Date: Mon, 11 Nov 1996 00:34:06 +0100 From: "Dr. Thomas V. Giordano" Subject: CASE REPORT - Syringomyelia Dear Fellow Listers, Please excuse my absence over the last several months; I've been quite busy, both at the office and on a personal genealogy research. Both endeavors have been quite satisfying, but left me with little time to devote to further case histories of some of the more interesting clinical experiences I've encountered. This case deals with the chiropractic treatment of an anesthesiologist, who was referred to my care by a neurosurgeon for an acute phase lumbosacralgia. An interesting, long-standing cervical syringomyelia was treated concommitantly, with very satisfying results. The patient has had no major complaints in over 6 months from his release from care. A follow-up MRI of the cervical spine is still pending, but deemed superfluous by the neurosurgeon. ANAMNESIS On Friday, the 15th of March, 1996, Dr. Carmelo C., a married 42 year old, was accompanied (possibly forcibly!?!) to my chiropractic office by Dr. Antonio Montinaro, a local neurosurgeon. Dr. Carmelo, specialized in both orthopaedic surgery and anesthesiology, was suffering from an acute phase lumbosacralgia. He reported that he had a chronic, intermitent central lumbalgia with no sciatic radiations for at least 8 years. An underlying, chronic, gastroduodenitis prevented the use of NSAIDS. Although Dr. Montinaro suggested to his colleague to seek chiropractic care, PT (US, TENS and axial mechanical traction) was attempted for two weeks with a progressive increase in the subjective complaint, as Dr. Carmelo was admittedly ignorant of and unsure about chiropractic. The non-surgical nature of the case was verified by Dr. Montinaro prior to their consultation with me. An added complication, was a 7-year (minimum)*, MRI-confirmed, syringomyelia extending from C1 to C3. The doctor reported subjective complaints of low-grade cephalgia, unilateral left cervicobrachial paresis and formication and numbness of the left arm and hand (globally manifested). Intermitent exacerbations were followed immediately with MRI studies over the years, but Dr. Montinaro refused to intervene surgically for this complaint - for reasons I'll discuss later in the conclusion of this report. This, however, was not the chief complaint and was reported to me with a certain resignation and acceptance. The low back complaint was of primary concern to both men, as Carmelo was entering his third week of sick leave from his hospital duties as chief anesthesiologist in the neurosurgical division. (* - That is to say, confirmed by MRI 7 years past. The lesion is probably from a much earlier date.) PHYSICAL EXAM (N.B.: The examination was a relatively brief screen and performed in the presence of the referring neurosurgeon.) INSPECTION: Dr. Carmelo presented with an antalgic scoliosis with a severe contracture of the right, lumbar paraspinal musculature. Static postural analysis was not performed due to the severity of the myospasm (this is my habit until the severity of the algic state subsides). The left side of the face was slightly reddened with some lacrimation to the left eye. PALPATION: Myospasms were also palpated along the piriformis muscles bilaterally, as well as both biceps femorii. Pain was elicited upon deep palpation to the SI joint bilaterally and to the L5/S1 interval on the right. Trigger point tenderness was also reported in the left supraspinatus, levator scapula and trapezius ridge. Slight fasciculations were also palpated in the left biceps brachii and left supinator. PERCUSSION: Not Performed. INSTRUMENTATION: Not performed. ROM: Cervical Spine - Flexion: reduced and painful; Extension: normal with limited discomfort; Left Lat. Bending: reduced with limited discomfort; Right Lat. Bending: limited with severe discomfort. Lumbar Spine - Forward Flexion: extremely limited with lancinating pain to the SI Joint; Extension: Limited with minor discomfort; Left Lateral Bending: severely reduced with strong, contralateral pain; Right Lateral Bending: Limited and with slight discomfort. (N.B.: For brevity, precise measurements were not performed, as the patient was being screened for adjustment purposes only.) ORTHOPAEDICS: Lumbar - Lasegue's: + @ 55 deg.; Braggard's: + @ 50 deg. Contralateral Lasegue's: + @ 65 deg.; Contralat. Braggard's: + @ 60 deg.; Patrick's: -/-; Iliac Compression: + ; Ely's test: +/+; Cerivcal - Sotto-Hall's Test: (+/-) ; George's Test: performed with difficulty, but negative; Cervical Distraction: (+/-) on the left, + on the right (but with difficulty); Maximum Cervical Compression: +/+, but the pain provoked was local to the C7/T1 jucntion. NEUROLOGICS: LUMBAR - DTRs: Patellar (L4/L5): present and hyperreflexive bilaterally; Achille's + Medio Plantar (L5/S1): present and hyperreflexive bilaterally. - Muscle Testing: Hip Flexors (L1-L3): 5/5; Dorsiflexors (L4/L5): 5/5; Ext. Hallicus Longus (L5/S1): 5/5. - Pathologics: Babinsky's: -/-; Valsalva's Maneuvre: -; Rhomberg's Test: Negative. - Sensory: Pin prick, vibration, light touch: present and normal in all areas tested. CERVICAL - DTRs: present and normal on the right in all areas; present and slightly hyperreflexive in all areas on the left. - Muscle Testing: Deltoids/Biceps Brachii: 5/4; Wrist Ext.: 5/3; wrist Flex.: 5/4; Finger Flex.: 5/3; Interossei: 5/3. (On Right/On Left) - Pathologics: Hoffman's and Tromner's: Negative bilaterally; Naffziger's Test: Negative. - Sensory: On the right, pin prick, light touch and vibration were readily appreciated; on the left, the 128 hz tuning fork was readily discernable, but the light touch and pin prick was only truely appreciable in the deltoid area (C5), all other areas were practically obliterated. CRANIAL NERVES - the only noteworthy abnormality was a temporal nystagmus of the left eye, Chvostek's was difficult to interpret, but deemed negative. RADIOLOGICS: Lumbosacral Plain Films taken in AP and LL in Clinostasis. The films were not dated nor were they accompanied with a report, but were reported to have been shot in the radiology department of the hospital on March 2, 1996. AP: Evidenced a left convex, non-rotatory scoliosis. The SI joints showed signs of exostosis at the inferior aspects bilaterally. The lower lumbar SPs were irregular and suggestive of Bastrup's in orthostatsis. The Psoas Major shadows were readilly apparent. Zygopophyseal remodelling was apparent. There were no signs of fracture, gross pathology, anomaly or dislocation. LL: Osteophytosis of the anterior margins of the vertebral bodies was noted at L3/L4 and L4/L5 and at the inferior aspect of L5. Loss of L4 and L5 disc spacing suggestive of degenerative discopathy was also noted. The zygopophyseal joints were widely spaced, suggestive of inflammation of the joint capsules at L4/L5 and L5/S1. No other signs of anomaly, dislocation, fracture, listhesis or gross pathology was noted. A MRI of the brain and cervical spine without contrast medium, dated February 24, 1996, was also presented. Dr. Montinaro and I evaluated the images together. They clearly revealed the presence of an Arnold-Chiari Malformation and the presence of a centrally-located, cystic formation (syrinx) in the cord begining at C1 and descending down to the level of the inferior aspect of C3. There were no signs of apendymoma or any other tumoral formation present. The fourth ventrical showed a slight enlargement, but was reported to me to be unaltered from previous investigations. Some effusion into the arachnoid membrane space was also noted at the C1/C2 level. Dr. Montinaro (also a neuroradiologist), interpreted the images as that of a communicating syringomyelia secondary to the Arnold-Chiari Malformation, which partially compromised the CSF flow from the ventricles. From the above findings, we concurred that the lumbosacralgia was due to a sacroilitis and not directly related to the syringomyelia. I proceded to prepare Dr. Carmelo for the lumbosacral adjustment. Prior to the adjustment, the doctor was placed of a spinolator for 12 minutes. The listings palpated on the adjustment table were recorded as a PIL Sacrum, an AS Right Ilium, an L5:PRS-M and an L1:PLI. The side-posture technique was employed. The immediate reaction was a reduction of the antalgic posture and a moderate reduction in pain. We decided upon a treatment plan to commence the next day, even though it was my day off. TREATMENT COURSE: On Saturday, the 16th, Dr. Carmelo came to the office and reported that the pain had been considerably reduced since the previous day. His antalgic posture had returned slightly, but he rated the discomfort at about 20% of what it was. Only the PIL sacrum and the AS Right Ilium were adjusted. The antalgic posture was again reduced. On Monday, the 18th, the doctor presented and was no longer in antalgic posture. The pain was still as it was on Saturday, but he reported that he had gone to the shore to "breathe some fresh air" on Sunday, and may have overdone it a bit. A brief Static postural analysis was performed. The results were as follows: Pes Cavus (Grade II) in pronation (bilaterally); Genu Valgum on the right; apparent left leg dismetria; PI Left Ilium; AS Right Ilium; Left convex lumbar scoliosis/right convex dorsal compensation (intersection at T12); Left convex cervical deviation with a high left shoulder. Adam's Test was Positive, implying a functional scoliosis secondary to the heterometry of the lower extremities and pelvic obliquity. A podometric study was performed to qantify the pedal deformity and a 5mm Heel lift was provided for the left leg dimetria as a temporary measure. Dr. Carmelo was again adjusted in the lumbosacral area. At his request, he asked if he might also benefit from cervical adjustments for the other complaints. I related to him that I would only attempt a supine cervical adjustment of the lower vertebrae first, to see how he'd respond. The listings found on palpation were recorded as - C1: ASRA; C2: CPBR; C6: PL; C7: PL. C6 and C7 were adjusted. On Wendesday, the 20th, Dr. Carmelo returned to the office and reported the L/S complaint had gone into complete remission. He also reported a slight improvement in the cervicobrachial complaint and was eager to attempt an upper cervical adjustment. On this visit, only C1 and C2 were addressed. (Nota bene: Seated rotary breaks were NOT EMPLOYED at ANY TIME in this case.) The doctor rose from the table with a slight vertigo. This sensation subsided in a few moments. On Friday, the 22nd, a very enthusiastic Dr. Carmelo reported to the office to report that his cervicobrachial complaint had all but disappeared. The only remaining effect was a slight numbness to the superficial radial nerve distribution on the left. His cephalgia was gone for the last day and a half and he felt the sensation pain upon pinching his left hypothenar and fingertips. He also reported an increase in grip strength. His plantar orthotics (semi-rigid and corrected for the left leg dismetria) were given and another adjustment to the upper cervicals was performed. Dr. Carmelo returned to work on the following Tuesday. That afternoon, Dr. Montinaro called to thank me for the handeling of his colleague's case. Carmelo's reaction to the cervical adjustments were the topic of discussion among the neurosurgeons that day; one after the other ran a cursory physical examination on the doctor and were delighted with the results. The consensus among them was that the upper cervical manipulations had effectively reduced the CSF pressure at or below the Arnold-Chiari malformation, and was responsible for the attenuation of the symptoms. I suggested a follow-up MRI to verify this hypothesis, but Dr. Montinaro deemed it unnecessary for now. Carmelo came back to the office on the following Friday. He was quite satisfied with the results of his treatment. The upper cervicals were again adjusted and he was checked for any imbalances in the hips. He reported no difficulty adapting to the orthotics. He was dismissed from care, but told to report in two months for another podometric study (which he did) or if there were any changes in his physical state. I met Carmelo at the shopping center last week. He told me that he experienced a slight cephalgia three times in the last six months, but each time it lasted less that two hours. CONCLUSION: In this particular case of Communicating Syringomyelia secondary to an Arnold-Chiari Malformation, non-rotory, supine chiropractic cervical adjustments prooved of benefit in the reduction of associated signs and symptoms. The neurosurgeon's option for syringotomy was not considered justified due to the lack of gross neurologic deficit or pathologic reflexes (Babinsky's, Hoffman's and Tromner's Negative). Although there was evidence of dissociated sensation (loss of pain and maintained vibration sense) in the upper left extremity, no upper motor neurone effects in the lower extremities were noted. Due to the lack of effective medical treatment and unproven surgical protocols in these cases, chiropractic adjustment (or osteopathic manipulation) should be investigated as a viable approach to selected patients afflicted with communicating syringomeylia unrelated to neoplasm. Due to the length of this post, I'd like to discuss syringomyelia - its' causes and its' effects (and why) - in another post; possibly after comments or questions from my colleagues. I'd also like to know if anyone else has had a similar experience with syringomyelia of the cervical spine. Thank you all for you time and consideration. Ciao da Lecce, Tom Giordano Dr. Thomas V. Giordano via Taranto 58/A 73100 LECCE (LE) Italia ******************************** Date: Thu, 14 Nov 1996 03:12:59 +0100 From: "Dr. Thomas V. Giordano" Subject: Syringomyelia - Addendum Dear Fellow Listers, Thank you all for the responses. Firstly, I'd like to summerize briefly, as an addition to the original Case Report, and answer some of the questions which were posted back to me. Syringomyelia is a relatively rare disorder, generally appearing in young adults and probably developmental in origin. It is defined as a fluid-filled neuroglial cavity - syrinx - within the substance of the spinal cord or brainstem.(1) "The Merck Manual" suggests that about 50% of these cases are congenital and the other 50% arise secondary to intramedulary tumor or trauma. To answer Dr. Morgan, the congential forms are often associated with the Arnold-Chiari Malformation or other neurologic defects, such as encephalocele or myelomenigocele. Also, about 30% of all spinal tumors present with a syrinx.(2) Alterations in the cord are usually confined to the cervical area, but may extend cephalad into the medulla, reported as a 'syringobulbia'. Macroscopic examination reveals swelling and thickening of the meninges at the site of involvement. The syrinx is defined as a cyst and has no connection to the central canal and no ependymal lining.(3) The formation suggests that the gliosis precedes the cavitation. According to Dr. Montinaro, who has had much experience with these cases, at times, the effusion into the arachnoid membrane spaces actually forms a ring around the cord and gradually constricts it, but the major problems arise because of the central location of the SOL. The fibers of pain and temperature which cross the cord and pass up the lateral spinothalamic tract are interupted, as well the fibers of touch of the anterior spinothalamic tract, but the posterior columns transducing light touch and vibration sense are unaffected - resulting in a 'dissociated' sensory loss in the early stages of the condition. As the cyst becomes larger, pressure on the long tracts, such as the pyramidal tract demonstrate signs of upper motor neurone lesions in the lower extremities. The anterior horn cells also become involved in the affectd segmental levels and produce lower motor neurone lesions in the upper extremities.(4) Over the course of many years, the progressive neurologic deficit and disability ensue. The anesthesia predisposes these unfortunate people with trophic ulceration of the hands and neuropathic arthropathy. No specific therapy has proved of benefit in these cases. Radiation has been employed with doubtful results, only in association with intramedulary tumor. Dr. Montinaro either employs posterior fossa decompression; basically, the removal of the posterior rim of the foramen magnum and the posterior arches of C1 and C2. Another choice is syringotomy - that is, the surgical drainage of the syrinx. In any case, no really effective treatment has been demonstrated. To answer Wendy; briefly, its only one case! I would only consider a publication of this type if it were more than anecdotal in nature. I would love to see a study done and published by a joint effort of Neurosurgeons and DCs, with confirmatory, follow-up MRI studies to quantify changes, if any. Another point is, it can be argued that the remarkable findings do not necessarily support the chiropractic tenet, as it was a medical subluxation that was reduced using a chiropractic technique! Not to get into semantics about VS, VSC or subluxation in medical terms, this may be a viable modality to treat a medically defined condition, not our VS. (Please forgive me! :-( ) No soft tissue work was employed, other than a spinolator and moist heat to prepare for the adjustments. Virgil Seutter posted the following observation: "...I have noted your methods of treatment with some curiosity. You always seem to start with the low back, and then venture into the cervical region, and with specific, limited intervention, always waiting for some time lapse before attempting another intervention. You also seem to address the feet in terms of orthotic support (I remember Valentina's case). This seems to be typical in spinal disease patterns." Yes, this is my pattern in treatment. My particular view is very basic and simple. My 'battlecry' is simply that structure governs function. I view the spine as part of a larger kinetic chain, dependent the relationship between the interface at gravity (feet), the fulcrum (pelvii) and the ultimate effects upon the column and terminus (head). The first question to ask is ,"why does the VS exist?" When one imagines the myriad of effects upon the human frame in movement, it is essential to attain balance. My attempt is to limit the number of office visits as much as possible by breaking the predisposing patterns leading to the subluxations. This in no way discounts the importance of adjustment, just reduces the number necessary to get a desired effect. Any method can be as valid, but it has been my experiencethat this approach is valid. You raise an interesting point, however, about attaining similar results with differing approaches. I live in Italy, all roads lead to Rome:-). Perhaps the idea of non-linear systems is as valid as you've hypothesized! (If anyone wants to discuss the importance of the ground effect of the feet in deambulation on spinal biomechanics, it would be an interesting discourse! I'd have much to add to it, as I've been activly involved with a few lymphoflebologists who are studying my protocols on shared patients.) I'd like to openly thank Drs. Guebert, Deutsch, Miller, Morgan, Stockwell, Cockburn, and Green for their kind words and assessments, as well as Joe Ierano - a colleague in the making! I'll be happy to clarify, or amplify anything I've posted here. Please post to the list for all to consider. Distinti Saluti da Lecce, Dr. Thomas V. Giordano via Taranto 58/A 73100 LECCE (LE) Italia References: (1) "The Merck Manual of Diagnosis and Therapy", 16th Edition; Merck Research Laboratories; Rahway, NJ, 1992; pg. 1506. (2) Idem (3) "Lecture Notes on Pathology"; Thompson, A.D. and Cotton, R.E.; Blackwell Scientific Publications, 3rd. Edition; Alden Press, Oxford UK, 1983; pgs. 615-616. (4) "Merritts Textbook of Neurology"; 8th Edition; Lea and Febiger, Philadelphia, PA, 1989; pgs. 687-690. *************************** From: Croesus107@aol.com Date: Sun, 17 Nov 1996 08:49:08 -0500 Subject: A-C type 1 malformation In a message dated 96-11-16 08:48:26 EST, LB Weitz writes: << I believe that a case can be made for Chiari I with or without syringomelia being a contraindication for upper cervical manipulation, especially involving rotation or extension. What do others on the list think? >> I had a recent whiplash case with multiple vestibular S/S and numbness UE and LE but no solid neuro exam findings. He had spreading of C1 greater than normal on cervical flexion but no A-P slippage. Adjusted C1 rotationally once while waiting for MRI, which showed an A-C type 1. He had horrible dizziness, nausea, and headache. I went on to switch to Activator only, but while I was at a seminar, the substitute DC overlooked the alert note on the patient's folder and manipulated rotationally, again with (fortunately <48 hour duration) exacerbation. I would be interested to know whether there is commonly mild atlantoaxial and atlantoocciptial instability with A-C type 1, or whether this can be attributed to the MVA. The neurologist I referred him to thinks the latter,and that his greater than normal CNS S/S can be attributed to the A-C malformation combined with an upper cervical sprain. Anyone with similar cases? Peri Dwyer, D.C. ************************ From: DACBR131@aol.com Date: Tue, 12 Nov 1996 08:12:25 -0500 Subject: Re: CASE REPORT - Syringomyelia In a message dated 96-11-11 10:24:00 EST, lmorgan@primenet.com (Lon Morgan, DC) writes: << does anyone know if the incidence of syringomyelia is increased in Arnold-chiari syndrome, or whether there is any association between the two conditions? >> Yes, about 20% of patients with syrinx have Arnold Chiari malformation. Check my chapter on anomalies and variants in Yochum & Rowe for more info. Whenever MRI demonstrates a syrinx, always check the foramen magnum for the herniation of the cerebellar tonsils. Gary M. Guebert, D.C., DACBR *********************