Evaluation and management of spinal cord emergency and cervical spondylotic myelopathy in the chiropractic office

By James Lehman

It is my opinion that chiropractic physicians are dedicated to alleviating the incidence, degree, and consequence of human physical pain. In order to provide evidence-based and patient-centered care, chiropractic clinicians are required to perform evaluation procedures and a differential diagnosis process prior to treatment of painful spinal conditions. Hopefully, this discussion will be enlightening and enhance your clinical patient care.

During my training at Logan College of Chiropractic (1968-72) and subsequent post-doctoral training in chiropractic orthopedics, I became aware of the need to recognize spinal cord emergencies and avoid spinal manipulation. Yet, while serving as a chiropractic orthopedist at the Lovelace Medical Center, I was advised by a neurosurgeon that my geriatric patient was not a candidate for neurosurgical intervention. In spite of her cord compression with long tract signs and bowel and bladder dysfunction, she was not a surgical candidate because of her age and desire to avoid surgery. The neurosurgeon then suggested that I figure out how to manage her condition.

After explaining to the patient that she might not respond to my new plan of care or even get worse, she granted permission to proceed. Since spinal manipulation was a relative contraindication at best, I decided to provide soft tissue treatment and long axis distraction with a flexion/distraction table. To my amazement, this geriatric patient demonstrated a favorable response and her quality of life improved. Subsequent referrals from Lovelace neurosurgeons for conservative management of similar patients revealed that approximately 50 percent of these patients responded favorably to this plan of care. I now wonder if I had used a percussion instrument if the clinical responses would have improved the response rate.

It is common for the chiropractic physician to encounter an initial visit with a patient presenting with acute or chronic pain because of a neuromusculoskeletal condition. Normally, patients with neurological deficits present with lower motor neuron conditions. A patient with intervertebral discopathy compressing one of the lumbar nerve roots demonstrates signs of a lower motor neuron lesion, which includes flaccid atrophy, paresis, and reduced deep tendon reflexes. Normally, chiropractic clinicians are capable of evaluating and managing the patient with a lower motor neuron lesion.

Then there are the exceptions that present less frequently in the chiropractic clinic with signs of an upper motor neuron lesion. Chiropractic clinicians are trained to perform neurological examinations that will demonstrate upper motor neuron lesion findings, which include pathological reflexes, increased deep tendon reflexes, clonus, and spastic paralysis. One of the more common upper motor neuron lesions encountered by the chiropractor includes spinal cord compression. Degenerative spinal conditions or acute trauma to the spine may cause spinal cord compression and resultant myelopathy.

It is essential that a chiropractic provider recognize the patient with a spinal cord injury (SCI). To do so, the doctor must correlate anatomy and the patients’ signs and symptoms in order to identify cervical spondylotic myelopathy (CSM). SCIs are critical emergencies that must be recognized and treated early to increase the possibility of preventing permanent loss of function. History and clinical presentation can provide the most important information in the assessment of a possible emergency. The red flags to be observed with SCI include the following:

• Night pain/sweats/fever
• Unexpected weight loss
• Bowel and bladder dysfunction
• Long tract signs
• Signs of neurogenic claudication
• Weakness and paresthesias in extremities

Oftentimes, patients present to chiropractic clinicians for the evaluation and management of the spine following motor vehicle incidents. Whiplash associated disorders (WAD) are the most common non-hospitalized injuries resulting from a motor vehicle crash. Frequently, these rear-end, or side-impacts cause the whiplash type injury and its myriad of symptoms including:

• Pain
• Dizziness
• Visual and auditory disturbances
• Temporomandibular joint dysfunction
• Photophobia
• Dysphonia
• Dysphagia
• Fatigue
• Cognitive difficulties such as concentration and memory loss, anxiety, insomnia, and depression

When the clinical presentation includes the history of a roll-over motor vehicle incident or a blow to the head, the clinician should be highly suspicious of an upper cervical spine instability until proven otherwise. One of the clinical signs observed with the clinical presentation is the Rust Sign. The patient may grab his/her head upon removal of cervical collar with an anxious behavior. Another Rust Sign involves the patient rising from supine position with one hand lifting the head.

If this injured patient attempts to reduce the neck pain by stabilizing the head with slight traction and demonstrates guarded movements with nuchal rigidity, imaging studies must proceed any provocative testing. A CT or MRI scan is indicated with acute trauma to the cervical spine when radiographic examination is negative. Realize that a non-displaced fracture may not be demonstrated with a cervical spine radiographic study during the first 7-10 days post-trauma.

One must not become overconfident, depending on imaging studies alone. The clinical presentation including history, observation and neurological testing may provide only clinical findings of spinal cord injury. A spinal cord injury without radiographic or CT abnormality (SCIWORA) was first introduced by Pang and Wilberger with the first case reported in 1974.

The acronym SCIWORA (Spinal Cord Injury Without Radiographic Abnormality) was first developed and introduced by Pang and Wilberger who used it to define “clinical symptoms of traumatic myelopathy with no radiographic or computed tomographic features of spinal fracture or instability”. SCIWORA is a clinical-radiological condition that mostly affects children.

The chiropractic clinician will be challenged when a patient presents with signs of cervical myelopathy without a history of trauma. Recognizing spinal cord compression secondary to a space occupying lesion requires a differential diagnosis of several diseases including metastatic disease, primary spinal tumor (multiple myeloma), and infections. The patient presenting with acute onset neck or back pain without a history of trauma may indicate a history of infection or suffering with a current fever. Labs might reveal abnormal SED rates or elevated WBC count. Spinal cord compression is frequently misdiagnosed in the ER and an MRI is indicated in order to identify the pathological condition. Metastatic disease of the spine is the most common spinal tumor. A primary spinal tumor is most often the result of multiple myeloma in adults.

Everyday walking is a complex process that is a combination of brain and spinal cord input. With cervical cord compression an unsteady walking pattern can develop. Some people can develop a wide based gait. Early signs of this can be tested in the office with tandem gait observation. Another sign of cervical spondylotic myelopathy (CSM) will present itself with hand dysfunction. Ask if patient has a difficult time holding a cup of coffee or buttoning their clothes.

As the cervical spinal cord is compressed, the spinal nerves will be impacted.  This can lead to numbness in the arms and hands (paresthesias). Unlike carpal tunnel syndrome, cervical myelopathy will often involve numbness throughout the arms and hands. Cervical radiculopathy can cause numbness in the arms and hands but is usually limited to specific dermatomes. With continued compression of the cervical spinal cord, the innervation to the muscles in the arms and hands can be diminished. As a result, the muscles can diminish in size and demonstrate atrophy of the involved musculature.

CSM usually demonstrates signs of an upper motor neuron lesion. One of these signs, hyper-reflexia may be described by the patient as a twitching of the muscles. Neurological examination will probably reveal upper and lower extremity reflexes to be increased. The hyper-reflexia is due to the loss of inhibition, normally mediated by the corticospinal tract. Because of the loss of inhibition in patients will demonstrate not only hyperreflexia but also the presence of pathological reflexes. Stroking of the plantar surface of the feet should demonstrate dorsiflexion of the large toe and majestic fanning of the other toes. This phenomenon is known as the Babinski sign.

The common signs of cervical spine myelopathy include the following:

• Unsteady walking
• Disuse of hands
• Numbness in the arms and hands
• Atrophy
• Twitching reflexes or muscles

Cervical spondylotic myelopathy (CSM) is the most common spinal cord disorder in persons more than 55 years of age in North America and perhaps in the world.

Chiropractic providers are most competent with both the evaluation and management of lower motor neuron lesions caused by neuromusculoskeletal conditions. Manual medicine services, rehabilitation exercises, proper nutrition and hydration, and injury prevention may provide satisfactory outcomes with reduced pain and neurological deficits.

Chiropractors that identify patients with upper motor neuron lesions should consider referral to another provider for evaluation and management, such as a neurosurgeon or a spine surgeon. I suggest that chiropractors create a team of medical specialists to complement patient care. We should investigate the availability of other skilled health care providers that will work co-manage with us our problem cases.

Remember that older patients with CSM that refuse surgery may benefit from chiropractic management providing the clinician realizes that spinal manipulation is a relative contraindication, which requires modifying of the interventions. Use of a percussion instrument rather than a high velocity, low amplitude manipulation, and other conservative care to reduce pain and improve function might prove beneficial.

I would appreciate hearing of your experiences with cervical spinal myelopathy patients.  [email protected]

References

Glick TH, et al. Spinal cord emergencies: False reassurance from reflexes. Acad Emerg Med 1998.

Carrie R. Living with ongoing whiplash associated disorders: a qualitative study of individual perceptions and experiences. BMC Musculoskeletal Disord. 2017; 18: 531.

Tanaka N. Pathology and Treatment of Traumatic Cervical Spine Syndrome: Whiplash Injury. Adv Orthop. 2018 Feb 28; 2018.

Szwedowski D and Walecki J. Spinal Cord Injury without Radiographic Abnormality (SCIWORA) – Clinical and Radiological Aspects. Pol J Radiol. 2014; 79: 461–464. 

Young WF. Cervical Spondylotic Myelopathy: A Common Cause of Spinal Cord Dysfunction in Older Persons. Am Fam Physician. 2000 Sep 1; 62(5):1064-1070.