Diagnosis

723.0 - cervical spine foraminal stenosis

722.6 - cervical spine disc space narrowing

737.0 – hypolordosis

739.1 – intersegmental dysfunction of the cervical spine

Treatment Recommendations

According to the North American Spine Society that modalities such as physical therapy, traction and injections should be considered when no improvement relative to the natural history of cervical radiculopathy has been demonstrated. Mr. X did not seek any care for his cervical spine symptoms in over 6 years. The symptoms progressively got worse and his neurosurgeon recommended a 6 week course of conservative chiropractic care prior to any surgical intervention. Flexion-distraction to the cervical spine was performed. Setting the patient up for a chiropractic adjustment created symptoms down the arm, so this technique was avoided.

Treatment Frequency: Up to 3 times per week for the first 4 weeks as indicated by the severity of involvement and the desired effect, then up to 2 treatments per week for the next 4 weeks with re-evaluation for evidence of functional improvement or need for further workup. Continuance of his treatment will depend upon functional improvement.

Active Care: Cervical axial retraction exercises daily (to patient tolerance). Patient education about proper posture was provided. There is some evidence to support the continuation of normal daily activities as the recommended treatment for acute and chronic neck injuries without neurologic symptoms. However, this patient is to avoid any work or ADL that requires that power grip strength (i.e. holding a chainsaw).