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Category: Case Studies

Date	13-may-2008
Case Title	Chiropractic Management Adult Male-Lumbosacralgia and Long-Standing Syringomyelia Arnold-Chiari
Author	Thomas V. Giordano, D.C.
Main Condition/ Disease	Arnold-Chiari Malformation
Source	Thomas V. Giordano, D.C.
Abstract	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 concomitantly, 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.
Summary	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 M., a local neurosurgeon. Dr. Carmelo, specialized in both orthopedic surgery and anesthesiology, was suffering from an acute phase lumbosacralgia. He reported that he had a chronic, intermittent central lumbalgia with no sciatic radiation for at least 8 years. An underlying, chronic, gastroduodenitis prevented the use of NSAIDS. Although Dr. M. 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. M. 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). Intermittent exacerbations were followed immediately with MRI studies over the years, but Dr. M. 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: +/+; Cervical - 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 junction. NEUROLOGICS: LUMBAR - DTRs: Patellar (L4/L5): present and hyperreflexive bilaterally; Achilles' + 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 Maneuver: -; 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 discernible, but the light touch and pin prick was only truly 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 Baastrup's in orthostatsis. The Psoas Major shadows were readily apparent. Zygopophyseal remodeling 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. M. 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 beginning at C1 and descending down to the level of the inferior aspect of C3. There were no signs of ependymoma or any other tumor formation present. The fourth ventricle 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. M. (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 proceeded to prepare Dr. Carmelo for the lumbosacral adjustment. Prior to the adjustment, the doctor was placed on intersegmental traction 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 quantify the pedal deformity and a 5mm Heel lift was provided for the left leg dismetria 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 Wednesday, 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 provided and another adjustment to the upper cervicals was performed. Dr. Carmelo returned to work on the following Tuesday. That afternoon, Dr. M. called to thank me for the handling 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 were responsible for the attenuation of the symptoms. I suggested a follow-up MRI to verify this hypothesis, but Dr. M. deemed it unnecessary for the time being. 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. DISCUSSION: 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 congenital 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. M., 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 interrupted, 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 affected 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, in association with intramedullary tumor. Dr. M. either employs posterior fossa decompression; basically, the removal of the posterior rim of the foramen magnum and the posterior arches of C1 and C2, or a syringotomy - that is, the surgical drainage of the syrinx. In any case, no really effective treatment has been demonstrated. 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. No soft tissue work was employed, other than intersegmental traction and moist heat to prepare for the adjustments. CONCLUSION: In this particular case of Communicating Syringomyelia secondary to an Arnold-Chiari Malformation, non-rotary, supine chiropractic cervical adjustments proved 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 unproved surgical protocols in these cases, chiropractic adjustment (or osteopathic manipulation) should be investigated as a viable approach to selected patients afflicted with communicating syringomyelia unrelated to neoplasm. I'd like to openly thank Drs. Guebert, Deutsch, Miller, Morgan, Seutter, Stockwell, Cockburn, and Green for their kind words and assessments, as well as Joe Ierano www.chiropracticierano.com.au - a colleague in the making!
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.

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