Conservative Treatment of a Patient With Syringomyelia Using Chiropractic Biophysics Protocols

Case Report 

The patient, a 41-year-old, 210-pound, 5-foot 10-inch man, had cluster headaches, neck pain, thoracic pain, back pain, arm/hand numbness, and knee pain. He had fallen on his head, neck, and upper back in a construction accident 9 years before presentation to the chiropractic clinic. Previously, he had been treated by several physicians, including physicians at the Mayo Clinic in Bethesda, Md. He presented to the Life Chiropractic College West where his care was rendered. His chief complaint was cluster headaches, which he reported the feeling of his jaw, teeth, and side of his head “exploding.” The headaches were described as debilitating and the medications he was taking were stated to have little effect. Immediately after his fall, he was diagnosed by MRI with a trauma-induced syrinx in his cervical spinal cord and was hospitalized for decompression surgery of his occiput and atlas. Fig 1 shows the MRI of the patient's cervical spine where a syrinx is noted at the area of C2/3-C3/4.

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Fig 1. This figure shows the pretreatment MRI. The syrinx is visualized at the C2/3-C3/4 levels by the increased signal intensity. The MRI was taken in the supine position with no head elevation.

A suboccipital foraminotomy was performed and was described as originally successful, but the syrinx development was not halted and an insidious progression of symptoms ensued. After his traumatic fall and before his chiropractic treatment, he reported previous bilateral carpal tunnel decompression surgeries, knee surgery, and an L5 partial laminectomy with partial discectomy. At the time of his visit to the chiropractic college clinic, he was taking medications including Amitrex, Cyclobazabar, Oxycontin, Prilosec, Celebrex, Vicodin, and Neurontin.

The patient reported a large intake of caffeine and smoked cigarettes. On a pain severity scale, the patient rated the intensity of his pain as 8 to 9 out of 10. His physical examination showed several positive orthopedic and neurologic tests including Romberg's, Trendelenberg's, Valsalva's, and Kemp's on the right with radiation down the right leg into the right foot. He had bilateral loss of sharp/vibration sensations paradoxically in his upper right and lower left extremities. He had multiple weak muscles and positive thoracic outlet syndrome tests on his right side. Palpation revealed tenderness, edema, and multiple thoracic muscles showing splinting/spasm.

A visual postural evaluation was performed. The posture of the head, thorax, and pelvis were categorized into their respective rotation (R) and translation (T) displacements in 3D. Using a right-handed Cartesian coordinate system where the x-axis is positive to the left, the y-axis is positive superiorly, and the z-axis is positive anteriorly, there are 6 rotations and 6 translations of the head, thorax, and pelvis, respectively, in 3D.14, 15, 16 The patient's posture showed the following: (1) anterior head translation (+TzH); (2) posterior thoracic translation (−TzT); (3) anterior pelvic translation (+TzP); (4) pelvic rotation posterior on the left (+RyP); and (5) lateral translation of his head to the right (−TxH).

Radiographs were measured according to Chiropractic Biophysics (CBP) protocols using the Harrison posterior tangent method for assessing segmental angles and global angles of curvature.17, 18, 19 His lateral cervical radiograph showed a midcervical kyphosis (C3-C6 of +7°) and an absolute rotation angle (ARA) from C2-C7 of −10° lordosis. Using the horizontal distance of the posterior superior body corner of C2 relative to a vertical line originating at the posterior inferior of C7, 38 mm of anterior head carriage was measured (Fig 2A and Table 1).

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Fig 2. A, The patient's pretreatment neutral lateral cervical radiograph. The ARA from C2-C7 is −10°, there is a midcervical reversal (C3-C6) of +7° and +38 mm of forward head carriage (TzH). B, The posttreatment radiograph shows dramatic correction. The ARA from C2-C7 is now −30°, the midcervical curve is lordotic, and the TzH has been reduced to +15 mm.

Table 1. Before, after 26 in-office treatments, and 1-year follow-up x-ray alignment data

	Lateral cervical alignments	Pretreatment radiograph	Posttreatment radiograph	1-Year follow-up radiograph
	C1-horizontal	0°	−14°	−15°
	C2-C3 RRA	−2°	−6°	−6°
	C3-C4 RRA	+2°	−5°	−5°
	C4-C5 RRA	+2°	−2°	−2°
	C5-C6 RRA	+2°	−6°	−6°
	C6-C7 RRA	−14°	−11°	−11°
	Maximum kyphosis C3-C6	+7°	−13°	−13°
	C2-C7 ARA	−10°	−30°	−30°
	TzH (mm)	+38	+15	+3

Negative values indicate extension for angles. All angles are drawn with the Harrison posterior tangent method. Relative rotation angle (RRA), absolute rotation angle (ARA), and translation of the posterior superior body corner of C2 relative to a vertical line originating at the inferior body corner of C7 (TzH).

Chiropractic Treatment and Intervention 

During his first visit, the patient was briefed on his condition and the possibility of little or no long-term resolution of his symptoms. He agreed to a protocol14, 15, 16, 20, 21, 22 including CBP Mirror Image drop table adjustments, Mirror Image exercises, Mirror Image cervical extension compression 2-way traction, and Meyers translation traction. In addition, changes in his lifestyle were recommended including caffeine reduction and smoking cessation. The patient informed us that he was only staying in the area for a 3- to 4-week interval. Because of this, a high-frequency rehabilitative program was recommended.

For the Mirror Image drop table adjustments, 4 setups were used on each visit. Prone and supine full-spine sagittal plane adjustments were administered to the patient with the intention to reduce the anterior pelvic, posterior thoracic, and anterior head translations (Fig 3A and B). A left lateral head translation adjustment was administered to the patient with the intention to reduce the right lateral head translation (Fig 3C). A prone adjustment was administered to the patient with the feet rotated to the left with the intention to reduce the left posterior pelvic rotation (Fig 3D). The patient's Mirror Image exercise consisted of a full-spine sagittal plane exercise performed in the standing position where the patient retracted and extended the head, anteriorly translated the thorax, and posteriorly translated the pelvis. The patient was instructed to perform 100 to 200 repetitions of this exercise daily holding the position for 5 to 10 seconds (Fig 4).

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Fig 3. Mirror Image drop table adjustments. A, The patient is prone with the pelvis posterior to the feet, the thorax anterior to the pelvis, and the head posterior to the thorax. The thrust is delivered to the thoracolumbar region in this case but can be delivered to the upper dorsal region too. B, The patient is supine with the head posterior to the thorax, the thorax anterior to the pelvis, and the pelvis posterior to the feet. The hands are on the zygomatic bones and the thrust is delivered to direct the head posterior. C, The patient is lying left side down with the head translated to the left. Before the thrust, the physician loads the lower neck and skull further into left lateral translation. D, The patient is prone with the feet turned to the side of posterior pelvic rotation. The thrust is delivered into each acetabular region. Reprinted with permission from Harrison CBP Seminars, Inc, Evanston, Wyo.

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Fig 4. Mirror Image exercise. A full spine sagittal plane exercise was performed in the standing position where the patient retracted and extended the head (due to loss of lordosis), anteriorly translated the thorax with a block, and posteriorly translated the pelvis compared with the feet. The patient was instructed to perform 100 to 200 repetitions daily holding the position for 5 to 10 seconds. Reprinted with permission from Harrison CBP Seminars, Inc.

In-office Mirror Image traction consisted of 2-way compression extension traction22 with a weight ratio of 10:5 lb with the 10 lb pulling from the front and the 5 lb pulling from the rear. The angle of front pull was 10° to 15° from the horizontal and directed at the midcervical spine. Initially, traction was applied for 3 minutes and progressed to 20 minutes per session as patient tolerance allowed. Over consecutive visits, the weight was increased per patient tolerance, where after 25 visits, the weight had increased to 25:18 lb for 20 minutes with the same arrangement as before (Fig 5A). At home, the patient was instructed to use the Meyers translation traction collar for 10 to 20 minutes per day in the sitting or upright posture. This collar induces posterior head translation and slight head extension over a fulcrum at midneck (Fig 5B).

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Fig 5. Mirror Image traction. A, Two-way compression extension traction with a front to back weight ratio of 10:5 lb. The angle of front pull was 10° to 15° from the horizontal and directed at the midcervical spine. Initially, traction was applied for 3 minutes and progressed to 20 minutes per session as the patient tolerance allowed. Over consecutive visits, the weight was increased per patient tolerance to 25:18 lb for 20 minutes. B, The Meyers translation traction collar was used at home for 10 to 20 minutes per day in the sitting or upright posture. This collar allows for posterior head translation and slight head extension over a fulcrum at midneck. Reprinted with permission from Harrison CBP Seminars, Inc.

The patient was seen for 26 visits in the clinic over 3 weeks and home care was to be supervised by one of the chiropractic teaching clinic clinicians. The patient was compliant and missed no appointments. Reexamination and posttreatment lateral cervical x-ray were performed after 26 in-office visits and approximately 20 home traction treatments.

Discussion 

Syringomyelia is a rare condition with a poor prognosis for some patients; some individuals never recover function and have unbearable intractable pain and sensations and most die with the disorder. The use of noninvasive conservative rehabilitative care has shown improvements in several other conditions such as acute and chronic back pain, neck pain, and headaches.23, 24, 25 This is the first case to describe the treatment of impairments due to a chronic cervical spine syrinx; the patient's condition remained improved at 1-year follow-up.

After the application of conservative chiropractic care using CBP protocol, exercise, adjustments, and traction, the patient's reported symptoms improved. There was a decrease in positive orthopedic and neurologic tests after treatment. It is hypothesized that the positive improvement may have been due to the visual reduction of abnormal postural positions of the head, thorax, and pelvis and the radiographic documented correction of an S-shaped cervical curve to a near-normal lordotic value.26, 27

Theories have been put forth concerning the pathological course of syringomyelia. The syrinx cavity formation may result from several factors: hematoma, myelomalacia, cell necrosis, or the release of enzymes including protease and lysozyme, which contribute to the further breakdown of tissue integrity.28 Arachnoid adhesions and cord tethering have been discussed in the literature and these adhesions may also play a role in the formation of stresses and strains, which decrease tissue integrity.7 The presence of Arnold-Chiari malformation has also been associated with syrinx formation and the tonsilar invagination of the cerebellar tonsils can explain some of the bizarre and varied symptoms.4, 12, 28, 29 Arnold-Chiari malformation is estimated to be associated with syringomyelia in as many as 40% of cases. It is unknown, however, if the patient discussed here had tonsilar invagination before the trauma.

Breig30, 31 had discussed tension on the central nervous system as a causative factor in spinal cord abnormalities including syrinx formation and progression. Increased spinal cord stress and strain may have an implication for our current case. Other studies have found that spinal cord stress and strain are directly related to the alignment of the cervical spine in the sagittal plane.30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40 In a cadaveric study, Breig and Marions32 showed that slight cervical extension from the neutral position reduced tensile strain in the spinal cord. Conversely, with cadavers in a neutral cervical spine and head posture, there was an increase in tension as far down as the cauda equina. Using MRI of cervical spine flexion and extension, Ishida et al33 found correlations between spinal cord position and adjacent vertebral alignment. Summarily, McCormick and Stein34 stated, “The segmental anatomic arrangement does not allow significant independent movement of the vertebral column relative to the spinal cord.” They further state,34 “Changes in the canal length (strain), therefore, are transmitted to the dura and spinal cord, resulting in generated stress in both structures.”

Specific to syringomyelia, increased stress and strain of the spinal cord tissues from flexed postures of the head and neck have been implicated in the development and progression of the syrinx.35, 36, 37 Mechanically, head and neck flexion of 2 to 3 vertebral levels may increase the tension stress and longitudinal strain on the spinal cord that increases the intramedullary pressure. The elevated pressure from static and dynamic cervical positions can cause accentuation of the cavity and impair oxidative metabolism in the neuron at the cellular level.35, 36, 37, 40 The patient in this report received a decompression surgery to reduce pressure; however, after the surgery, the patient still had a kyphotic cervical curve. Thus, the patient did not have his lordosis restored until the year 2001 after chiropractic care. We hypothesize that the reductions of abnormal postures and correction of the cervical S-shaped curve may have decreased the amount of stress on tissues including the spinal cord21, 22, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40 and thus enabled better function through better structure.

Conclusion 

This case report describes outcomes, including subjective and objective findings, in a 41-year-old patient with syringomyelia after treatment with CBP rehabilitative procedures. The improvement of the cervical lordosis is a possible factor in the patient's improvement. Further studies concerning the effectiveness of postural and structural rehabilitation are needed before conclusions can be made in other syringomyelia cases.