A 48-year-old electrician presented to my office on 4/6/96. He complained of left arm pain, which was acute in the morning, but would improve during the day. Later in the evening the pain would worsen.
The pain interfered with sleep and activities of daily living. There was no dyspnea, no constitutional symptoms, or other joint pain. There was some left sided neck pain one day prior to presentation. There were no sensory complaints. The patient reported some left elbow weakness associated with pain.
The onset of the arm pain was in December of 1995, perhaps associated with stress, or possibly from carrying a bucket down the hall. That same December the patient had three weeks of chiropractic care, but with little relief.
Subsequently the pain eased up on its own, but worsened under stressful conditions.
Other History
- a motor vehicle accident five years earlier, but did not recall any injuries;
- knocked unconscious at 18, but with no subsequent residuals;
- fractured his left arm as a child;
- injured low back 15 years ago in a fall;
- history of psoriasis.
- quit smoking two weeks prior to presentation.
The patient has no surgical history. Medications used include a topical anti-inflammatory to control his psoriasis, and Advil or Tylenol on an as-needed basis.
Family History
Father deceased in from cancer in the '70s. Patient does not know what type of cancer. Mother is alive.
Examination
Cervical range-of-motion elicited left neck pain, except right and left lateral flexion.
Right and left flexion restricted 30/40 with crepitus, but no pain.
Compression/distraction: negative.
Adam's position: right dorsal convexity.
No motor, reflex, or sensory deficits.
Left internal shoulder rotation painful.
X-ray report from prior chiropractor, 2/12/96: C5,7 degenerative changes.
Diagnosis: Left cervical brachial neuralgia
Recommendations: Diversified chiropractic adjustments, moist heat, therapeutic exercise, and patient education regarding activities of daily living.
Response to Treatment: On 4/16 the patient reported numbness of the left arm and leg after a rotary cervical adjustment performed by a covering chiropractor on 4/8/96.
Patient also reported a drunken gait and dragging of the right foot. Prior cervical adjustments did not elicit this response.
Upon questioning, the patient stated he had a similar episode years ago, was "worked up" by a neurologist and "everything" came back negative. Upon examination, no objective signs were noted. He was "feeling better."
Cervical adjustments were discontinued. Cervical manual traction and soft tissue work were performed.
Response to Treatment: Based on the absence of objective findings for VBAI, spinal tumors, and MS, I suspected a psychogenic etiology. We treated the patient through 5/3/96, and his response ranged from transient significant improvement to right and left arm pain and numbness, more so right-sided now, right chest tingling, and transient staggering gait reported, but not observed.
After nine visits (4/6 to 5/1/96), I referred the patient to a neurologist.
The neurologist performed an MRI performed on 5/13/96 which revealed:
- Moderate focal spinal cord stenosis at C6,7 secondary to large, broad based central HNP.
- C3-7 moderate spondylosis
- C5,6 IVD narrowing
- C3-5 decreased lordosis
- C2-5 fistula
On receiving the MRI report, I called the neurologist. The neurologist having seen the MRI report referred the patient to a neurosurgeon.
However, having not seen the actual MRI, he wants to rule out a spinal cord tumor or demyelinating disease such as MS. He recommended an MRI of the brain and a spinal tap.
Conclusion
The results of any further testing are not available yet. What is important to learn is that a patient who is not responding to care the way you would expect needs to be investigated further.
Although some patients present with symptoms that may appear to be psychogenic based upon your exam and the patient's demeanor, organic disease must be ruled out.
Michael Horney, DC
East Setauket, New York
