Title:  The chiropractic management of cervical Myelomalacia

Abstract:  To examine the diagnosis and condition of a patient suffering from neck pain and radiation of pain into arms following a motor vehicle accident. Diagnostic studies include chiropractic, orthopedic and neurological examination, digital x-rays, range of motion, and cervical MRI.

Introduction:  On 10/10/2016, a 38-year-old male presented to our office for injuries he sustained in an MVA 10/01/2016. The patient stated that he was stopped at an intersection when the pickup behind him hit him quickly, pushing him through the intersection. The patient stated that he had neck pain and stiffness that radiated into the trapezius area. He also complained about “tingling” in both hands. He also complained of lower back pain that he felt more than the neck. His review of systems was benign, other than the current symptoms of neck and back pain and tingling.

The patient’s Social/Family Medical History included his mother having high blood pressure and Diabetes.

Clinical Findings of Chiropractic and Myelomalacia

The patient is 6’0”. The patient weighs 211 pounds. The sitting blood pressure measured was 122/74.

An evaluation and management exam was performed. The exam consisted of a visual inspection of the spinal ranges of motion, digital palpation, manual testing of muscles, deep tendon reflexes, and orthopedic and neurological findings. The Cervical exam showed the following decreased motion on the visual exam in flexion, extension, left rotation, right rotation, right lateral flexion, and left lateral flexion. All of the above motions produced pain.

When digital palpation was performed in the cervical and thoracic spinal areas, a moderate spasm was noted bilaterally in paraspinal areas with moderate tenderness.

In the cervical orthopedic and neurological testing, positive findings were present bilaterally with Foraminal Compression and Foraminal Decompression. Soto Hall test was positive when performed in the thoracic spine area. Manual, subjectively rated muscle testing was performed on certain muscles of the upper extremities. Based on the AMA Guides to the Evaluation of Permanent Impairment, 4^th Ed., 1993/5^th ed. 2001, differences were noted using the rating scale of five to zero. Five is full Range of Motion/Maximum Strength; Four is Full Range of motion with Moderate Resistance; Three is Full Range of Motion/Perceptible Weakness. The Deltoids and Triceps normally tested bilaterally at 5. The Biceps, forearm, and intrinsic hand muscles all tested as a four on the right and a three on the left.

Grip Strength tests the strength of the hands, which indicates nerve integrity from the cervical spine. In evaluation, the normal would be for a difference of strength in the preferred hand of 10% more. More than that would be a weakness in the opposite hand, and less than that would be a weakness in the preferred hand.   The preferred hand for this patient is the right hand. The testing below shows a definite decrease in strength in the left hand.

 

Hand tested	Rep one	Rep two	Rep three
Right	28	30	30
Left	18	18	20

 

Deep Tendon Reflexes were performed on the patient and were noted at a plus two bilaterally.

Using a Whartenburg pinwheel, dermatomes showed normal findings except for C8, which was hypersensitive on the left.

A Lumbar orthopedic and neurological exam was then performed. Upon visual examination, there was decreased motion in flexion and extension. Right and left lateral flexion with pain present on all of the motions.

Lasegue’s Straight Leg Raising test was performed and was negative with 80-degree movement. Braggarts test was performed and were negative bilaterally.

Kemps was done with the patient on both sides and was noted as negative. Ely’s test was noted as negative.

Digital palpation was performed, and there was severe tenderness and spasm bilaterally in the lumbar paraspinal muscles.

Manual, subjectively rated muscle testing was performed on certain lower extremities muscles. Based on the AMA Guides to the Evaluation of Permanent Impairment, 4^th Ed., 1993/5^th ed. 2001, differences were noted using the rating scale of five to zero. Five is full Range of Motion/Maximum Strength; Four is Full Range of motion with Moderate Resistance; Three is Full Range of Motion/Perceptible Weakness.    Muscle testing was done bilaterally in the Quadriceps, Hamstrings, Calf Muscles, and Extensor Hallicus Longus and showed Full ROM and Strength.

Deep Tendon Reflexes were performed. They were negative in the Achilles bilaterally but +3 in the Patella bilaterally.

Based on the ortho/neuro findings and the history, the following x-rays were ordered:

AP/Lat/Flex/Ext/Bilateral Oblique’s/ APOM of the cervical spine, AP/Lat Thoracic

AP/Lat/Lateral Flexion/Oblique Lumbar’s. The x-rays were read, the Lumbar spine showed the discs were of a normal height, and Georges’s line was uninterrupted. There the Lumbar curve appeared to be hypolordotic. On visual inspection, there was a decrease in the lateral bending bilaterally.

The Cervical spine showed that there was anterior spurring present in the C5/6 region of the cervical spine. In the lateral view, the spine’s normal curvature was no longer lordotic but noted as a “Military Neck.”  There was decreased range of motion noted in the flexion and the extension views. Also noted on flexion and extension was paradoxical motion present at C1. Disc spaces were normal throughout the spine, except for narrowing the disc space at C5/6 and spurring in the anterior part of the vertebral body.

Due to the injuries, orthopedic and neurological, and x-ray findings, a cervical MRI was ordered. I recommended that the patient receive palliative therapy until a Cervical MRI could be obtained.

The MRI was obtained and personally reviewed. The Cervical MRI performed on 10/14/2016 revealed that C1/2 was unremarkable. There was a mild disc bulge at C2/3 and a moderate disc bulge that abuts the ventral cord, resulting in mild spinal canal stenosis at C3/4. There is also bilateral uncovertebral hypertrophy with moderate bilateral neural foraminal narrowing noted at C3/4. At C4/5, There is a mild disc bulge that abuts the ventral cord. There is mild spinal canal stenosis. There is a bilateral uncovertebral hypertrophy with moderate bilateral neural foraminal narrowing. At C5/6, There is a moderate disc bulge that indents the ventral cord and results in severe spinal canal stenosis. At this level, there is a resultant T2-weighted hyperintense (high) signal abnormality in the spinal cord. This may represent edema or myelomalacia. C6/7 shows a mild disc bulge that abuts the ventral cord and results in mild spinal canal stenosis. There is bilateral uncovertebral hypertrophy with moderate bilateral neural foraminal narrowing. C7/T1 presents as unremarkable.

Test Study Treatment Impressions

At C5/6, a moderate disc bulge indents the ventral cord and results in severe spinal canal stenosis. There is a resultant abnormal signal in the spinal cord at C5/6, which may represent myelomalacia or edema.

An alert was placed on this study.

Fig.1 (A)  Sagittal T2 MRI of Cervical Spine

(B)   Axial T2 MRI of the Cervical Spine.

A

B

 

The patient was notified of the MRI findings.   The patient was informed that care would be discontinued until a consultation was done with a neurosurgeon. The patient stated that he was going to do that. He continued to try to get care, but we refused. The patient was instructed to go to the emergency room. The patient became angry, stating that he wanted his records and that he was going to go to another chiropractor for them to “crack his neck.” Based on our records, the patient went to another chiropractor who refused to see the patient. The patient finally decided to go to the surgeon, where disc surgery was performed to decompress the spinal cord.

The patient contacted our office and thanked us for being adamant about his treatment.

Discussion of Results

There is much discussion in the MRI report concerning “bulges,” and one must first have a handle on what is a bulge and herniation.

General radiologists often utilize nomenclatures such as bulge, protrusion, prolapse, herniation, and many other descriptors. However, the nomenclature has been standardized and accepted by the North American Spine Society, the American Spine Society of Radiology, and the American Society of Radiology by Fardone, Williams, Dohring, Murtagh, Rothman, and Sze (2014):

“Degeneration may include any or all of the following: desiccation, fibrosis, narrowing of the disc space, diffuse bulging of the annulus beyond the disc space, fissuring (i.e. ., annular fissures), mucinous degeneration of the annulus, intradiscal gas, osteophytes of the vertebral apophyses, defects, inflammatory changes, and sclerosis of the endplates.” pg. 2528⁽¹⁾

“Bulging disc, bulge (noun [n]), bulge (verb [v]) ⁽¹⁾

1. A disc in which the contour of the outer annulus extends, or appears to extend, in the horizontal (axial) plane beyond the edges of the disc space, usually greater than 25% (90°) of the circumference of the disc and usually less than 3 mm beyond the edges of the vertebral body apophysis.

2. (Nonstandard) A disc in which the outer margin extends over a broad base beyond the edges of the disc space.

3. (Nonstandard) Mild, diffuse, smooth displacement of disc.

4. (Nonstandard) Any disc displacement at the discal level.

Note: Bulging is an observation of the contour of the outer disc and is not a specific diagnosis. Bulging has been variously ascribed to the redundancy of the annulus, secondary to the loss of disc space height, ligamentous laxity, response to loading or angular motion, remodeling in response to adjacent pathology, unrecognized and atypical herniation, and illusion from volume averaging on CT axial images. Mild, symmetric posterior disc bulging may be normal at L5–S1. Bulging may or may not represent pathological change, physiological variant, or normalcy. Bulging is not a form of herniation; discs known to be herniated should be diagnosed as herniation or, when appropriate, as specific types of herniation.” Pg. 2537⁽¹⁾

Studin and Owens discuss this “nomenclature” in their article “Bulging Discs and Trauma: Causality and a Risk Factor.”

“There is now, based upon the literature and well-respected experts, categories of disc bulges that can be deemed as direct sequella from trauma vs. those cases with pre-existing degeneration. It can also now be concluded, again based on the literature, that those patients can have an aggravation of the pre-existing condition that could persist for a lifetime requiring perpetual care. To conclude these findings, a doctor trained in understanding the underlying pathology and sequella must be consulted to be able to render an accurate diagnosis that is demonstrable.”² Pg. 26

Understanding Cervical Myelomalacia

What is Myelomalacia? According to the MedicoLexicon, it is simply the “softening of the spinal cord.”³  It is ischemia in the spinal cord from abnormal pressure placed upon it. If left untreated, that continues to spread and cause further damage to the cord. Once the cord has been damaged, there is no repair. Brandy Carrelli gives us a concise definition, and the ramifications of it left untreated:

“The myelomalacia definition, strictly speaking, is the “softening of the spinal cord.” After an acute injury, bleeding of the spinal cord may occur. As a result, there is “subsequent softening of normal tissues.”  Myelomalacia can be caused by trauma or disease, but if it worsens and the bleeding reaches the cervical region of the body, it can be fatal. Bleeding can make the tissue necrotic. Fractured vertebrae can lead to bleeding in the spinal cord, as can some back surgery. Osteoporosis may also contribute to spinal instability and hemorrhaging. Sometimes circulatory problems can lead to a deterioration of tissues and bleeding. Myelomalacia can progress into impairment in the functioning of the lower extremities, below-normal or absent reflexes of the anus and pelvic limbs, loss of pain perception in the caudal region (near the coccyx), depression, respiratory problems due to “diaphragmatic paralysis,” and even neurological issues. Death could result from respiratory paralysis. Damage occurs to the central nervous system. At first, the spinal cord damage may be minor. The most commonly injured areas are the lumbar spine (lower back) and cervical vertebrae (upper spine area).⁴ 

Disc degeneration, herniations (all variations), and bulging all describe what has happened to the disc. Once you have established a definitive diagnosis, the question becomes, how is the disc affecting surrounding neurological components? Myelomalacia is the effect of that disc when the cord is affected by pressure. If there is bleeding into the cord, then the cord begins a degenerative spiral that can happen rather quickly. As you have read above, it can take what may appear as a minor issue to the patient that can lead to major neurological compromise and, in extreme cases, may lead to paralysis or death. Therefore, it is important carefully analyze the clinical indicators and image accordingly.

Myelomalacia is a relatively rare occurrence. According to Zhou, Kim, Vo, and Riew,

“The overall prevalence of cervical myelomalacia was relatively low in the studied population and was affected by age, sex, and the specialties/subspecialties of referring providers. These results may help direct treatment guidelines and allow for informed discussions with patients in terms of the risk versus the benefit of surgery.”⁵  Pg. E252

It is a very common occurrence for the presence of disc bulging and herniations in chiropractic practices. It is of utmost importance for the chiropractor to not only order MRI when clinically indicated but also be able to interpret those images. Once the clinical indicators begin to show a different story than what is presented by the patient symptomatically, it is the responsibility of the chiropractor to make the appropriate diagnosis, prognosis, and treatment plan. In this case, that is an immediate neurosurgical referral. Although not a common finding in a chiropractic office, one must still be alert to the possibility of Myelomalacia.   Managing the patient based on an accurate diagnosis is your ultimate goal, and sometimes adjusting the patient isn’t the best first option as diagnosis and prognosis supersede treatment.

Additional Topics: Recovering from Auto Injuries

After being involved in an automobile accident, many victims frequently report neck or back pain due to damage, injury, or aggravated conditions resulting from the incident. Various treatments are available to treat some of the most common auto injuries, including alternative treatment options. Conservative care, for instance, is a treatment approach that doesn’t involve surgical interventions. Chiropractic care is a safe and effective treatment option that focuses on naturally restoring the original dignity of the spine after an individual suffered an automobile accident injury.

Neck Pain

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REFERENCES:

1. Fardon, D. F., Williams, A. L., Dohring, E. J., Murtagh, F. R., Gabriel Rothman, S. L., & Sze, G. K.
2. Studin M., Owens W. (2016) Bulging Discs and Trauma: Causality and a Risk Factor, American Chiropractor 34(6) 18, 20,22-24, 26, 28
3. www.medilexicon.com/dictionary/58294
4. Carrelli, B (2016)  What is Myelomalacia? www.echiropractor.org/myelomalacia/
5. Zhou, Yihua; Kim, Sang D.; Vo, Katie; Riew, K. Daniel (2015) Prevalence of cervical myelomalacia in adult patients requiring a cervical magnetic resonance imagingSpine (Phila Pa 1976). 2015 Feb 15;40(4):E248-252.