Rehab/PT?Chiropractic for Cervical Spondylosis

[AndyA]

Hello,

I am a 41 year old doctor with MRI proven cervical spondylosis with a narrowed foramen along with a C6 radiculopathy involving the left side.  I had acute onset of symptoms (pain in neck, posterior shoulder, and deltoid area with eventual parasthesias down the arm and numbness in the thumb) about 3 months ago.  There was no inciting factor or injury.  

I saw a neurosurgeon who felt that my symptoms would resolve in about three months.  He did not feel that NSAIDS, PT, or for that matter anything else has ever been shown in studies to substantially improve the problem---except time.  In the absence of significant disc disease, traction was not felt to be indicated.  Indeed, I tried multiple NSAIDS without relief.  Some Neurontin a psychiatrist colleague prescribed at HS has definitely helped me sleep at night.

At this forum and at other forums, professionals (neurologists, chiropractors, etc.) have felt that "rehab" or "PT" is extremely useful and indeed essential to a case such as mine.  I like and have confidence in the neurosurgeon (who incidently was not anxious to do surgery initially).  When I called back as he suggested (after patiently waiting 3 months in pain for this to resolve) his response was that I needed sugery (the surgery that he planned to do was a posterior approach--foraminectomy--no disc surgery per se as I apparently do not have significant disc disease).

There is no doubt that I have improved from three months ago.  There are days however when I feel I am back 2 to 3 months ago with significant pain.  I have never had a day that is without symptoms.

My question(s):  Is it reasonable to wait longer--is it likely I will have complete resolution of symptoms?  Is this the kind of thing I just accept and live with daily pain?  Am I destined to eventually have surgery at some point in my life given the onset at age 41?  I you feel rehab/PT/Chiropractic is useful and would be a good thing to pursue, which (a physical therapist or chiropractor) in your experience would be better?

Finally, I would never want to do any intervention to exacerbate the problem or injur my neck.  I have concerns about chiropractic "adjustments" that might worsen the problem.  Exactly what kinds of intervention from a PT or chiropractor can help this problem?

My sincere appreciation for your advice.

[CCF-Neuro-M.D.-RPS]

Dear Andy:

I am sorry that your having neck pain.  If you remember the NEJM article several months ago which showed that osteopathic manipulation and medications but not chiropractic manipulation was useful in back pain?  The numbers were pretty good and if you believe the stats, osteopathic manipulation was actually better than the other modalities.  We have seen PT/Rehab work fairly well.  Some of the treatment is adjustments of lifestyle, carriage of the body, lifting techniques, sleeping techniques, etc.  The problem with surgery in a foramen problem is that the healing process also includes an inflammatory component (the healing process itself) which can induce osteo changes in the area of the foramen and in itself induce foramen closure and nerve compression.  It is not a good situation either way.  We think that the surgical option is the last approach.  But each case is unique.  Multiple inputs are usually best, including multiple neurosurgeon inputs, neurologist input, and rehab input. Neurontin works well for neuropathic pain as you have found out.  I hope that things work out.  I am sorry that I am not giving you more formative answers.

Sincerely,

CCF Neuro MD

[nor]

Dear Andy,

I'm very interested in learning more specifics about what kind of PT, etc. you've considered.   If you know of good references (esp. websites) that detail what works, what's a waste of time, and what's dangerous for cervical injuries, could you post them here?  I've been told by my doc. I should get physical therapy (I posted my description a few days ago), but what it should be has been pretty vague.  

Thanks,
nor

[Dr. Dendrites]

Dear Andy,

It is more likely than not that you will decrease the compressive aspects of your spondylosis with engaging in active strenghening of you extensor muscles of your neck.Simply put,It could be said that your body is laying down bone in order to compensate for weakness of neck muscles that maintain the anit-gravitational forces. This is best done with a  computerized machine  that shows you at what areas or range of motion you are weak. It is manufactured by Med-x and there are many locations across the country in hospitals and rehab centers if you look on their web site.
The doc

[ChiroDoc]

Andy,
I am a chiropractor. Chiropractic is a conservative approach applied by a highly trained individual. The difference between a osteopathic manipulation and the chiropractic adjustment is the difference between the professionals applying them and not the editorial veiwpoint of a magazine. Get a refferal for the name of a competent Chiro, visit them and get a opinion. We are caring professionals as you are.

[lc]

I have cervical spondylosis and suffer terribly.  After a year or more of suffering, I desperately needed relief.  I went to a chiropractor, who did an adjustment on my neck.  I never knew what neck pain was until after that visit.  It has been 2 months since that "adjustment" and I can barely move my neck or shoulder and have had severe migraine headaches with nausea every day since, with no relief.  I am now in Physical therapy: heat, ultrasound and soft tissue massage and feel like a million bucks after my treatments.  Each week gets me closer to manageable pain.  I'm probably back to where I was before the chiropractor, but I will continue PT and hope it keeps improving.  Medicines don't work.  Tylenol takes the edge off.  A heating pad 3-4 times a day helps, and the neck excercises the PT gave me are a help if done regularly. My advice:  DON'T LET ANYONE TOUCH YOUR NECK if you have a proven injury.  The chiropractor took Xrays first, so I thought it would be okay.  My neurologist (after spending 6 days admitted to the hospital right after the chiropractor) told me to stay away from chiropractic with my condition.  Good luck to you....and beware.

[ChiroDoc]

This is quite a sad tale....Did you chiro say by any chance that it would take more than ONE adjustment?? Any responsible Dr. knows it does and communicates this with the patient. I hope yours did and it was just your misunderstanding of the process that chiropractic requires to get the results that are possible.
Good Luck

[ginny]

My opinion to your direct questions based on 20 years as a physiotherapist (in Australia) are;  In respect to surgery vs waiting, most definitely wait,  I have seen conditions such as yours take a long period to resolve but patience and correct physical management is mostly successful.  Secondly, you may well end up with chronic stiffness, with intermittent pain in your neck to a certain degree but this would result with or without surgical intervention.  Thirdly, an appropriately prescribed physical management programme is very important, as the pain that results from the musculoskeletal system is not necessarily proportional to the structural changes.

Physical therapy of any variety is unlikely to change the pathology. However, an experienced practitioner near you should teach you pain management techniques, evaluate your posture and working positions, look at the pattern of muscle tightness and/or weakness, evaluate the joint mobility. The goal is to alter the mechanical environment around the pathological joint thus reducing the neural irritation.  A good practitioner should be able to assess how irritable the neural structures are and avoid exacerbating the pain I would suggest that simply launching into high thrust manipulations would be quite likely to aggravate your pain.  A better approach can be through correcting the muscle dysfunction with Myofascial releases as per Travell and Simons textbook.  This approach is very useful before applying traction or mobilizations. There are always factors that precipitate and perpetuate neck pain due to spondylosis and if you can identify them you will find that you will be better able to manage your pain. An example of these factors are sleeping posture, pillows, poked chin posture, anxiety, depression, chronic infections, teeth clenching or grinding to name a few.   It is always good to add good analgesic medication and or antiinflammatories , and relaxation techniques.

Sometimes putting your affected hand on your head for about 10 minutes eases the parasthesias and pain of a radiculopathy, its worth a try,  (this position takes tension off the nerve root).   If this even temporarily eases the arm pain then do this frequently as the less you aggravate the referred pain the more settled the whole lower cervical spine will become.
  Please let me know if any of this info is helpful to you, Kind regards