Manual Therapy xxx (2014) 1e5
Contents lists available at ScienceDirect
Manual Therapy journal homepage: www.elsevier.com/math
Case report
Cervical Spondylotic Myelopathy presenting as mechanical neck pain: A case report Benjamin E. Smith a, *, Claire J. Diver b, Alan J. Taylor b a b
London Road Community Hospital (LRCH), Derby Hospitals NHS Foundation Trust, London Road, Derby DE1 2QY, UK University of Nottingham, UK
a r t i c l e i n f o
a b s t r a c t
Article history: Received 30 January 2014 Received in revised form 9 April 2014 Accepted 10 April 2014
Cervical Spondylotic Myelopathy (CSM) is the most common type of myelopathy in adults over 55 years of age. In the early stages symptoms may include local neck pain and stiffness that might mimic the presentation of non-specific mechanical neck pain (NSMNP). The patient was a 79 year old male, who complained of eight weeks of neck pain. He had been referred for physiotherapy by his family physician with a diagnosis of NSMNP. Initial presentation was consistent with the referral, but further assessment by the physiotherapist revealed findings suggestive of CSM. He was referred for an urgent cervical MRI scan, which revealed myelomalacic changes at C3/4 due to spondylotic changes. The patient was unsuitable for manual therapy intervention and was referred to a spinal orthopaedic surgeon who performed a posterior decompression and stabilisation at C3eC5, 2 months after the initial presentation. This case report highlights the importance of considering CSM in adults over 55 years of age presenting with NSMNP, particularly as the prevalence of both increases with age. It demonstrates the need for health professionals to carry out detailed examination where CSM may be a potential differential diagnosis. Outcomes are less favourable for patients over the age of 70, therefore an urgent surgical opinion was required for this patient. Deterioration of symptoms whilst he awaited surgery demonstrates how missed diagnosis may lead to possible long term spinal cord damage, with potential medico-legal concerns for the therapist. Ó 2014 Elsevier Ltd. All rights reserved.
Keywords: Cervical Myelopathy
1. Introduction Cervical Spondylotic Myelopathy (CSM) is the most common type of myelopathy in adults over 55 years of age (Montgomery and Brower, 1992). The precise prevalence of CSM is unknown, but 60% of men over the age of 40 show spondylotic degenerative changes (Boden et al., 1990), and this increases to 95% over the age of 60 (Gore, 2001). The diagnosis of cervical myelopathy is challenging as it may present with a variety of symptoms. It is known that in the early stages these may include local neck pain and stiffness (Cook et al., 2009) that can mimic non-specific mechanical neck pain (NSMNP). As a consequence, there is a strong likelihood this type of patient may be referred for physiotherapy management.
* Corresponding author. Tel.: þ44 (0)1332 254631. E-mail address: [email protected] (B.E. Smith).
NSMNP can be described as neck pain without specific underlying disease (Tsakitzidis and Remmen, 2013), and the 12 month prevalence in the UK population is 34% (Palmer et al., 2001). In Europe, 50% of patients with NSMNP are referred for physiotherapy assessment and treatment (Borghouts et al., 1999). Increasingly physiotherapists are required to be the primary point of contact (Moffett and McLean, 2006) and as such become key decision makers in the patient’s journey. CSM refers to the cascading effect of degenerative spondylotic changes of the spine, resulting in the direct compression of the spinal cord within the vertebral foramen. Loss of articular joint space is associated with osteophyte formation, plus hypertrophy and buckling of ligaments. Ventral overgrowth of osteophytes can compress the spinal cord ventrally, and buckling of the ligamentum flavum compresses the spinal cord dorsally. In addition, disc herniation or spondylolisthesis can cause spinal cord compression (Young, 2000; Toledano and Bartleson, 2013). Please see Fig. 1.
http://dx.doi.org/10.1016/j.math.2014.04.008 1356-689X/Ó 2014 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Smith BE, et al., Cervical Spondylotic Myelopathy presenting as mechanical neck pain: A case report, Manual Therapy (2014), http://dx.doi.org/10.1016/j.math.2014.04.008
2
B.E. Smith et al. / Manual Therapy xxx (2014) 1e5
and Bartleson, 2013). Examination findings are consistent with upper motor neurone syndrome, including: hyperreflexia, global motor weakness, sensory loss, spasticity, gait disturbances, positive Hoffman’s test, Clonus sign and extensor plantar response to the Babinski test (Montgomery and Brower, 1992; Kadanka et al., 2000; Young, 2000; Bartleson and Gordon Deen, 2009; Toledano and Bartleson, 2013). Physiotherapists routinely assess patients whose primary complaint is neck pain alone. This case report highlights the importance of including CSM in differential diagnosis. Consideration of CSM in hypothesis generation and refinement requires knowledge of pathophysiology, clinical presentation and diagnostic testing. Failure to correctly diagnose a patient with CSM could place the patient at risk of severe disability and possible permanent spinal cord damage (Yoshimatsu et al., 2001). The purpose of this case report is to increase clinicians’ awareness of the signs and symptoms of CSM that can manifest as NSMNP, and describe the assessment and diagnostic process.
2. Case description 2.1. Patient history
Fig. 1. (A) Axial view of normal cervical spine. (B) Axial view of cervical spine with cervical spondylotic myelopathy.
Spondylotic changes alone do not account for myelopathic changes within the spinal cord (Toledano and Bartleson, 2013). Predisposing factors associated with CSM include; KlippeleFeil syndrome, previous surgery, congenital fusions, Down syndrome and repeated trauma (Olive et al., 1988; Guille et al., 1995; Yoo and Origitano, 1998; Berge et al., 1999; Hilibrand et al., 1999; Bartolomei et al., 2005; Toledano and Bartleson, 2013), all of which, should raise the clinician’s index of suspicion. Signs and symptoms of CMS are variable, progressive and differ from patient to patient (Young, 2000; Toledano and Bartleson, 2013). Symptoms may include neck pain, reduced cervical range of movement, global muscle weakness, loss of fine motor control of the hands, unsteady gait, urgency of the bladder and bilateral or unilateral limb pain (Montgomery and Brower, 1992; Kadanka et al., 2000; Young, 2000; Bartleson and Gordon Deen, 2009; Toledano
The patient was a 79 year old retired male who complained of an eight week history of acute neck pain. He had not suffered previous neck complaints. There was no associated trauma and the symptoms developed insidiously over 2e3 days. The patient complained of intermittent neck pain associated with movement in all directions and had initially sought the help of his family physician, who had arranged a cervical x-ray. The result showed “severe degenerative changes C4-T1”, and the family physician referred him for physiotherapy with a diagnosis of ‘mechanical neck pain’. At the physiotherapy consultation the patient described being pain free at rest, but suffered lower neck pain, 5/10 on the visual analogue scale, associated with all movements. He reported no night pain and reported no upper or lower limb symptoms. He had hypertension and hypercholesterolaemia which were controlled with Amlodipine, Simvastatin and Aspirin. On further questioning, the patient disclosed increasing episodes of “unsteadiness on his feet”, though this was not associated with falls. He also reported loss of fine motor control of hands and fingers (bilaterally) affecting writing, eating and fastening buttons. He was unsure how long he had these symptoms for, but thought they predated the neck pain by several months. He wasn’t concerned by the symptoms and had disregarded them as the normal ageing process, not linking them to his reported neck dysfunction. There were no other neurological symptoms reported.
Table 1 Neurological examination findings. Clinical test
Result left side
Result right side
Strength C3-T1 Strength L2-S2 UL Reflexes LL Reflexes Upper Limb Sensation Lower Limb Sensation Hoffman’s Babinski Clonus
4/5 5/5 3þ 3þ Reduced all finger tips Normal Positive No response No response
4/5 5/5 3þ 3þ Reduced all finger tips Normal Positive No response 5 beats
Please cite this article in press as: Smith BE, et al., Cervical Spondylotic Myelopathy presenting as mechanical neck pain: A case report, Manual Therapy (2014), http://dx.doi.org/10.1016/j.math.2014.04.008
B.E. Smith et al. / Manual Therapy xxx (2014) 1e5
2.2. Examination It was immediately noticeable that the patient walked with a slow and shuffling gait. He did not appear to be distressed by pain and was able to remain seated for the duration of the subjective assessment. The patient’s active cervical range of movement was concomitant with that expected for his age group. Specifically, he was able to flex his chin onto his chest, extend 50 and rotate left and right 60 . All movements reproduced the patient’s neck pain, which ceased immediately once the neck returned to the neutral position. Neurological testing included deep tendon reflexes, sensation, strength, Babinski, Clonus and Hoffmann’s test (see Table 1). Reflexes were tested and scored using the National Institute of Neurological Disorders and Stroke (NINDS) myotatic scale as described by Hallett (1993). The scale has been shown to have near perfect intraobserver reliability and good interobserver reliability (Litvan et al., 1996). Sensation was tested with pin prink from the C3-T1 and L2-S1 nerve roots. It was recorded as normal, diminished or absent (Gilroy and Holliday, 1999). Strength testing was score using the Oxford Scale (Hislop and Montgomery, 1995). Babinski testing is described by Miller and Johnston (2005) and Clonus and Hoffman’s are both described by Cook et al. (2009). Interrater reliability of the Babinski test, Clonus and Hoffman’s sign has been shown to be acceptable to very good, with kappa coefficients of 0.56, 0.66 and 0.76 respectively in patients with neck pain (Cook et al., 2009). 3. Evaluation The patient’s initial presenting complaint was consistent with musculoskeletal impairment. He complained of local neck pain with stiffness on movement, with no radicular symptoms. On that basis it is understandable that the physician diagnosed mechanical neck pain. However, the patient’s interview revealed signs and symptoms conflicting with NSMNP, and were indicative of CSM (Young, 2000; Toledano and Bartleson, 2013). The disclosure that he experienced episodes of unsteadiness with gait and loss of fine motor control of the hands, raised the index of suspicion of CSM and it was included as a possible hypothesis in the differential diagnoses. Differential diagnoses for unsteadiness of gait and/or loss of fine motor control of the hands include cerebral lesions, stroke, carpal tunnel syndrome, neuropathy, GuillaineBarré syndrome, motor neurone disease, spinal cord lesions, vertebral neoplasm, vertebral infection and inflammatory demyelination (Toledano and Bartleson, 2013). GuillaineBarré syndrome and strokes usually present acutely, and the patient’s neurological symptoms were chronic (Feldmann et al., 1993; Hughes and Cornblath, 2005). Cerebral lesions would normally present with nausea, vomiting and headaches, all of which were absent in the patient (Snyder et al., 1993). A plain film radiograph showing spondylosis makes spinal cord lesions and neoplasms unlikely, and infections would usually be coupled with fever, chills and malaise (Wong et al., 1990; Toledano and Bartleson, 2013). Further differential diagnoses can be ruled out from the physical examination. Peripheral neuropathy, for example GuillaineBarré syndrome, can present with multiple and bilateral nerve involvement, but is likely to produce findings of absent reflexes (Chang, 2002). The presence of hyperreflexia suggested this was unlikely and supported a probable diagnosis of upper motor neurone involvement or spinal cord compression. The clinical tests used during the examination of the patient are routine for assessing CSM, but their diagnostic accuracy are yet to be fully established (Cook et al., 2011). A 2011 Systematic Review
3
showed that the tests had high levels of specificity and low levels of sensitivity when used in isolation and that the majority of the studies included were of low to moderate quality only (Cook et al., 2011). One study looked at combining certain tests, and this improved diagnostic accuracy (Cook et al., 2010). The combination of age greater than 45, positive Hoffman’s test and gait disturbances, as the patient in this case report presented with, gave a positive likelihood ratio of 30.9 and a post test probability of 94 (Cook et al., 2010). Based upon the patient’s interview and clinical examination, an index of suspicion of CSM was raised. It is known that diagnosis can only be confirmed after imaging, and so an urgent orthopaedic referral was made (Cook et al., 2011). The patient underwent a cervical spine MRI scan, which confirmed “myelomalacic changes at C3/4 due to disc osteophyte complexes in conjunction with ligamentum flavum hypertrophy causing severe central canal stenosis” (see Fig. 2). For mild CSM there is inconclusive evidence that either conservative or surgical treatment is more favourable, but for moderate to severe cases surgery should be considered (Toledano and Bartleson, 2013). For moderate to severe cases, between 50% and 75% of patients improve with regard to pain and function following surgery (Lunsford et al., 1980; Ebersold et al., 1988; Emery et al., 1998).
4. Intervention Surgery was proposed and subsequently performed via posterior decompression and stabilisation C3eC5, (see Fig. 3) approximately two months after the patient was referred by the physiotherapist. Of particular note, the patient’s neurological symptoms drastically deteriorated and he started to experience frequent falls and worsening upper limb numbness during the wait for surgery. Prior to surgery the patient was only able to walk with the aid of a frame.
Fig. 2. Cervical MRI.
Please cite this article in press as: Smith BE, et al., Cervical Spondylotic Myelopathy presenting as mechanical neck pain: A case report, Manual Therapy (2014), http://dx.doi.org/10.1016/j.math.2014.04.008
4
B.E. Smith et al. / Manual Therapy xxx (2014) 1e5
Missed or delayed diagnosis may lead to a deterioration of neurological symptoms and could progress onto permanent disabling spinal cord damage (Yoshimatsu et al., 2001). Furthermore, patients may receive inappropriate manual treatment which may be contraindicated (Cook and Hegedus, 2008), and put the therapist at risk of potential medico-legal complications. Adverse events from contraindicated treatments, such as thrust manipulation (Cook and Hegedus, 2008), on patients with an undiagnosed CSM have not been studied (Cook et al., 2011). However, it is plausible that such treatment could result in deterioration of patient’s symptoms (Young, 2000). Therefore, the decision to refer patients for further investigations should be based on a combination of the presenting symptoms, with thorough subjective questioning and examination findings combined, and not rely exclusively on clinical tests alone. Outcomes are less favourable for patients over the age of 70 with longer symptom duration (Matsuda et al., 1999; Furlan et al., 2011; Toledano and Bartleson, 2013), so once CSM is suspected a rapid surgical orthopaedic opinion is required. The combination of subjective and objective findings in this case report that directed the diagnosis of CSM were; patient’s age, neck pain, loss of fine motor control of the hands, unsteady gait, gross upper limp muscle weakness and paraesthesia, positive Hoffman’s and equivocal Clonus testing. Future research confirming the diagnostic accuracy of the clinical tests would be helpful for clinicians and might enable practitioners to identify CSM early in the diagnostic process. This case serves to illustrate that CSM should be included as a possible hypothesis in patients over the age of 55 years presenting with NSMNP.
Fig. 3. Post operative X-ray.
5. Outcome Three and a half weeks following surgery the patient was reviewed by the orthopaedic team. There were no post-operative complications. There was a noted improvement in the upper limb numbness, and he was walking with the aid of two sticks. 6. Discussion This case report highlights the importance of considering CSM in patients presenting with NSMNP in certain age groups, particularly over the age of 55. In this case report the salient symptoms, which directed the differential diagnosis, were not deemed significant enough by the patient to report to the clinician, nor did he believe they were in any way related to his main complaint of neck pain. This may explain the referral for NSMNP by the family physician, and highlights the need for health professionals to ask specific key questions relating to CSM, predominantly in this patient age group, when presenting with neck pain. Questioning should investigate for the presence of any global muscle weakness, loss of fine motor control of the hands, unsteadiness of gait, trips or falls, urgency of the bladder and bilateral upper and/or lower limb pain (Montgomery and Brower, 1992; Kadanka et al., 2000; Young, 2000; Bartleson and Gordon Deen, 2009; Toledano and Bartleson, 2013). Consequences of omitting key questions and building a complete picture may result in missed or delayed diagnosis. One of the conundrums for the therapist is that the clinical tests used for diagnostic workup CSM have poor sensitivity. This means that there is a high possibility of false negative findings, which may also lead to a missed or delayed diagnosis (Cook et al., 2011).
Acknowledgement The authors would like to thank Samantha Vincent, who created the art work. References Bartleson JD, Gordon Deen H. Spine disorders: medical and surgical management. 1st ed. Cambridge University Press; 2009. Bartolomei JC, Theodore N, Sonntag VKH. Adjacent level degeneration after anterior cervical fusion: a clinical review. Neurosurg Clin N Am 2005;16(4):575e87. Berge J, Marque B, Vital JM, Sénégas J, Caillé JM. Age-related changes in the cervical spines of front-line rugby players. Am J Sports Med 1999;27(4):422e9. Boden SD, McCowin PR, Davis DO, Dina TS, Mark AS, Wiesel S. Abnormal magneticresonance scans of the cervical spine in asymptomatic subjects. A prospective investigation. J Bone Jt Surg 1990;72(8):1178e84. Borghouts J, Janssen H, Koes B, Muris J, Metsemakers J, Bouter L. The management of chronic neck pain in general practice. A retrospective study. Scand J Prim Health Care 1999;17(4):215e20. Chang I. Diagnosis of peripheral neuropathies. Peripher Neuropathies 2002;13(2). Cook C, Brown C, Isaacs R, Roman M, Davis S, Richardson W. Clustered clinical findings for diagnosis of cervical spine myelopathy. J Man Manip Ther 2010;18(4):175e80. Cook C, Hegedus E. Physical examination tests: an evidence-based approach. Upper Saddle River, NJ: Pearson Prentice Hall; 2008. Cook C, Roman M, Stewart KM, Leithe LG, Isaacs R. Reliability and diagnostic accuracy of clinical special tests for myelopathy in patients seen for cervical dysfunction. J Orthop Sports Phys Ther 2009 Mar;39(3):172e8. Cook CE, Wilhelm M, Cook AE, Petrosino C, Isaacs R. Clinical tests for screening and diagnosis of cervical spine myelopathy: a systematic review. J Manip Physiol Ther 2011 Oct;34(8):539e46. National University of Health Sciences. Ebersold MJ, Pare MC, Quast LM. Surgical treatment for cervical spondylitic myelopathy. J Neurosurg 1988;1(1):745e51. Emery SE, Bohlman HH, Bolesta MJ, Jones PK. Anterior cervical decompression and arthrodesis for the treatment of cervical spondylotic myelopathy. Two to seventeen-year follow-up. J Bone Jt Surg 1998;80(7):941e51. Feldmann E, Gordon N, Brooks JM, Brass LM, Fayad PB, Sawaya KL, et al. Factors associated with early presentation of acute stroke. Stroke A J Cereb Circ 1993;24(12):1805e10. Furlan JC, Kalsi-Ryan S, Kailaya-Vasan A, Massicotte EM, Fehlings MG. Functional and clinical outcomes following surgical treatment in patients with cervical spondylotic myelopathy: a prospective study of 81 cases. J Neurosurg Spine 2011;14(3):348e55. American Association of Neurological Surgeons.
Please cite this article in press as: Smith BE, et al., Cervical Spondylotic Myelopathy presenting as mechanical neck pain: A case report, Manual Therapy (2014), http://dx.doi.org/10.1016/j.math.2014.04.008
B.E. Smith et al. / Manual Therapy xxx (2014) 1e5 Gilroy J, Holliday P. Basic neurology. 3rd ed. McGraw-Hill Professional; 1999. Gore DR. Roentgenographic findings in the cervical spine in asymptomatic persons: a ten-year follow-up. Spine Phila Pa 1976 2001;26(22):2463e6. Guille JT, Miller A, Bowen JR, Forlin E, Caro PA. The natural history of KlippeleFeil syndrome: clinical, roentgenographic, and magnetic resonance imaging findings at adulthood. J Pediatr Orthop 1995;15(5):617e26. Hallett M. NINDS myotatic reflex scale. Neurology 1993;43(12):2723. Hilibrand AS, Carlson GD, Palumbo MA, Jones PK, Bohlman HH. Radiculopathy and myelopathy at segments adjacent to the site of a previous anterior cervical arthrodesis. J Bone Jt Surg JBJS 1999;81(4):519e28. Hislop HJ, Montgomery J. Daniel’s and Worthingham’s muscle testing: techniques of manual examination. 6th ed. Philadelphia, Pa: WB Saunders Co; 1995. Hughes R a C, Cornblath DR. GuillaineBarré syndrome. Lancet 2005 Nov 5;366(9497):1653e66. Kadanka Z, Bednarík J, Vohánka S, Vlach O, Stejskal L, Chaloupka R, et al. Conservative treatment versus surgery in spondylotic cervical myelopathy: a prospective randomised study. Eur Spine J 2000;9(6):538e44. Litvan I, Mangone CA, Werden W, Bueri J, Estol C, Garcea D, et al. Reliability of the NINDS myotatic reflex scale. Neurology 1996;47(4):969e72. Lunsford LD, Bissonette DJ, Zorub DS. Anterior surgery for cervical disc disease. Part 2: treatment of cervical spondylotic myelopathy in 32 cases. J Neurosurg 1980;53(1):12e9. Matsuda Y, Shibata T, Oki S, Kawatani Y, Mashima N, Oishi H. Outcomes of surgical treatment for cervical myelopathy in patients more than 75 years of age. Spine Phila Pa 1976 1999;24(6):529e34. Miller T, Johnston. Should the Babinski sign be part of the routine neurologic examination? Neurology 2005;65(8):1165e8.
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Moffett J, McLean S. The role of physiotherapy in the management of non-specific back pain and neck pain. Rheumatol Br Soc Rheumatol 2006;45(4):371e8. Montgomery D, Brower R. Cervical spondylotic myelopathy. Clinical syndrome and natural history. Orthop Clin North Am 1992;23(3):487e93. Olive PM, Whitecloud TS, Bennett JT. Lower cervical spondylosis and myelopathy in adults with Down’s syndrome. Spine Phila Pa 1976 1988;13(7):781e4. Palmer KT, Walker-Bone K, Griffin MJ, Syddall H, Pannett B, Coggon D, et al. Prevalence and occupational associations of neck pain in the British population. Scand J Work Environ Health 2001;27(1):49e56. Snyder H, Robinson K, Shah D, Brennan R, Handrigan M. Signs and symptoms of patients with brain tumors presenting to the emergency department. J Emerg Med 1993;11(3):253e8. Toledano M, Bartleson JD. Cervical spondylotic myelopathy. Neurol Clin 2013 Feb;31(1):287e305. Elsevier Inc. Tsakitzidis G, Remmen R. Non-specific neck pain and evidence-based practice. Eur Sci 2013;9(3):1e19. Wong DA, Fornasier VL, MacNab I. Spinal metastases: the obvious, the occult, and the impostors. Spine Phila Pa 1976 1990;15(1):1e4. Yoo K, Origitano TC. Familial cervical spondylosis. Case report. J Neurosurg 1998;89(1):139e41. Yoshimatsu H, Nagata K, Goto H, Sonoda K, Ando N, Imoto H, et al. Conservative treatment for cervical spondylotic myelopathy. Prediction of treatment effects by multivariate analysis. spine J Off J North Am Spine Soc 2001;1(4):269e73. Young W. Cervical spondylotic myelopathy: a common cause of spinal cord dysfunction in older persons. Am Fam Physician 2000;1;62(5):1064e70.
Please cite this article in press as: Smith BE, et al., Cervical Spondylotic Myelopathy presenting as mechanical neck pain: A case report, Manual Therapy (2014), http://dx.doi.org/10.1016/j.math.2014.04.008
Contents lists available at ScienceDirect
Manual Therapy journal homepage: www.elsevier.com/math
Case report
Cervical Spondylotic Myelopathy presenting as mechanical neck pain: A case report Benjamin E. Smith a, *, Claire J. Diver b, Alan J. Taylor b a b
London Road Community Hospital (LRCH), Derby Hospitals NHS Foundation Trust, London Road, Derby DE1 2QY, UK University of Nottingham, UK
a r t i c l e i n f o
a b s t r a c t
Article history: Received 30 January 2014 Received in revised form 9 April 2014 Accepted 10 April 2014
Cervical Spondylotic Myelopathy (CSM) is the most common type of myelopathy in adults over 55 years of age. In the early stages symptoms may include local neck pain and stiffness that might mimic the presentation of non-specific mechanical neck pain (NSMNP). The patient was a 79 year old male, who complained of eight weeks of neck pain. He had been referred for physiotherapy by his family physician with a diagnosis of NSMNP. Initial presentation was consistent with the referral, but further assessment by the physiotherapist revealed findings suggestive of CSM. He was referred for an urgent cervical MRI scan, which revealed myelomalacic changes at C3/4 due to spondylotic changes. The patient was unsuitable for manual therapy intervention and was referred to a spinal orthopaedic surgeon who performed a posterior decompression and stabilisation at C3eC5, 2 months after the initial presentation. This case report highlights the importance of considering CSM in adults over 55 years of age presenting with NSMNP, particularly as the prevalence of both increases with age. It demonstrates the need for health professionals to carry out detailed examination where CSM may be a potential differential diagnosis. Outcomes are less favourable for patients over the age of 70, therefore an urgent surgical opinion was required for this patient. Deterioration of symptoms whilst he awaited surgery demonstrates how missed diagnosis may lead to possible long term spinal cord damage, with potential medico-legal concerns for the therapist. Ó 2014 Elsevier Ltd. All rights reserved.
Keywords: Cervical Myelopathy
1. Introduction Cervical Spondylotic Myelopathy (CSM) is the most common type of myelopathy in adults over 55 years of age (Montgomery and Brower, 1992). The precise prevalence of CSM is unknown, but 60% of men over the age of 40 show spondylotic degenerative changes (Boden et al., 1990), and this increases to 95% over the age of 60 (Gore, 2001). The diagnosis of cervical myelopathy is challenging as it may present with a variety of symptoms. It is known that in the early stages these may include local neck pain and stiffness (Cook et al., 2009) that can mimic non-specific mechanical neck pain (NSMNP). As a consequence, there is a strong likelihood this type of patient may be referred for physiotherapy management.
* Corresponding author. Tel.: þ44 (0)1332 254631. E-mail address: [email protected] (B.E. Smith).
NSMNP can be described as neck pain without specific underlying disease (Tsakitzidis and Remmen, 2013), and the 12 month prevalence in the UK population is 34% (Palmer et al., 2001). In Europe, 50% of patients with NSMNP are referred for physiotherapy assessment and treatment (Borghouts et al., 1999). Increasingly physiotherapists are required to be the primary point of contact (Moffett and McLean, 2006) and as such become key decision makers in the patient’s journey. CSM refers to the cascading effect of degenerative spondylotic changes of the spine, resulting in the direct compression of the spinal cord within the vertebral foramen. Loss of articular joint space is associated with osteophyte formation, plus hypertrophy and buckling of ligaments. Ventral overgrowth of osteophytes can compress the spinal cord ventrally, and buckling of the ligamentum flavum compresses the spinal cord dorsally. In addition, disc herniation or spondylolisthesis can cause spinal cord compression (Young, 2000; Toledano and Bartleson, 2013). Please see Fig. 1.
http://dx.doi.org/10.1016/j.math.2014.04.008 1356-689X/Ó 2014 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Smith BE, et al., Cervical Spondylotic Myelopathy presenting as mechanical neck pain: A case report, Manual Therapy (2014), http://dx.doi.org/10.1016/j.math.2014.04.008
2
B.E. Smith et al. / Manual Therapy xxx (2014) 1e5
and Bartleson, 2013). Examination findings are consistent with upper motor neurone syndrome, including: hyperreflexia, global motor weakness, sensory loss, spasticity, gait disturbances, positive Hoffman’s test, Clonus sign and extensor plantar response to the Babinski test (Montgomery and Brower, 1992; Kadanka et al., 2000; Young, 2000; Bartleson and Gordon Deen, 2009; Toledano and Bartleson, 2013). Physiotherapists routinely assess patients whose primary complaint is neck pain alone. This case report highlights the importance of including CSM in differential diagnosis. Consideration of CSM in hypothesis generation and refinement requires knowledge of pathophysiology, clinical presentation and diagnostic testing. Failure to correctly diagnose a patient with CSM could place the patient at risk of severe disability and possible permanent spinal cord damage (Yoshimatsu et al., 2001). The purpose of this case report is to increase clinicians’ awareness of the signs and symptoms of CSM that can manifest as NSMNP, and describe the assessment and diagnostic process.
2. Case description 2.1. Patient history
Fig. 1. (A) Axial view of normal cervical spine. (B) Axial view of cervical spine with cervical spondylotic myelopathy.
Spondylotic changes alone do not account for myelopathic changes within the spinal cord (Toledano and Bartleson, 2013). Predisposing factors associated with CSM include; KlippeleFeil syndrome, previous surgery, congenital fusions, Down syndrome and repeated trauma (Olive et al., 1988; Guille et al., 1995; Yoo and Origitano, 1998; Berge et al., 1999; Hilibrand et al., 1999; Bartolomei et al., 2005; Toledano and Bartleson, 2013), all of which, should raise the clinician’s index of suspicion. Signs and symptoms of CMS are variable, progressive and differ from patient to patient (Young, 2000; Toledano and Bartleson, 2013). Symptoms may include neck pain, reduced cervical range of movement, global muscle weakness, loss of fine motor control of the hands, unsteady gait, urgency of the bladder and bilateral or unilateral limb pain (Montgomery and Brower, 1992; Kadanka et al., 2000; Young, 2000; Bartleson and Gordon Deen, 2009; Toledano
The patient was a 79 year old retired male who complained of an eight week history of acute neck pain. He had not suffered previous neck complaints. There was no associated trauma and the symptoms developed insidiously over 2e3 days. The patient complained of intermittent neck pain associated with movement in all directions and had initially sought the help of his family physician, who had arranged a cervical x-ray. The result showed “severe degenerative changes C4-T1”, and the family physician referred him for physiotherapy with a diagnosis of ‘mechanical neck pain’. At the physiotherapy consultation the patient described being pain free at rest, but suffered lower neck pain, 5/10 on the visual analogue scale, associated with all movements. He reported no night pain and reported no upper or lower limb symptoms. He had hypertension and hypercholesterolaemia which were controlled with Amlodipine, Simvastatin and Aspirin. On further questioning, the patient disclosed increasing episodes of “unsteadiness on his feet”, though this was not associated with falls. He also reported loss of fine motor control of hands and fingers (bilaterally) affecting writing, eating and fastening buttons. He was unsure how long he had these symptoms for, but thought they predated the neck pain by several months. He wasn’t concerned by the symptoms and had disregarded them as the normal ageing process, not linking them to his reported neck dysfunction. There were no other neurological symptoms reported.
Table 1 Neurological examination findings. Clinical test
Result left side
Result right side
Strength C3-T1 Strength L2-S2 UL Reflexes LL Reflexes Upper Limb Sensation Lower Limb Sensation Hoffman’s Babinski Clonus
4/5 5/5 3þ 3þ Reduced all finger tips Normal Positive No response No response
4/5 5/5 3þ 3þ Reduced all finger tips Normal Positive No response 5 beats
Please cite this article in press as: Smith BE, et al., Cervical Spondylotic Myelopathy presenting as mechanical neck pain: A case report, Manual Therapy (2014), http://dx.doi.org/10.1016/j.math.2014.04.008
B.E. Smith et al. / Manual Therapy xxx (2014) 1e5
2.2. Examination It was immediately noticeable that the patient walked with a slow and shuffling gait. He did not appear to be distressed by pain and was able to remain seated for the duration of the subjective assessment. The patient’s active cervical range of movement was concomitant with that expected for his age group. Specifically, he was able to flex his chin onto his chest, extend 50 and rotate left and right 60 . All movements reproduced the patient’s neck pain, which ceased immediately once the neck returned to the neutral position. Neurological testing included deep tendon reflexes, sensation, strength, Babinski, Clonus and Hoffmann’s test (see Table 1). Reflexes were tested and scored using the National Institute of Neurological Disorders and Stroke (NINDS) myotatic scale as described by Hallett (1993). The scale has been shown to have near perfect intraobserver reliability and good interobserver reliability (Litvan et al., 1996). Sensation was tested with pin prink from the C3-T1 and L2-S1 nerve roots. It was recorded as normal, diminished or absent (Gilroy and Holliday, 1999). Strength testing was score using the Oxford Scale (Hislop and Montgomery, 1995). Babinski testing is described by Miller and Johnston (2005) and Clonus and Hoffman’s are both described by Cook et al. (2009). Interrater reliability of the Babinski test, Clonus and Hoffman’s sign has been shown to be acceptable to very good, with kappa coefficients of 0.56, 0.66 and 0.76 respectively in patients with neck pain (Cook et al., 2009). 3. Evaluation The patient’s initial presenting complaint was consistent with musculoskeletal impairment. He complained of local neck pain with stiffness on movement, with no radicular symptoms. On that basis it is understandable that the physician diagnosed mechanical neck pain. However, the patient’s interview revealed signs and symptoms conflicting with NSMNP, and were indicative of CSM (Young, 2000; Toledano and Bartleson, 2013). The disclosure that he experienced episodes of unsteadiness with gait and loss of fine motor control of the hands, raised the index of suspicion of CSM and it was included as a possible hypothesis in the differential diagnoses. Differential diagnoses for unsteadiness of gait and/or loss of fine motor control of the hands include cerebral lesions, stroke, carpal tunnel syndrome, neuropathy, GuillaineBarré syndrome, motor neurone disease, spinal cord lesions, vertebral neoplasm, vertebral infection and inflammatory demyelination (Toledano and Bartleson, 2013). GuillaineBarré syndrome and strokes usually present acutely, and the patient’s neurological symptoms were chronic (Feldmann et al., 1993; Hughes and Cornblath, 2005). Cerebral lesions would normally present with nausea, vomiting and headaches, all of which were absent in the patient (Snyder et al., 1993). A plain film radiograph showing spondylosis makes spinal cord lesions and neoplasms unlikely, and infections would usually be coupled with fever, chills and malaise (Wong et al., 1990; Toledano and Bartleson, 2013). Further differential diagnoses can be ruled out from the physical examination. Peripheral neuropathy, for example GuillaineBarré syndrome, can present with multiple and bilateral nerve involvement, but is likely to produce findings of absent reflexes (Chang, 2002). The presence of hyperreflexia suggested this was unlikely and supported a probable diagnosis of upper motor neurone involvement or spinal cord compression. The clinical tests used during the examination of the patient are routine for assessing CSM, but their diagnostic accuracy are yet to be fully established (Cook et al., 2011). A 2011 Systematic Review
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showed that the tests had high levels of specificity and low levels of sensitivity when used in isolation and that the majority of the studies included were of low to moderate quality only (Cook et al., 2011). One study looked at combining certain tests, and this improved diagnostic accuracy (Cook et al., 2010). The combination of age greater than 45, positive Hoffman’s test and gait disturbances, as the patient in this case report presented with, gave a positive likelihood ratio of 30.9 and a post test probability of 94 (Cook et al., 2010). Based upon the patient’s interview and clinical examination, an index of suspicion of CSM was raised. It is known that diagnosis can only be confirmed after imaging, and so an urgent orthopaedic referral was made (Cook et al., 2011). The patient underwent a cervical spine MRI scan, which confirmed “myelomalacic changes at C3/4 due to disc osteophyte complexes in conjunction with ligamentum flavum hypertrophy causing severe central canal stenosis” (see Fig. 2). For mild CSM there is inconclusive evidence that either conservative or surgical treatment is more favourable, but for moderate to severe cases surgery should be considered (Toledano and Bartleson, 2013). For moderate to severe cases, between 50% and 75% of patients improve with regard to pain and function following surgery (Lunsford et al., 1980; Ebersold et al., 1988; Emery et al., 1998).
4. Intervention Surgery was proposed and subsequently performed via posterior decompression and stabilisation C3eC5, (see Fig. 3) approximately two months after the patient was referred by the physiotherapist. Of particular note, the patient’s neurological symptoms drastically deteriorated and he started to experience frequent falls and worsening upper limb numbness during the wait for surgery. Prior to surgery the patient was only able to walk with the aid of a frame.
Fig. 2. Cervical MRI.
Please cite this article in press as: Smith BE, et al., Cervical Spondylotic Myelopathy presenting as mechanical neck pain: A case report, Manual Therapy (2014), http://dx.doi.org/10.1016/j.math.2014.04.008
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B.E. Smith et al. / Manual Therapy xxx (2014) 1e5
Missed or delayed diagnosis may lead to a deterioration of neurological symptoms and could progress onto permanent disabling spinal cord damage (Yoshimatsu et al., 2001). Furthermore, patients may receive inappropriate manual treatment which may be contraindicated (Cook and Hegedus, 2008), and put the therapist at risk of potential medico-legal complications. Adverse events from contraindicated treatments, such as thrust manipulation (Cook and Hegedus, 2008), on patients with an undiagnosed CSM have not been studied (Cook et al., 2011). However, it is plausible that such treatment could result in deterioration of patient’s symptoms (Young, 2000). Therefore, the decision to refer patients for further investigations should be based on a combination of the presenting symptoms, with thorough subjective questioning and examination findings combined, and not rely exclusively on clinical tests alone. Outcomes are less favourable for patients over the age of 70 with longer symptom duration (Matsuda et al., 1999; Furlan et al., 2011; Toledano and Bartleson, 2013), so once CSM is suspected a rapid surgical orthopaedic opinion is required. The combination of subjective and objective findings in this case report that directed the diagnosis of CSM were; patient’s age, neck pain, loss of fine motor control of the hands, unsteady gait, gross upper limp muscle weakness and paraesthesia, positive Hoffman’s and equivocal Clonus testing. Future research confirming the diagnostic accuracy of the clinical tests would be helpful for clinicians and might enable practitioners to identify CSM early in the diagnostic process. This case serves to illustrate that CSM should be included as a possible hypothesis in patients over the age of 55 years presenting with NSMNP.
Fig. 3. Post operative X-ray.
5. Outcome Three and a half weeks following surgery the patient was reviewed by the orthopaedic team. There were no post-operative complications. There was a noted improvement in the upper limb numbness, and he was walking with the aid of two sticks. 6. Discussion This case report highlights the importance of considering CSM in patients presenting with NSMNP in certain age groups, particularly over the age of 55. In this case report the salient symptoms, which directed the differential diagnosis, were not deemed significant enough by the patient to report to the clinician, nor did he believe they were in any way related to his main complaint of neck pain. This may explain the referral for NSMNP by the family physician, and highlights the need for health professionals to ask specific key questions relating to CSM, predominantly in this patient age group, when presenting with neck pain. Questioning should investigate for the presence of any global muscle weakness, loss of fine motor control of the hands, unsteadiness of gait, trips or falls, urgency of the bladder and bilateral upper and/or lower limb pain (Montgomery and Brower, 1992; Kadanka et al., 2000; Young, 2000; Bartleson and Gordon Deen, 2009; Toledano and Bartleson, 2013). Consequences of omitting key questions and building a complete picture may result in missed or delayed diagnosis. One of the conundrums for the therapist is that the clinical tests used for diagnostic workup CSM have poor sensitivity. This means that there is a high possibility of false negative findings, which may also lead to a missed or delayed diagnosis (Cook et al., 2011).
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