI immediately before treating the patient with manual manipulation. The case is likely to go to trial and there is a good chance that I will be called in as an expert witness. It is almost a guarantee that the defense attorney will ask me if I would have treated the patient for such a long period of time without an MRI or whether the treating doctor could have made the problem worse. The failure to accurately determine a diagnosis may result in malpractice action or a board hearing or both for this treating doctor and I would have ordered the MRI immediately considering the radicular findings and symptoms. After any myelopathic or significant radiculopathic symptoms a referral of advanced imaging needs to be performed in order to conclude and accurate diagnosis, prognosis and treatment plan prior to rendering care. Diagnostic appropriateness in the case of traumatic injury or with any etiology with neurologic symptoms or findings necessitates following triage protocols. In this case, an immediate 2-3mm MRI of the cervical spine is clinically indicated and proved integral to the safe care of this patient.
1. Haris, A.M., Vasu, C., Kanthila, M., Ravichandra, G., Acharya, K. D., & Hussain, M. M. 2016. Assessment of MRI as a modality for evaluation of soft tissue injuries of the spine as compared to intraoperative assessment. Journal of Clinical and Diagnostic Research, 10(3), TC01-TC05
2. Schneider RC, Cherry G, Pantek H. The syndrome of acute central cervical spinal cord injury, with special reference to the mechanisms involved in hyperextension injuries of cervical spine. J Neurosurg 1954; 11: 546–577.
3. Tewari MK, Gifti DS, Singh P, Khosla VK, Mathuriya SN, Gupta SK et al. Diagnosis and prognostication of adult spinal cord injury without radiographic abnormality using magnetic resonance imaging: analysis of 40 patients. Surg Neurol 2005; 63:
4. Miyanji F, Furian J, Aarabi B, Arnold PM, Fehlings MG. Acute cervical traumatic spinal cord injury: MR imaging Findings correlated with neurologic outcome-prospective study with 100 consecutive patients. Radiology 2007; 243: 820–827.
CASE REPORT: The chiropractic management of cervical Myelomalacia
By Timothy Weir, D.C., Mark Studin DC
Title: The chiropractic management of cervical Myelomalacia
Abstract: To examine the diagnosis and condition of a patient suffering from neck pain and radiation of pain into arms following a motor vehicle accident. Diagnostic studies include the chiropractic orthopedic and neurological examination, digital x-rays, range of motion and cervical MRI.
Keywords: cervical spine pain, whiplash, myelomalacia, cervical disc degeneration, uncovertebral hypertrophy, spinal canal stenosis
Introduction: On 10/10/2016, a 38-year-old male presented to our office for injuries he had sustained in an MVA on 10/01/2016. The patient stated that he was stopped at an intersection when the pickup behind him hit him at a fast speed, pushing him through the intersection. The patient stated that he had neck pain and stiffness the radiated into the trapezius area. He also complained about “tingling” into both hands. He also complained of lower back pain that he felt more than the neck. His review of systems was benign, other than the current symptoms of neck and back pain and tingling.
The patients Social/Family Medical History included his mother having high blood pressure and Diabetes.
The patient is 6’0”. The patient weighs 211 pounds. The sitting blood pressure measured was 122/74.
An evaluation and management exam was performed. The exam consisted of a visual inspection of the spinal ranges of motion, digital palpation, manual testing of muscles, deep tendon reflexes and orthopedic and neurological findings. The Cervical exam showed the following decreased motion on visual exam in flexion, extension, left rotation, right rotation, right lateral flexion and left lateral flexion. All of the above motions produced pain.
When digital palpation was performed in the cervical and thoracic spinal areas, there was moderate spasm noted bilaterally in paraspinal areas with moderate tenderness noted.
In performing the cervical orthopedic and neurological testing, positive findings were present bilaterally with Foraminal Compression and Foraminal Decompression. Soto Hall test was positive when performed in the thoracic spine area. Manual, subjectively rated muscle testing was performed on certain muscles of the upper extremities. Based on the AMA Guides to the Evaluation of Permanent Impairment, 4th Ed., 1993/5th ed. 2001, differences were noted using the rating scale of five to zero. Five is full Range of Motion/Maximum Strength, Four is Full Range of motion with Moderate Resistance, Three is Full Range of Motion/Perceptible Weakness. The Deltoids and Triceps tested normally bilaterally at 5. The Biceps, forearm muscles and the intrinsic hand muscles all tested as a four on the right and a three on the left.
Grip Strength tests the strength of the hands which indicate nerve integrity from the cervical spine. In evaluation, the normal would be for a difference of strength in the preferred hand of 10% more. More than that would be a weakness in the opposite hand, less than that would be a weakness in the preferred hand. The preferred hand for this patient is the right hand. The testing below shows a definite decrease in strength in the left hand.
Deep Tendon Reflexes were performed on the patient and were noted at a plus two bilaterally.
Using a Whartenburg pinwheel, dermatomes showed normal findings except for C8, which was hyposensitive on the left.
A Lumbar orthopedic and neurological exam was then performed. Upon visual examination, there was decreased motion in flexion, extension. right and left lateral flexion with pain present on all of the motions.
Lasegue’s Straight Leg Raising test was performed and was negative with 80 degree movement. Braggards test was performed and was negative bilaterally.
Kemps was done with the patient on both sides and was noted as negative. Ely test was noted as negative.
Digital palpation was performed and there was severe tenderness and spasm bilaterally in the lumbar paraspinal muscles.
Manual, subjectively rated muscle testing was performed on certain muscles of the lower extremities. Based on the AMA Guides to the Evaluation of Permanent Impairment, 4th Ed., 1993/5th ed. 2001, differences were noted using the rating scale of five to zero. Five is full Range of Motion/Maximum Strength, Four is Full Range of motion with Moderate Resistance, Three is Full Range of Motion/Perceptible Weakness. Muscle testing was done bilaterally in the Quadriceps, Hamstrings, Calf Muscles and Extensor Hallicus Longus and showed Full ROM and Strength.
Deep Tendon Reflexes were performed. They negative in the Achilles bilaterally, but +3 in the Patella bilaterally.
Based on the ortho/neuro findings and the history, the following x-rays were ordered:
AP/Lat/Flex/Ext/Bilateral Oblique’s/ APOM of the cervical spine, AP/Lat Thoracic
AP/Lat/Lateral Flexion/Oblique Lumbar’s. The x-rays were read and the Lumbar spine showed the discs were of a normal height and Georges line was un-interrupted. There the Lumbar curve appeared to be hypolordotic. On visual inspection, there was a decrease in the lateral bending bilaterally.
The Cervical spine showed that there was anterior spurring present in the C5/6 region of the cervical spine. In the lateral view, the normal curvature of the spine was no longer lordotic, but noted as a “Military Neck.” There was decreased range of motion noted in the flexion as well as the extension views. Also, noted on flexion and extension was paradoxical motion present at C1. Disc spaces were normal throughout the spine, except for narrowing of the disc space at C5/6, as well as spurring noted in the anterior part of the vertebral body.
Due to the injuries, orthopedic and neurological and x-ray findings, a cervical MRI was ordered. I recommended that the patient receive palliative therapy until a Cervical MRI could be obtained.
The MRI was obtained and personally reviewed. The Cervical MRI performed on 10/14/2016 revealed that C1/2 was unremarkable. There was a mild disc bulge at C2/3 and a moderate disc bulge which abuts the ventral cord and results in mild spinal canal stenosis at C3/4. There is also bilateral uncovertebral hypertrophy with moderate bilateral neural foraminal narrowing noted at C3/4. At C4/5, There is a mild disc bulge which abuts the ventral cord. There is a mild spinal canal stenosis. There is a bilateral uncovertebral hypertrophy with moderate bilateral neural foraminal narrowing. At C5/6, There is a moderate disc bulge which indents the ventral cord and results in severe spinal canal stenosis. There is a resultant T2 weighted hyperintense (high) signal abnormality in the spinal cord at this level. This may represent edema or myelomalacia. C6/7 shows that there is a mild disc bulge which abuts the ventral cord and results in mild spinal canal stenosis. There is bilateral uncovertebral hypertrophy with moderate bilateral neural foraminal narrowing. C7/T1 presents as unremarkable.
IMPRESSION: At C5/6, there is a moderate disc bulge which indents the ventral cord and results in severe spine canal stenosis. There is resultant abnormal signal in the spinal cord at C5/6, which may represent myelomalacia or edema.
An alert was placed on this study.
Fig.1 (A) Sagittal T2 MRI of Cervical Spine
(B) Axial T2 MRI of the Cervical Spine.
The patient was notified of the MRI findings. The patient was informed that care would be discontinued until a consultation was done with a neurosurgeon. The patient stated that he was going to do that. He continued to try to get care, but we refused. The patient was instructed to go to the emergency room. The patient became angry stating that he wanted his records, that he was going to go to another chiropractor for them to “crack his neck”. The patient went to another chiropractor and based on our records, also refused to see the patient. The patient finally decided to go to the surgeon where disc surgery was performed to decompress the spinal cord.
The patient contacted our office and thanked us for being so adamant about his treatment.
There is much discussion in the MRI report concerning “bulges” and one must first have a handle on what is a bulge and herniation.
General radiologists often utilize various nomenclature such as bulge, protrusion, prolapse, herniation and a myriad of other descriptors. However, the nomenclature has been standardized and accepted by the North American Spine Society, the American Spine Society of Radiology and the American Society of Radiology by Fardone, Williams, Dohring, Murtagh, Rothman and Sze (2014):
“Degeneration may include any or all of the following: desiccation, fibrosis, narrowing of the disc space, diffuse bulging of the annulusbeyond the disc space, fissuring (i.e. ., annular fissures), mucinous degeneration of the annulus, intradiscal gas, osteophytes of the vertebral apophyses, defects, inflammatory changes, and sclerosis of the endplates.” pg. 2528(1)
“Bulging disc, bulge (noun [n]), bulge (verb [v]) (1)
1. A disc in which the contour of the outer annulus extends, or appears to extend, in the horizontal (axial) plane beyond the edges of the disc space, usually greater than 25% (90°) of the circumference of the disc and usually less than 3 mm beyond the edges of the vertebral body apophysis.
2. (Nonstandard) A disc in which the outer margin extends over a broad base beyond the edges of the disc space.
3. (Nonstandard) Mild, diffuse, smooth displacement of disc.
4. (Nonstandard) Any disc displacement at the discal level.
Note:Bulging is an observation of the contour of the outer disc and is not a specific diagnosis. Bulging has been variously ascribed to redundancy of the annulus, secondary to the loss of disc space height, ligamentous laxity, response to loading or angular motion, remodeling in response to adjacent pathology, unrecognized and atypical herniation, and illusion from volume averaging on CT axial images. Mild, symmetric, posterior disc bulging may be a normal finding at L5–S1. Bulging may or may not represent pathological change, physiological variant, or normalcy. Bulging is not a form of herniation; discs known to be herniated should be diagnosed as herniation or, when appropriate, as specific types of herniation.” Pg. 2537(1)
Studin and Owens discuss this “nomenclature” in their article “Bulging Discs and Trauma: Causality and a Risk Factor”.
“There is now, based upon the literature and well respected experts, categories of disc bulges that can be deemed as direct sequella from trauma vs. those cases where there is pre-existing degeneration. It can also now be concluded, again based upon the literature that those patients can have an aggravation of the pre-existing condition that could persist a lifetime requiring perpetual care. To conclude these findings, a doctor trained in understanding the underlying pathology and sequella must be consulted to be able to render an accurate diagnosis that is demonstrable.”2 Pg. 26
What is Myelomalacia? According to the MedicoLexicon, it is simply the “softening of the spinal cord”.3 Basically, it is ischemia that takes place in the spinal cord from abnormal pressure placed upon it. If left untreated, then that continues to spread and cause further damage to the cord. Once the cord has been damaged, there is no repair. gives us a concise definition and the ramifications of it left untreated:
“The myelomalacia definition, strictly speaking is the “softening of the spinal cord”. After an acute injury, bleeding of the spinal cord may occur. As a result, there is “subsequent softening of normal tissues”. Myelomalacia can be caused by trauma or disease, but if it worsens, and if the bleeding reaches the cervical region of the body, it can be fatal. Bleeding can make the tissue necrotic. Fractured vertebrae can lead to bleeding in the spinal cord, as can some back surgery. Osteoporosis may also contribute to spinal instability and hemorrhaging. Sometimes circulatory problems can lead to a deterioration of tissues and bleeding. Myelomalacia can progress into impairment in the functioning of the lower extremities, below-normal or absent reflexes of the anus and pelvic limbs, loss of pain perception in the caudal region (near the coccyx), depression, respiratory problems due to “diaphragmatic paralysis”, and even neurological issues. Death could result from the respiratory paralysis. Damage occurs to the central nervous system. At first, the spinal cord damage may be minor. The most commonly injured areas are the lumbar spine (lower back) and cervical vertebrae (upper spine area).4
Disc degeneration, herniations (all variations) and bulging all describe what has happened to the disc itself. Once you have established a definitive diagnosis, then the question becomes, how is the disc affecting surrounding neurological components? Myelomalacia is the effect of that disc when the cord is affected by pressure. If there is bleeding into the cord, then the cord begins a degenerative spiral that can happen rather quickly. As you have read above, it can take what may simply appear as a minor issue to the patient that can lead to major neurological compromise and in extreme cases may lead to paralysis or death. Therefore, it is important carefully analyze the clinical indicators and image accordingly.
Myelomalacia is a relatively rare occurrence. According to Zhou, Kim, Vo and Riew,
“The overall prevalence of cervical myelomalacia was relatively low in the studied population, and it was affected by age, sex, and the specialties/subspecialties of referring providers. These results may help direct treatment guidelines and allow for informed discussions with patients in terms of the risk versus the benefit of surgery.”5 Pg. E252
It is a very common occurrence for the presence of disc bulging and herniations in chiropractic practices. It is of utmost importance for the chiropractor to not only order MRI when clinically indicated, it is important to be able to interpret those images as well. Once the clinical indicators begin to show a different story than presented by the patient symptomatically, it is the responsibility of the chiropractor to make the appropriate diagnosis, prognosis and treatment plan. In this case, that is an immediate neurosurgical referral. Although not a common finding in a chiropractic office, one must still be alert to the possibility of Myelomalacia. Managing the patient based upon an accurate diagnosis is your ultimate goal, and sometimes adjusting the patient isn’t the best first option as diagnosis and prognosis supersede treatment.