Case Report

1
Case Report

• Cervical Spine

2
History

• On 3-23-06 a 49 year old white female presented
  to the Palmer Clinics with a chief complaint of
  right arm coldness sensation.
• The sensation starts at her elbow and moves down
  to her forearm. The sensation started 3 days ago.
  
• There was not trauma at that time. She also
  experienced chest cramping for 20 minutes at
  the time she first noticed the cold feeling in
  her arm.

3
History

• She also complains of neck discomfort at the C-T
  junction and a cold feeling in her neck as well.
• She indicated on our intake form that this
  condition interferes with her activities of daily
  living.
• She has received chiropractic care in the passed
  and has been treated recently for an auto
  accident.
• She has had arm and shoulder problems in the past
  but nothing that felt like this.
• She has not felt any chest cramping since the
  episode 3 days ago.

4
History

• She has been diagnosed with a spondylolisthesis
  at L4-5.
• She states that the exercises moderately, has a
  fair diet, does a lot of sitting during her work
  day, smokes 3 cigarets per day and drinks 2 cups
  of coffee per day.
• She has been under stress recently due to her
  husband is in the hospital with diabetic
  complications.

5
Initial Differential Diagnosis

• Please list at least 2 Differential Diagnoses
• Coldness sensation
• Neck Pain
• Chest cramping

6
Examination

• Left Head tilt
• Right Shoulder and hip tilt
• BP 140/90(L), 150/100(R)
• Reflexes normal
• Cervical ROM was decreases upon flexion and
  lateral flexion which also produced pain

• Muscle strength is normal
• Cervical distraction produced pain at the left
  side of the C6 level.
• Spinal fixations notes at C1, 2 and 6, T 3 and 7
  with TT fibers from T1-6.
• Decreased amplitude of the right radial pulse
• Peripheral Pulse orthopedic tests were negative.

7
Examination
8
Radiology Report
9
Now What

• Do you treat this person?
• Blood Pressure?
• Chest Cramping?
• Cold Arm Sensation?
• Cause of cervical pain?

10
Patient Management Plan

• This Patient was referred to her MD for a medical
  evaluation of the high blood pressure and chest
  cramping.
• She returned to our office and informed us that
  the MD was monitoring her care but no medication
  was prescribed.

11
Patient Management Plan

• Patient will be seen 3 times per week and
  evaluated upon each visit.
• If no improvement in noticed in her symptoms an
  MRI will be ordered.

12
What is the prognosis?

• Due to the osteophytic formation and advanced
  degeneration in the cervical spine, her prognosis
  is POOR.

13
Office Visits

• Visit 1 She states her arm coldness in a
  constant feeling and graded as a 9/10. The cold
  is felt in the right arm, neck and face. Her low
  back is sore from moving furniture in her office
  today.
• Chiropractic examination found subluxations at
  SAC, T4 and C2
• R/S in 2 days, if improvement is found we will
  continue care. If no change in symptoms, an MRI
  will be ordered.

14
Office Visits

• Visit 2 Her low back is much better but no
  change noted in the cold symptoms.
• We discussed the need for more information on the
  cause of the coldness.
• No cervical adjustments were to be given until
  the results of the MRI were obtained.
• Patient received chiropractic adjustments to her
  Left SI and T5.

15
Office Visits

• Visit 3 She reports today that her arm, neck and
  face are as bad as it has ever been. Her BP is
  148/90. Her MRI was preformed this morning. She
  still has some low back discomfort.
• She received a chiropractic adjustment to her
  Left SI and T5 and was rescheduled for 3 days.

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MRI
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19
Office Visits

• Visit 4 She Continues to notice cold feeling in
  her right arm, neck and face. She saw her MD
  yesterday for a follow-up visit for the high
  blood pressure. She was prescribed Celebrex and
  has been taking it.
• Findings from the MRI indicated we can adjust in
  the cervical spine and subluxations were found at
  C4 and Occ. She received SUD adjustments to her
  cervical spine and as well as adjustments to her
  T6 and Right SI.
• She was reschedules in 2 days

20
Office Visits

• Visit 5 She continues to have the symptoms in
  her arm, neck and face. With no change noticed.
• Subluxations were found at T6 and C2. (C2 was
  adjusted SUD)

21
Office Visits

• Visit 6 She reports the cold sensation went away
  completely for 2 days after the last adjustment.
  Now it is back in her face and over her right
  wrist.
• Today we changed our adjusting technique and
  segment adjusted.
• C5 was adjusted with a prone distraction- drop,
  C2 was adjusted SUD, as well as T4 and the Right
  SI.

22
Office Visits

• Visit 7 She reports having some neck soreness
  today. Her cold symptoms went away again after
  the last adjustment. It came back to its full
  intensity for a few hours over the weekend. Now
  it has dissipated to a coolness around her wrist
  and fingers.
• Adjust C2 and C5 and T5.

23
Office Visits

• Visit 8 She reports now feeling a warm sensation
  in the arm, neck and face instead of a coldness.
• Adjusted C2,5 and T5
• Visit 9 She reports more warmth feelings in her
  arm, neck and face. Her arm muscles have been
  sore since the last adjustment.
• Adjusted Occ, C2, C5, T4 and R-SI

24
Office Visits

• Visits 9-21 She continues her healing. Setbacks
  have been attributed to the patient sleeping in
  chairs and hard days at work. These setbacks have
  only been minimal exacerbations to her symptoms.
  She reports of intermittent warmth and coolness
  in different areas of her arm, neck and face with
  an intensity of a 1-2/10. The sensations do not
  last more than a day when the appear and the
  adjustments will take them away.

25
Office visits

• Visit 22 She is being seen once a week at this
  time and was last seen on 7/14/2006. She reports
  having intermittent symptoms of coolness that
  last for about 20 seconds in different areas of
  her arm, neck and face. They always go away. She
  has felt this way for the last 5 days.
• The only segments that continue to be adjusted
  each visit are the C5 and T5 vertebrae.

26
Points of consideration

• Symptoms that were most likely disc related but
  could have been vasculature.
• Possibility of making her condition worse if we
  adjusted without knowing her specific health
  condition.
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