Cervical Pain (Full Version)

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Alex Brenner PT MPT OCS -> Cervical Pain (November 21, 2004 10:52:00 PM)

History: 70 year old male complains of radiating pain from c-spine down his right arm and into the right hand along with numbness and tingling in middle finger for 3 days. States no specific mechanism of injury, he just started having the pains before going to bed at night.

On physical exam he has some biceps weakness and some wrist extension weakness. Cervical quadrant reproduces his hand pain.

He was referred to you from a physician with a diganosis of "Neck pain". The patient does not have his medical records, but he is hand carrying the radiographs that were taken yesterday.

What findings do you see that may be contributing to the findings on the physical exam?

Answers will be posted in one week.

(All images obtained and posted with permission)
[image]http://img.photobucket.com/albums/v85/brennerak/DDDC6-7StenosisLat.jpg[/image]


[IMG][image]http://img.photobucket.com/albums/v85/brennerak/DDDC6-7StenosisAP.jpg[/image][/IMG]

[IMG][image]http://img.photobucket.com/albums/v85/brennerak/DDDC6-7StenosisOblique.jpg[/image][/IMG]



jma -> Re: Cervical Pain (November 28, 2004 11:44:00 AM)

Hello,
Very nice of you to post this case study. I agree that interpreting radiographs can prove helpful when a patient brings them in the clinic.

If I read this right, there is decreased space in the intervertebral foramen b/w C4-C5 with decreased space in the transverse foramen and perhaps C5-C6. There is also an increased signal in the frontal image b/w C4-C5 with diminshed space between the vertebral bodies. Definite decreased cervical lordosis.

I admit that I am new at this interpretation. With a 70 year with no traumatic history to report, this may viewed as OA to DJD to DDD. I'm probably way off but this proves that this case study is worth looking into.

Lets see what others have to say about this.

JMA



FLAOrthoPT -> Re: Cervical Pain (November 28, 2004 12:35:00 PM)

I'll take a stab, hard to see on my screen, but here it goes. First and foremost, looks like everyone elses X-ray who has this complaint at this age or about 10 years younger to 10 years older. So, since I have nothing to lose but my humility...

doesn't look too odd for a 70 year old. Significant degeneration of disk space, loss of cervical lordosis, typical spondylitic degenerative changes C3/4, 4/5, 5/6, 6/7. Possible scoliotic curve, or most likely patient presenting in position of left side flecion because this increases foraminal space around nerve root to help eliminate nerve impingement pain caused by loss of foraminal space from spondylitic and DDD changes associated with ageing.

Now, I would like to confirm this with some clinical tests: specific PIVM testings, neural tesnion testing, DTR testing, MMT and neuro fatigue tests, some sort of neuravacular testing i.e Roo's, etc, dynamometer grip testing, compression testing, see if traction relieves s+s...

My guess is going to be with my gut initial feeling, and I would say teach this guy proper positioning for sleeping etc to help avoid right sided closing of his facets, education of posiitons to avoid activities to avoid, avoid impact throught the spine longitudianlly or activities that promote right rotation.sf.ext. collar at night if needed, light cervical and neural/fascial stretching if needed, traction if needed to relieve symptom.

However, I've seen too many X-rays like this with these s+s to be naive ot think PT is the end all be all..so follow up with MD for possible anti inflamm regiment as well as ortho/neuro/surgical consult for MRI/NCV/EMG testing during course of Tx. If in acute flare up I'd go 3-4x wk for 1-2 wks, then 3-4 follow up visits to help educate patient and monitor progress.

I am now off the BudWeiser hot seat...



SJBird55 -> Re: Cervical Pain (November 28, 2004 2:22:00 PM)

I'm not great at radiographs either. It looks like there may be some osteophytes or at least a change in what the right facets look like compared to the left which may be causing a foraminal stenosis. There may be some degenerative disc changes based on vertebral height changes. It looks like there is some anterior hypertrophy or whatever radiologists call that of the vertebral body (an endplate something or another?).



PTupdate.com -> Re: Cervical Pain (November 28, 2004 4:09:00 PM)

I would say definitely DDD, and the first view shows the bottom half of C5 looking peculiar, and not seen on C6...perhaps just superimposed view.

Definite and severe end plate spurring, and foramenal narrowing on oblique view. Lordosis is lost, and the second view does show a definite "S" type curve.

John Duffy, PT OCS
[URL=http://www.PTupdate.com]www.PTupdate.com[/URL]



jbeneciuk -> Re: Cervical Pain (November 29, 2004 6:21:00 PM)

Thank you for the posting.

1rst image: (lat view) decreased lordosis, common for this age group..C4/5 osteophytes anteriorly & C4/3,C4/5 post osteophytes

2nd image: (A/P view) pt appears SB to R slightly
with much increased intensity of R C4/5 & C5/6 articular column region

3rd image: (L oblique view)I beleve that is a good view of an anterior osteophyte at C4/5

upon exam, I would tend to agree with FLA orhto,
in that I would need to confirm some PIVM, especially at the lower cervical levels and also the 1rst rib region for any restrictions. I would imagine that a Spurlings test may produce sx when performed to the R (just a speculation), and also check pt responses to general distraction.

I would also agree that I may intialize Rx with some light manual traction and investigate further as to why these sx come on before bedtime. it may be that the pt is sitting in an awkward position in his recliner before going to bed or possibly some sleeping posture that is provoking the sx ??

I also agree that sending the pt for some additional testing would be beneficial just to rule out any other serious pathology in the cervical region, especially if we want to take on the challenge as direct access practitioners.

I would also like to thank our fellow colleague (Army PT) in sharing his experiences and assisting those of us who do not always have the access to these kinds of images...looking forward to more responses and studies
Thank you
jbeneciuk,DPT, MTC



Jon Newman -> Re: Cervical Pain (November 30, 2004 5:25:00 PM)

I don't have anything intelligent to add to the case study but enjoy this new forum, keep it up.

jon



SJBird55 -> Re: Cervical Pain (December 1, 2004 2:09:00 AM)

Actually, I do have one little suggestion. Army, when you do your final thing, could you maybe repost the radiographs and use little colored arrows or specifically identified arrows to assist with your discussion? For me, I'm generally pointing at the area and asking the physician if whatever is whatever and the physician is pointing out and showing me things. So, if you just verbally describe, I know for me I'm going to lose the visual of pointing.



Alex Brenner PT MPT OCS -> Re: Cervical Pain (December 1, 2004 3:14:00 AM)

SJBird,
You are reading my mind. Sunday, look for a reposting of the radiograph with areas highlighted along with the actual radiology report. Thanks!



jma -> Re: Cervical Pain (December 1, 2004 3:41:00 AM)

Hello,
The idea of using arrows would be very helpful in the short run for educational purposes. However, we still need to be educated on what to exactly look for in a radiograph or what is considered to "look" normal. Short of going to medical school to learn radiograph interpretation, the APTA Radiology for Physical Therapists is a great introduction for these scenarios. In the end, we just get the radiographs as were posted here to look at and wonder what is going on, based on what we found during the evaluation. Perhaps other imaging studies, i.e CAT scan, MRI (T1 or T2) and bone scan images would help us as well. Keep up the good work.

JMA



chiroortho -> Re: Cervical Pain (December 1, 2004 11:19:00 AM)

Diffuse degenerative disc disease with proliferative changes at the vertebral body margins of C3 through C6. Foraminal narrowing on the oblique view at C3-4 and C4-5. Lower cervical foramina not adequately visualized. Suggest Swimmer view for better visualization of C7-T1. Small oval opacities anterior to C4-5 interspace consistent with calcification within the anterior longitudinal ligament. Osteopenia consistent with patient's age. Calcification within aortic knob consistent with atherosclerotic disease (hard to tell on my screen). No acute bony abnormalities identified. No prevertebral swelling or other tumefactive processes seen. Visualized lung apices clear.



Jeep -> Re: Cervical Pain (December 2, 2004 7:46:00 PM)

-anterior weight bearing of head and neck
-diffuse osteoporosis

LCN:
-marked disc space narrowing at c2-3, c3-4, c4-5, c5-6
-extensive anterior vertebral margin spurring at c3,4,5
-extensive posterior vertebral margin spurring at c4-5, c5-6, c6-7
(probable canal stenosis)
-calcific deposit at anterior C4-5
-break in cortex, superior margin of C3
-radiolucencey noted at posterior c2-3


APLC:
-advanced apophyseal joint degenerative joint disease at c3,4,5,6,7
bilaterally
-mild right lateral convexity of lower cervical
spine

OBLIQUE:
-moderate foraminal encroachment at C3-4, marked at C4-5, C5-6



Alex Brenner PT MPT OCS -> Re: Cervical Pain (December 2, 2004 11:41:00 PM)

Hi. I will try and run these studies for one week, typically Sunday to Sunday. However, I will be out of town over this weekend and early next week so I will go ahead and post the findings for this study.

Overall, everyone was right on for the pathology. Here is the actualy radiology report.

AP, lateral, oblique views of cervical spine demonstrate degenerative disk
and facet disease. There is bilateral osseous neuroforaminal narrowing,
most significant at C6-7. There is no evidence of acute fracture.

IMPRESSION: Degenerative disk and facet disease, with osseous neuroforaminal
narrowing.

At my clinic when you order a standard c-spine series you only get two views, the AP and Lateral. If you are concerned about foraminal narrowing then the oblique view is best to visualize this. So it was ordered in this case.

Below is the original oblique and lateral view. I attempted to highlight the areas of osteophytosis as mentioned by many above and by the radiologist. To me the most significant finding that correlates with the history is the foraminal narrowing at C5-6 which could cause impingement of the C6 nerve root thus causing the biceps weakness and weak wrist extensors.

Here is the lateral view showing the anterior and posterior osteophytes. Also, notice disk space narrowing at all levels.
[IMG]http://img.photobucket.com/albums/v85/brennerak/DDDC6-7StenosisLatHigh.jpg[/IMG]

Below is a lateral view of a normal c-spine to compare the disk heights with.

[IMG][image]http://img.photobucket.com/albums/v85/brennerak/NmlLat.jpg[/image][/IMG]

Below is the original oblique view showing the neural formainal narrowing highlighted.

[IMG][image]http://img.photobucket.com/albums/v85/brennerak/DDDC6-7StenosisObliquehighlighted.jpg[/image][/IMG]

Lastly, below is an oblique view of a patient of the same age with normal foraminal diameters to compare against our case study. Compare the below picture with the one above to see the differences in the neural foramina. Clearly, the one above has osseous formation causing the stenosis.

[IMG][image]http://img.photobucket.com/albums/v85/brennerak/Normobliquehighlighted.jpg[/image][/IMG]

(All images obtained and used with permission)



SJBird55 -> Re: Cervical Pain (December 3, 2004 2:37:00 AM)

Perfect, Army. That works great - in a way exactly like the pointing and discussion I had with the surgeons when I was with them.

By the way... quite a few people mentioned the lack of lordosis. The surgeons I worked notice the lack of lordosis but by that point in time in a patient's life it wasn't uncommon to see that type of change, nor did they believe anything could be done about it.



jma -> Re: Cervical Pain (December 3, 2004 3:51:00 AM)

Thanks Army for the information you provided. I like the way you pointed out the specific pathologies. It made it much more clearer in addition to reading about it. Keep up the good work.

JMA



VagusX -> Re: Cervical Pain (December 3, 2004 6:32:00 AM)

This is a great addition to the forum. This is a very effective way of learning about radiographs. Thank you very much ARMY.



steve -> Re: Cervical Pain (December 3, 2004 10:45:00 AM)

Army,

Hope I'm not being too redundant but thanks for setting up these case studies. Very educational and thought provoking.

Steve



atoz76 -> Re: Cervical Pain (December 11, 2004 1:02:00 PM)

Very nice Army,
I enjoyed following up the case and learning from it all throughout.
Alex



fapt -> Re: Cervical Pain (December 12, 2004 11:46:00 PM)

OH GoD!!
How could you see this finding details.
I can't see all findings...lol



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