Case of the Week 9-24-11: The Fusion that Shouldn't Have Been | Modern Manual Therapy Blog

Case of the Week 9-24-11: The Fusion that Shouldn't Have Been

If I am paraphrasing a great quote from Stanley V. Paris, PhD, PT, it's only because I can't remember the exact one.  "If a patient had surgery in the absence of trauma, either they didn't see a good enough physical therapist, or they didn't see a good enough one long ago." It is our job to prevent surgery if possible. Obviously we can't save everyone, but how can we even try if we're not given the option?

Subjective: Pt is a 55 yo male, OOW, referred by another PT for cervical pain. He is s/p fusion two years ago at C5-6 and C6-7. He never had any radicular pain, only intermittent right cervical pain radiating to his upper trap. His neurosurgeon wanted to give him aquatic therapy, but the patient refused and asked his co-workers if they knew any good PTs. This patient previously had been to PT in the past, at least 5 other clinics/therapists. He couldn't remember most of them. All he ever received was exercise, traction, estim, and ultrasound. No one EVER corrected his posture. When patients tell me this, I know the truth is somewhere in between what they said and what the provider actually did, but from 5 other PTs?!? SIGH.... Currently c/o right upper trap pain and cervical pain, intermittent rated 1/10 at best and 7/10 at worst. Sx worse with using right UE to lift in a curling motion and head and neck motions.

During history taking, I often show cause and effect of sitting up straight (a MDT approach). Upright sitting posture immediately reduced his right upper trap pain. I strength tested his right biceps which caused right upper trap pain. It was more anteriorly tipped and protracted with elevation. I then set his scapula in an over corrected neutral; upon retesting biceps, it was completely pain free and stronger. Having him slouch again increased right upper trap pain, and also his right arm strength test was weaker and painful. Postural correction should start right away! Don't save it for a few minute presentation at the end with a lumbar roll.

Cervical ROM

  • Flexion mod loss
  • Extension severe loss
  • SB Left sev loss Right mod loss
  • Rot Left mod loss Right sev loss
PIVM: severe restrictions in OA FB, grade 1, C2-4 downglide bilaterally, right 1st rib inferior glide
Myofascia: severe restrictions in occiput lateral to medial, right > left cervical paraspinals, scalenes and SCM. T1-3 grade 1 restricted in backward bending and bilateral rotation.

Assessment: Signs and Sx consistent with cervical derangement with accompanying soft tissue and joint restrictions.

Discussion: When doing residency 13 years ago, I worked in a part of Buffalo, NY that saw a lot of referrals from a pair of surgeons that do DOUBLE DIGIT spinal surgeries almost daily. They tell their patients "you needed surgery yesterday, PT won't work, but you have to have some first before your HMO will allow surgery."  I once saw a patient from those particular docs that was fused from C2 to T4, in SEPARATE surgeries. Yeah.... surgeon drives a Ferrari, is one of the most sued docs in Buffalo, has his own Sabres Box, but they keep him around b/c he makes so much $$...

I learned early on that you work on the dysfunctions above and below and hope for the best. This particular case responded immediately to some TASTM to his right upper trap and cervical paraspinals, subcranial shear distraction, and 1st rib mobilization. He left with cervical retraction, scapula setting, and the use of a lumbar roll. Since his Sx were intermittent to begin with and we were able to find a directional preference/static position of comfort, he has a very good prognosis.I plan on adding some TASTM to upper thoracic and MWMs to that area at the next follow up.

Only saw him once so far, but I'll update the post/case in a few weeks! I told him should be 3-4 weeks at biw and he should be anywhere at least 90%.

What do you readers think? I'm just glad I don't get referrals from those surgeons anymore! 

1 comment:

  1. Education on proper posture and body mechanics is very important. Many times patients will come back the next visit with a reduction in their pain by just using better posture and body mechanics. Patient education is a big key in successful outcomes. Good post.