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Glen M. Batson, DC

CHIROPRACTIC CERVICAL SPINE EVALUATION

The chiropractic approach to the evaluation and treatment of cervical radiculopathy is similar to the allopathic approach and diagnosis, however, the chiropractic evaluation centers on the spinal segments, their contiguous biomechanical function, and alteration of segmental biomechanical function which may cause associated neurological and soft tissue symptomatology. The chiropractic analysis reviews the symptomatology, however, further investigates to determine the primary mechanism of action causing the associated symptomatology. The doctor of chiropractic is trained to evaluate the patient as a whole. The point of pain is reviewed as is all integrated biomechanics and system functions. The point of pain is a symptom, and not always the direct point of pathology. The premise of the chiropractic philosophy is that the vertebral subluxation, whether caused through direct trauma or micro trauma, causes altered vertebral segmental function, causing joint instability, and thus a myriad of sequential events. The vertebral segmental dysfunction, subluxation, causes irritation to the facet joints and disc material via abnormal function, stretching of the supporting ligament structure, altered biomechanical function, irritation to neuro receptors, abnormal loading of facets and disc material with subsequent disc bulge or herniation, and thus neurological compromise. The subluxation complex not only causes altered joint function, but also biochemical changes at the joint level also facilitating in the degenerative process due to the direct insult or origin of this subluxation. The chiropractic examination encompasses a review of posture, gait, scoliosis, shoulder heights, and foot/ankle function. The chiropractic treatment for this condition is to correct and stabilize the subluxation process through spinal manipulation, soft tissue stabilization and reeducation through strengthening and conditioning, education of ergonomics and posture, and nutrition.

In the chiropractic field of medicine, spinal manipulation is utilized for the therapeutic correction of a subluxation. Spinal manipulation is delivered in many forms, however in this office, a spinal manipulation is defined as a predetermined specific degree of force delivered to a specific spinal segment by a trained chiropractic physician, in a specific direction, for a specific end result: the correction and restoration of the joint structure, and relief of associated soft tissue and neurological compromise. A chiropractic adjustment should be a therapeutic thrust or percussion to an osseous structure for correction of the joint instability, correction of biomechanical function, restoration of osseous and ligament function and integrity, for relief of the associated soft tissue and neurological compromise. The chiropractic adjustment should be delivered manually by the physician’s hand or a percussive machine, however, segmental specificity, degree of thrust or percussion, and direction of thrust is integral in the proper restoration of spinal function.

I utilize the “RESULTS” system of chiropractic analysis and procedures formulated by Dr. Walter V. Pierce.¹ The RESULTS system of chiropractic is exactly as it is read; results are the ultimate goal. The RESULTS technique for chiropractic analysis utilizes multiple diagnostic modalities for interpretation of the subluxation and neurological compromise, and a therapeutic treatment regiment for the restoration and correction of these structural and neurological conditions. The RESULTS system utilizes static X-ray examination of the spinal regions in question for evaluation of pathological process, subluxation complex, degenerative joint and disc disease, disc space thinning, osteophytic formation, and determination of postural integrity.

Static X-rays are performed for determination of the subluxation and for determination of the cervical lordosis. The cervical lordosis should be a curve apexed anterior with a 17cm anterior convexity. The normal lordosis is integral to the cervical biomechanical functioning. Loss of the normal lordosis, to any degree less than normal lordosis, indicates altered facet function, increased axial load to the intervertebral disc, and increased stress to the surrounding ligament structures. The loss of lordosis also indicates some degree of anterior head translation and ultimately compensatory loading throughout the lower lumbar spine and pelvis. (See Figures 1a & 1b.)

Fluoroscopic spinal X-ray imaging is also utilized and consists of dynamic imaging of the spinal regions in question for real-time imaging of the osseous structures in full ranges of motion for proper and specific diagnosis of facet function, ligament laxity, disc integrity, and pathological process.^2-14 Fluoroscopic analysis is the only diagnostic procedure to visibly evaluate the spinal segments in normal motion for determination of biomechanical function or pathology. All other imaging such as X-ray, MRI, CT are in a static mode, non-motion, possibly not demonstrating a segmental instability or pathology. All imaging is recorded on a DVD recorder for analysis and storage for comparison studies if needed. All radiographs and fluoroscopy scans are performed in the standing, weight bearing position. DTG instrumentation is utilized consisting of infrared diagnostic heat sensing of the dermatomal levels of the spinal regions for determination of vascular and neurological compromise. The readings are graphed and retained for comparison analysis.

I utilize a Variable Frequency Adjuster instrument for applying induced harmonic forces to spinal segments and other articular complexes. Resonant oscillations, when induced within a vertebral complex by a driven harmonic frequency have shown to improve range of motion, and muscle relaxation resulting from the reprogramming or re-education of mechanoreceptors within the articular complexes of the vertebral segments.¹⁵ Mechanoreceptors respond to continual changes in the loading and unloading of spinal articular complexes.¹⁶ This procedure is utilized by performing percussive activity to the posterior segments of a selected vertebra for restoration of joint and ligament function, restoration of cervical lordosis, and an increase in normal posture. This procedure can be performed in the prone or seated position. (See Figure 2.)

Deep tissue neuro-musculoskeletal re-education therapy is rendered to patients, as indicated, for the restoration of cervical function, reduction of spasm, increase in cervical range of motion, retraction of the cranial, cervical, and scapula region to increase the cervical lordosis and posture. A portable cervical Starr Traction appliance is utilized in conjunction to the manipulation for traction of the disc and osseous structures of the cervical spine to rehydrate the disc, educate ligaments and muscles, and to relieve the neurological irritation. Home ice therapy regiments are utilized for the reduction of edema, spasm, and pain.

RESULTS System normal X-ray line analysis findings: Cervical lordosis of 17cm, superior C1 angle of 18 to 24 degrees, zygapophysis angle at C5 or C6 of 35 to 55 degrees, C2 angle of 0.0 degrees, A-P vector intersection of 0.0. Fluid and contiguous function of facet, ligaments, and endplates via fluoroscopic analysis. (See Figure 3.)

CLINICAL CASE STUDY

Case # 4842: The patient is a 54 yearold female who experienced severe cervical spine pain and severe right upper extremity pain, numbness, and tingling resulting from lifting objects in her home. Patient has been diagnosed by primary physician and emergency room physicians as cervical radiculopathy. Medication was rendered consisting of Vicodin with mild relief. Patient presented to Batson Chiropractic with complaints of cervical spine pain, pain into the upper bilateral shoulder and scapular region with pain radiating to the right shoulder, right upper extremity region 8/10 in severity. Patient described numbness, tingling, and pain throughout the entire right upper extremity region extending into the hand and fingers consisting of the first, second, and third digits. Patient describes cervical crepitus, pain in all ranges of motion, muscle spasm and tension into the shoulders bilaterally, loss of strength of the right upper extremity region as well as pain into the right shoulder and scapula region.

Physical Examination: reveals a 54 year-old female, presenting with pain to the cervical spine and right upper extremity. Patient presents with positive orthopedic and neurological findings consistent with the diagnosis of cervical radiculopathy.

X-ray Examination: consisted of static A-P, Lateral, Flexion, Extension views of the cervical spine revealing loss of cervical lordosis with mild kyphosis of the lower cervical region measuring 34 cm, gross anterior head translation measuring 45 mm as measured from the anterior superior endplate of C7 to a perpendicular plum line from the anterior aspect of the C1 tubercle, C5 zygapophysis angle of 37 degrees, C2 angle of -30 degrees, and C1 angle of 22 degrees, degenerative joint and disc disease with disc space thinning C5- C6 with large osteophytic formation and vacuum phenomenon, milder vertebral and disc degeneration at the C4-C5, and C6-C7 segmental levels with mild osteophytic formation. Facet sclerosis noted at multiple levels. Flexion-extension views of the cervical region revealed subluxation: C0 in flexion, C1 flexion, C2 flexion, C6 flexion, C3 extension, C4 extension, C5 extension, C6 extension.

MRI examination: revealed mild atlantodental joint degeneration, minimal posterior disc bulge at C3-C4 right of midline, mild circumferential disc annual bulge C4-C5 with mild impression upon the thecal sac without evidence of spinal cord impingement or neuroforaminal or canal stenosis. C5-C6 revealed degeneration of the intervertebral disc with circumferential annular bulging approximately 3.5 mm posteriorly. There was effacement of the CSF space and slight flattening of the surface of the cord by the bulging disc annulus without evidence of cord compression. Moderate bilateral neuroforaminal narrowing due to the bulging of the intervertebral disc and adjacent posterolateral uncovertebral joint osteophytes. There was impingement of the C6 nerve root bilaterally. C6-C7 disc degeneration with eccentric right posterolateral annual bulging of approximately 2 mm. Moderate to marked right neuroforaminal narrowing due to the posterolateral soft disc protrusion with possible impingement of the right C7 nerve root and foramen.

Patient received twenty therapeutic chiropractic treatment sessions as outlined above and twelve cervical traction sessions over a nine week period of time. Patient responded to chiropractic procedures with positive outcome, experiencing complete resolution of all subjective symptomatology, normal findings of all objective findings, marked improvements in post radiographic findings. Patient returned to normal daily living status with mild restrictions.

Post static lateral radiographic findings after nine weeks of care demonstrated improvements in line analysis as: C1 angle 16 degrees (prior 22 degrees), C2 angle -17 degrees (prior -30 degrees), C5 zygapophysis angle 34 degrees (prior 37 degrees), lordosis angle -58 degrees (prior -34 degrees), measurement of anterior head translation of 16 mm (prior 45 mm).

Conclusion: Patient responded to chiropractic spinal care with complete resolution of cervical radiculopathy, and all subjective symptomatology. Resolution and restoration of proper objective findings are demonstrated by examination and post radiographic findings. Continued care was recommended for further structural spinal restoration.

CONCLUSION

Neck pain is encountered frequently and is considered one of the most common chronic pain conditions and a major problem in modern society.¹⁷ Pain associated with the cervical spine can be multi-factorial in etiology. Cervical radiculopathy is one set of conditions that is associated with the complications as related to the underlying mechanism of neck pain. Poterfield and DeRosa¹⁸ refers to the cycle wherein pain causes spasm which causes decreased blood flow and edema which causes hypoxia and biochemical change causing chemical irritation resulting in pain. There is substantial evidence that the chiropractic adjustments are beneficial in relieving a wide variety of pain syndromes. As discussed, the philosophy of chiropractic is that the primary mechanism of the condition is the vertebral subluxation causing the altered segmental function, instability, and the cascade of neurological and biomechanical ramifications as outlined above. The combination of the restoration of the segmental dysfunction/subluxation, ligament function and integrity, disc height and function, and postural changes all benefit the patient and their specific presenting symptomatology. A large number of case reports and documentation have appeared in peer-reviewed and literature supporting chiropractic treatment and chiropractic manual therapy.^19-23 As evidenced throughout, the multi-factorial condition of cervical radiculopathy may indicate a multidiscipline approach for therapeutic correction and recovery. The combination of chiropractic manipulation, Prolotherapy, physical therapy, traction, postural and ergonomic education all may play an integral role in the alleviation of the neurological compromise associated with cervical radiculopathy.

As a doctor of chiropractic, I am a proponent of preventative medicine. Understanding the sequella of complications which can cause ailments or serious health ramifications, Chiropractic analysis and treatment in conjunction to Prolotherapy, strengthening, and postural correction are essential for the well being of the population, young or old. The prevention, or even the correction, of a vertebral subluxation can have far reaching positive ramifications in our daily lives. Trauma or injury to the spinal regions causes splinting. Splinting causes prolonged fixations between segments which further decreases the overall range of motion in the neck and imposes unnecessary additional stress on damaged intersegmental units that are trying to heal. By reducing the adjacent fixations through manipulation, we restore more normal biomechanics to the spine, and in turn relieve the stress at the injured segments, thereby providing an environment more conductive to repair.²⁴ Correction of the subluxation reduces and eliminates the cycle of pain as outlined by Poterfield and DeRosa. Education of the population, both the public and health care providers, on spinal biomechanics and essentials of maintaining or correcting spinal biomechanics is imperative in the quest for preventative and optimal health.