This article discusses a patient presenting with chronic neck pain following a motor-vehicle accident, complicated by a pre-existing structural scoliosis. The case report serves as an example of a comprehensive SOAP note, which adequately documents the initial visit and a comprehensive new-patient evaluation. This evaluation and consultation with the patient would last a total of 45 minutes.
The chronic neck pain presentation becomes more interesting and challenging because of the previous history of adolescent idiopathic scoliosis (AIS) and an anatomical leg-length inequality, followed by a whiplash-associated disorder (WAD).
Adolescent idiopathic scoliosis is found between age 10 and skeletal maturity.1
Abnormalities on physical examination require radiographic evaluation with a single standing posteroanterior radiograph to allow measurement of the curve using the Cobb method and Risser grading of the iliac apophysis. Magnetic resonance imaging is indicated whenever there is a left thoracic curve, unusual pain or abnormalities on neurologic examination, or other red flags, to evaluate for spondylolisthesis, tumors or syringomyelia.2
Subjective Findings
A 40-year-old male presents for an initial evaluation with a chief complaint of “My neck is always stiff and sore.” The onset was 10 years prior following an injury. He was injured in a motor-vehicle incident at age 30. It was a rear-end collision. He was wearing his seat belt and braced for the impact.
A chiropractor diagnosed him with a whiplash-associated disorder. Chiropractic treatment was helpful, but since the accident, he has experienced daily stiff neck and muscle soreness in the neck and shoulders.
He enjoys flying his private plane, but the stiffness in his neck makes him uncomfortable when flying. Massage and spinal adjustments provide relief. He rates the morning neck stiffness at 3/10, which is relieved with a hot shower. The pain is worse with prolonged sitting and flying the plane, with severity at 5/10. He denies any radiating pain into the arms / hands. He also experiences episodes of lower back aching with prolonged standing or walking.
Recently, his primary care physician ordered a seven-view Davis series of his cervical spine, which demonstrated degenerative changes in the C4-5-6 zygapophyseal joints and decreased disc spacing at C5-6.
There is a history of adolescent idiopathic scoliosis as a child, which was successfully treated with bracing and chiropractic care. He brought his imaging report, which detailed his series of six 14x36” full-spine AP radiographs. The last Cobb method mensuration was 20 degrees, which was the same at ages 14, 15, and 16. His scoliosis was a right thoracic curve and a left lumbar curve.
Objective Findings
Vital signs: Height 72,” weight 210 lbs., BP 130/90, respirations 12/minute, pulse 70/minute.
Observation: Appears to be a well-developed, well-nourished, middle-aged male. He is a good historian with a pleasant demeanor.
Palpation of the cervical spine produces pain at the level of C4-6 with pain over the ligamentum nuchae and at the facet capsules. Hypertonicity of the cervical paravertebral muscles.
Myofascial trigger points: Bilateral upper trapezii and levator scapulae with taut bands, painful nodules, and twitch responses. The pain is localized and refers into the shoulders and scapulae.
Active cervical range of motion demonstrates restricted ROM to the right with pain at C4-6 right.
Maximal foraminal compression to the right is restricted with pain at C4-6 midline and on the right, but without radiations.
Cervical distraction is + with relief of the pain in the cervical spine.
Posterior joint dysfunction at C4-6 with pain, reduced range of motion, and hypertonicity of the PVM.
Posture: Standing with no antalgia, but with posterior inferior left iliac crest and anterior superior right iliac crest indicating a pelvic obliquity. There is an “S”-type scoliosis with a right thoracic curve and a left lumbar curve.
Adam’s forward bending demonstrates a posterior right rib hump.
Posture: Sitting with rounded shoulders and forward head posture of four finger widths.
Gillet’s sign is present with the left SIJ fixation.
Kemp’s maneuver is full and without pain bilaterally.
Long sit test: Supine with the appearance of a left short leg and a long right leg. Sitting with the appearance of a short left leg. Mensuration from each ASIS to the medial malleolus demonstrates a ½” anatomical left leg-length inequality.
Insertion of a ¼” heel lift into the left shoe is well-tolerated and demonstrates a level pelvis. The patient notices that his neck feels more comfortable while walking with the inserted heel lift.
Neurological examination: Sensory: upper and lower extremities intact bilaterally for light touch and sharp sensations; motor: upper and lower extremities 5/5 bilaterally; deep tendon reflexes: 2+ bilaterally for the upper and lower extremities.
Assessment
- Post-traumatic chronic neck pain syndrome with cervical degenerative joint and disc disease
- Structural scoliosis (stable)
- Anatomical leg-length inequality
- Chronic myofascial pain syndrome
Treatment Plan
- Consider long-term use of a ¼” left heel lift in shoe
- Spinal manipulation and soft-tissue treatments to reduce spinal pain, improve spinal joint function and deactivate the trigger points
- Rx 5 treatments and re-evaluation
- Rx spinal exercises to improve posture
Discussion
This case presents an interesting clinical challenge that requires additional evaluation time on the initial visit. The patient’s past history of AIS and WAD, plus the anatomical leg-length inequality, complicates the management plan. Without the insertion of the heel lift, it would be reasonable to expect frequent recurrent episodes of neck pain and stiffness.
Due to the scoliosis and degeneration of the spinal joints, it is reasonable to prescribe spinal exercises and the heel lift to complement the conservative chiropractic care.
Quiz Time
- A left thoracic spinal curve with pain substantiates the need for an MRI. True or False
- Adam’s forward bending demonstrated a posterior right rib hump, which indicates a functional scoliosis. True or False
Answers: 1. True. 2. False – the right dorsal rib hump indicates a structural scoliosis.
References
- Dobbs MB, Weinstein SL. Infantile and juvenile scoliosis. Orthop Clin North Am, 1999;30:331-41.
- Oestreich AE, Young LW, Young Poussaint T. Scoliosis circa 2000: radiologic imaging perspective. Diagnosis and pretreatment evaluation. Skeletal Radiol, 1998;27:591-605.
