Joel Alcantara, DC, Gregory Plaugher, DC,
Richard E. Thornton, DC, Chris Salem, DC
This study was funded by Life Chiropractic College West,
Hayward, Calif, Gonstead Clinical Studies Society,
Mount Horeb, Wis, and Palmer College of Chiropractic West,
San Jose, Calif.
OBJECTIVE: The chiropractic care of a patient with vertebral subluxations, neck pain, and cervical radiculopathy after a cervical diskectomy is described.
CLINICAL FEATURES: A 55-year-old man had neck pain and left upper extremity radiculopathy after unsuccessful cervical spine surgery.
STUDY SELECTION: Randomized clinical trials on chronic headache (tension, migraine and cervicogenic) were included in the review if they compared SMT with other interventions or placebo. The trials had to have at least 1 patient-rated outcome measure such as pain severity, frequency, duration, improvement, use of analgesics, disability, or quality of life. Studies were identified through a comprehensive search of MEDLINE (1966-1998) and EMBASE (1974-1998). Additionally, all available data from the Cumulative Index of Nursing and Allied Health Literature, the Chiropractic Research Archives Collection, and the Manual, Alternative, and Natural Therapies Information System were used, as well as material gathered through the citation tracking, and hand searching of non-indexed chiropractic, osteopathic, and manual medicine journals.
INTERVENTION AND OUTCOME: Contact-specific, high-velocity, low-amplitude adjustments (ie, Gonstead technique) were applied to sites of vertebral subluxations. Rehabilitation exercises were also used as adjunct to care. The patient reported a decrease in neck pain and left arm pain after chiropractic intervention. The patient also demonstrated a marked increase in range of motion (ROM) of the left glenohumeral articulation.
CONCLUSION: The chiropractic care of a patient with neck pain and left upper extremity radiculopathy after cervical diskectomy is presented. Marked resolution of the patient’s symptoms was obtained concomitant with a reduction in subluxation findings at multiple levels despite the complicating history of an unsuccessful cervical spine surgery. This is the first report in the indexed literature of chiropractic care after an unsuccessful cervical spine surgery.
From the Full-Text Article:
The medical treatment of musculoskeletal neck pain, conservative or surgical, remains largely based on empirical evidence. For example, the efficacy of traction has not been scientifically proven in a randomized controlled clinical trial; however, it is thought to be effective, particularly in the treatment of neck pain and associated radicular symptoms. [7, 8] According to Grob,  70% to 80% of cases of cervical radiculopathy symptoms could be treated by conservative means. These include the use of oral medications, soft collars, cervical traction, and other physical therapy modalities. Patients with associated radiculopathy might also achieve relief of neck pain with the use of corticosteroids. Failure of the above conservative approaches may result in cervical diskectomy and fusion for the patient. As such, spine surgery ranks as one of the most common inpatient surgical procedures in the United States. [10-14] In considering only spinal fusions, there was a 310% increase from 36,000 in 1985 to 111,400 in 1996. In 1996, 48% of the spinal fusions involved the cervical spine, and in 97% of these the indication was because of degenerative changes.  Despite the frequency of spinal fusions, there does not seem to exist a standard outcome tool for measuring clinical success after surgery. Using the status of the arthrodesis as an outcome assessment is of great controversy among surgeons, particularly when this measure of outcome does not necessarily correlate with clinical measures of success. [16, 17] Reliable outcome measures remain to be developed, and the effects of fusion on any functional spinal unit continue to be studied.  One of the supporting ideas behind this intervention is that the achievement of fusion results in the prevention of spondylotic spurs, the offending entity, whereas existing spurs regress because of the stability of the fused segments. However, degenerative joint disease, as evidenced on radiographic studies, has been found within the fused spinal segments. In addition, the segments above and, to a lesser extent, in the segments below also demonstrate degenerative joint changes. [19-22]
A recent descriptive paper by Klein et al  examined the health outcomes of 28 patients before and after cervical diskectomy and fusion for radiculopathy. They concluded that this procedure may improve a patient’s self-reported health assessment, especially for pain and physical function. Other studies also report positive outcomes from similar surgical intervention.  However, cervical spine surgery in general may lead to such complications as bone graft failure, cerebrospinal fluid leak, recurrent laryngeal nerve injury, nerve root injury, quadriplegia, and death.  For the patient presented in this case report, based on Odom’s criteria, the surgical outcome can be described as poor.  The patient’s signs and symptoms remained unchanged after surgery and eventually worsened.
This is the first description in the indexed literature of the chiropractic care of a patient with vertebral and sacroiliac subluxations with a history of unsuccessful cervical diskectomy of the cervical spine. In our experience, allopathic practitioners usually do not offer patients the option of chiropractic care before surgery. Perhaps more rarely is chiropractic care considered a viable option in instances of unsuccessful surgical care.
Since chiropractic’s inception, chiropractors have for the most part performed their clinical activities based on the detection and removal of a patient’s vertebral subluxations.  Subluxation is defined as a partial dislocation, a sprain.  Historically, chiropractors have described kinesiologic, neurologic, and histologic manifestations of this injury. The term vertebral subluxation complex (VSC) is used to highlight the diverse tissues that are involved and the impact of the lesion on the individual’s ability to maintain homeostasis. Several mechanisms and models have since been proposed [24,29-31] reflective of the state of knowledge encompassing the biopsychosocial sciences. For the purpose of this writing, mechanical and neurologic components of subluxation will provide the theoretical framework from which we will discuss this case.
The patient consulted one of us for chiropractic care approximately 3 years after surgical diskectomy. From a biomechanical point of view, the cervical spine of this patient had been compromised. Schulte et al  studied the kinematics of the cervical spine after diskectomy and stabilization and found that there were significant reductions in mobility at fused segments. Motion palpation of the patient’s neck exhibited decreased left lateral flexion and decreased spinous process rotation at the C5 vertebral level in addition to the fused segments at C6-7. Early studies have demonstrated a decrease in motion at the fused segments with concomitant increase in motion segments above or below the site(s) of cervical fusion.  This abnormal pattern of movement (ie, hypomobility) at one or several functional spinal units (including global and intersegmental malposition) is referred to as kinesiopathology. A possible consequence of this may be an increased rate of degenerative changes. [19-21] As previously described, degenerative joint disease was visible on the radiographs in the segments above the cervical fusion; particularly with the presence of anterior osteophytes, which are more frequent in anterior cervical fusions.  In addition to compromising activities of daily living and contributing to the persistence of pain, the presence of a cervical kyphosis after anterior cervical diskectomy/ fusion is correlated with a less successful outcome.  This patient had a mild cervical kyphosis, most apparent in the mid to lower cervical spine. This is associated with anterior carriage of a patient’s head, which may lead to further compromise of osseous and soft tissue structures.
The neuropathologic component of the VSC involves nerve root compression/irritation interfering with normal nerve root function resulting in pain or other clinical pathologies. The oblique views clearly demonstrated a decrease in diameter at the C5-C6 left intervertebral foramen (see Fig 1). Compressive radiculopathies are the result of pressure on the spinal nerve roots caused by protrusion of the intervertebral disk; retrolisthesis or Y-axis rotation of the segment; spondylotic spurring of the vertebral body, the uncovertebral joints, or the facet joints; or combinations thereof. For example, at the most medial aspect of the nerve root, osteophytic projections from the lateral aspects of the vertebral body end plates can compress the nerve root without resulting in clinical evidence of spinal cord compression. The patient discussed in this case report did not have spinal cord compression.
Mechanical compression combined with chemical mediators of inflammation likely produced the neck pain and radiculopathy experienced by the patient. Of interest in this case report is the immediate relief of neck pain and radiculopathy and the improved shoulder range of motion after adjustments at the sites of vertebral subluxations. The comparative radiographs (Fig 4) showed only minimal improvements in the patient’s posture, most notably in the upper cervical spine. A comparative oblique radiograph was not obtained on this patient. In our opinion, the intervertebral foramen (IVF) would not likely have demonstrated an increased diameter of the structure given the amount of retrolisthesis at C5 on the comparative lateral radiographs. Radiographs may not be sensitive to small changes in IVF size or changes in the patient’s outcome as a reflection of the changes in the IVF.
It is important to remember that functional characterisitics of nerve root compression are dependent, not only on the patency of the IVF, but also on the presence or absence of inflammatory products such as edema, interneural edema, and connective tissue fibrosis/scarring. The fact that the nerve root must telescope within the IVF during neck and arm movements may play a role in its susceptibility to compression. If nerve root adhesions are present, this may increase susceptibility. Theoretically, an adjustment could alter the mobility of an individual motion segment, the mobility of the nerve root within the IVF, or both. This may provide a possible explanation as to why functional improvements in the patient were obtained despite minimal changes to IVF architecture. The patient’s cervical curve became mildly more lordotic in the upper portions of the neck. It is well recognized that alterations in cervical lordosis can alter the function and/or circulation of the spinal cord and nerve roots.  We acknowledge the speculative nature of what putatively happened to this patient from a histologic standpoint. There is a considerable body of literature that demonstrates that patients who undergo spinal adjustments experience relief of pain. According to Vernon,  hypoalgesia may possibly be achieved through central facilitation from the stimulation of spinal structures through a spinal adjustment. This may result in changes of cutaneous and muscular pain thresholds and the release of endorphins.
In a pilot study, Cassidy et al  examined the effects of spinal manipulation on pain and range of motion in the cervical spine. They found a significant relationship between a decrease in pain and an increase in cervical range of motion. In a further study, Cassidy et al  found that both mobilization and manipulation increased range of motion; however, manipulation was more effective in decreasing pain. Hurwitz et al  performed a systematic review of the literature on manipulation and mobilization of the cervical spine and found that manipulation and mobilization provided short-term benefits for some patients with neck pain and headaches. The improvement in the patient’s shoulder range of motion may be attributed to the reduction of the components of subluxations in the cervical spine, because the glenohumeral articulation did not receive an adjustment. The mechanism by which this occurred remains to be elucidated.
Concomitantly, the patient’s complaints of myopathology (muscle weakness and atrophy) were also alleviated. This could be attributed generally to positive changes in nervous system function associated with removal of subluxations. In addition to spinal adjusting to sites of subluxations, the patient was provided with arm exercises to increase his shoulder range of motion, muscle strength, and muscle hypertrophy. These adjunctive procedures played an important role in ameliorating the muscle weakness and atrophy. Many clinicians support the use of ancillary therapies to improve the effect of the adjustment; however, scientific evidence of any putative effect is lacking. 
We presented the chiropractic care of a patient with neck pain and cervical radiculopathy after an unsuccessful surgical diskectomy. This unusual case may challenge the conventional allopathic clinical care pathways, as well as opinions within some chiropractic circles about the appropriateness of chiropractic care of patients with cervical radiculopathy or unsuccessful cervical surgery.