Fw: [CFSgroup] dissection

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Sometimes no matter what we do poop happens, but of course the great thing in chiropractic is that it just doesn't happen often!

[CFSgroup] dissectionFrom another list........ Case report of carotid artery dissection in a chiropractic patient after cervical hyperextension Priest, DC, DABCO drpriest@... This is a case report of a chiropractic patient that suffered a carotid artery dissection postulated to have been secondary to hyperextending her neck while at home. It is hoped that this report will demonstrate the importance of utilizing prudent clinical judgment when a patient presents with unusual symptoms. A 47 year old female presented herself to our facility approximately one week after bumping her head on the underside of a cabinet at home while doing some household cleaning, complaining of occipitofrontal headaches and neck/shoulder girdle pain. Based upon her report of the incident, she apparently rapidly hyperextended her neck as she was moving out from under the overhead cabinet under which she was working when she bumped the vertex of her head on the cabinet with sufficient force to make her cry briefly. She was not rendered unconscious, nor did she subsequently report any difficulties with dizziness, speech abnormalities, radicular symptoms, vomiting or problems with balance or equilibrium. She denied recent fever, chills or unexplained weight loss. Review of systems was noncontributory. She had been a prior patient at our facility for similar complaints, successfully treated with manipulation and various physiotherapeutic modalities. She was last seen in our of! fice 17 months prior to this incident, and had done well in the interim. In the week before her visit with us she had seen her family physician who prescribed medications but did not perform any imaging studies. Her past history was otherwise pertinent only for a whiplash-type injury 16 years earlier, and chronic migraine headaches. At presentation, she was improved significantly from a symptomatic standpoint, but wanted to see if further improvement would be forthcoming with chiropractic treatment because of the excellent results that she had experienced in the past. Pertinent examination findings included minimal cervical and midtrapezius tenderness accompanied by very minimal muscular spasm in these areas. Her gait and stance were normal, without overt limp or antalgic posture. There was no significant residual tenderness noted over the vertex of her skull nor was any swelling noted, but there was slight tenderness in the suboccipital region bilaterally. Active cervical ranging was actually quite normal. No segmental restriction was apparent upon motion-augmented palpation. There were no nerve root tension signs, nor was there any significant increase of her neck pain on gentle axial compression. Motor, sensory and reflex function was intact in the extremities. No cervical bruits were apprecia! ted. No pathologic reflexes were present. Premanipulative screen and Romberg were negative. Her responses during the course of her consultation and examination were consistent and appropriate, without overt evidence of symptom magnification. Prior cervical spine xrays had been normal, and because she had improved, further xray evaluation was not felt to be medically necessary at the time, taking into account her examination findings, and especially since her primary complaint was that of headaches. Informed consent was obtained and treatment was provided in the form of physiotherapeutic modalities to the midtrapezius region, in addition to empiric application of gentle, nonrotary cervical mobilization with the neck in shallow flexion. Treatment was tolerated very well and she was advised to return in one week’s time if she did not continue to improve. Seven days after her visit she called our office stating that although she felt better for a few days after her treatment, her headaches had persisted. She also stated that she was having some symptoms that made her feel like she “was having a stroke” although when asked to explain what she meant, the symptoms she described were those of photo-/phonophobia in association with her headaches. At that juncture, in an overabundance of caution, she was instructed to have her husband take her to the local hospital emergency department, which she did. At the hospital, she was evaluated, given medications for “stress and pain” (by her report), and released without further scheduled followup. After being seen at the hospital, she called our office a second time, asking if we would see her again for further evaluation and treatment. Despite the apparent benign findings in the hospital emergency room which resulted in provision of medicines for “stress and pain”, I felt that more! comprehensive evaluation was indicated so I directed my staff to schedule her for neurologic evaluation, and an appointment was arranged for two days later with an excellent local neurologist. Upon neurologic evaluation, an initial diagnosis of tension headaches, migraine without aura and possible psychologic abnormality was made. However, later that same day the patient called the neurologist’s office and spoke with his nurse, sounding somewhat confused and “almost nonsensical.” The patient was scheduled for a brain MRI study which was accomplished the next day. This study showed findings suggestive of high grade stenosis of the left intracranial carotid artery and left hemispheric findings felt to be possibly consistent with collateralization secondary to the carotid findings which would not be expected in an acute setting. Followup MRA (magetic resonance angiography) was suggested to further characterize these findings. Subsequent cerebral and carotid MRA studies confirmed carotid dissection. The neurologist called the patient as soon as he read the MRA, which was the next morning, and by that time she had experienced at least one episode of transient rig! ht-sided “burning numbness” which resolved quickly. He wanted to admit her immediately to the hospital but she inexplicably declined. She was started on prophylactic anticoagulant therapy on an emergent basis since there was no evidence of intracranial hemorrhage or mass lesion. At the time of this report, some four weeks post-event, the patient is doing remarkably well, without any further symptoms of cerebrovascular compromise. I received a phone call from the neurologist informing me that quick referral had potentially saved the patient’s life, and that it was his opinion that the likely genesis of the evolving episode was the rapid hyperextension of her neck when she bumped her head. She is expected to recover without residual neurologic sequelae, and she will continue neurologic followup and monitoring. DISCUSSION: This is an example of a very unusual case of carotid artery dissection that if not acted upon quickly and appropriately could have resulted in devastating consequences to the patient. Upon reflection and review of the events leading up to this incident, I do not believe that we would change any aspect of our approach to our management and recommendations regarding this patient. Carotid artery dissection is relatively uncommon in and of itself, and causative factors are not well understood. Certainly if a clinician is confronted with a patient with unusual symptoms that just don’t seem to “make sense”, prudence would dictate that further investigation be initiated and a definitive diagnosis obtained before proceeding further. There are times that one simply gets a sense that something is just not as it should be, and in this instance the patient benefited from appropriate action. One suggestion that we could consider relative to manipulation of the cervical ! spine would be to avoid hyperextension, if we want to exercise an overabundance of caution. We hope that this case report is helpful and of interest to you. If you have any questions or comments, feel free to send them to me at drpriest@.... Respectfully submitted, C. Priest, DC, DABCO Board Certified by the American Board of Chiropractic Orthopedists Fellow of the Academy of Chiropractic Orthopedists -- Warren T. Jahn, DC, MPS, FACO Board Certified Chiropractic Orthopedist and Sports Physician Forensic Examiner Roswell GA 30076 770-740-1999 770-619-3203 fax One learns people through the heart, not the eyes or the intellect. - Mark Twain