The cervical spine is the origin of many confusing clinical problems such as headache, migraine-like headache, arm pain, facial pain, periauricular pain, anterior chest pain and even visual dysfunction and dizziness. If the cervical spine is overlooked as a source of pain (such as in the head, shoulder, arm, upper chest—anterior and posterior—and around the ear or face) the cause of the symptoms will remain masked and mismanagement will follow. The following case histories illustrate such problems.
Nellie P, aged 39, a charge nurse presented with a seven-year history of unilateral headaches. They were migraine-like, associated with neck ache, and they appeared to follow a motor vehicle accident. After four years under the care of a neurologist she spent three years under a psychiatrist having psychotherapy for functional headache. My partner determined that it was referred from the left side of C2–C3 and administered one cervical manipulation after performing a Hallpike manoeuvre as a safety precaution. The headaches disappeared completely never to return (to date).
Tania B, aged 36, was a regular attender with multiple complaints especially ‘migraine’ headaches, which were unusual in that the headaches could last three days or so and occurred at least weekly. We had just completed a D and C for excessive uterine bleeding and were shifting her from the operating table onto the trolley when her head flopped to one side with a huge, resounding ‘crack’. We were most concerned about this wrench in her neck but relieved when she awoke with no ill effects. When she presented in about three months she said, ‘Well, my bleeding hasn’t improved much but I can recommend a D and C for migraines. I haven’t had one since’.
A 59-year-old woman was referred by a colleague for cervical manipulations because she had a six-month history of pain radiating down the arm to the fingers diagnosed as a C6–C7 disc lesion. I agreed to see her although I was not prepared to manipulate a neck with nerve root pain. On examination the pain and anaesthesia affected three nerve roots C6, C7 and C8. Remembering the golden rule 1 disc, 1 nerve root, I conducted a more searching examination and found several large, shotty nodes deep in the axilla. Biopsy revealed lymphoma.
A minister’s 62-year-old wife was referred because of a four-month history of pain and paraesthesia in the right hand, which was worse at night. She also had severe neck pain and headache. The first X-ray showed degenerative changes. She was diagnosed as having carpal tunnel syndrome but decompression of the carpal tunnel was unhelpful. Cervical manipulation aggravated the problem and also brought on tingling in the left hand. Examination confirmed weakness of both C6 and also C7 nerve roots. A CT scan revealed destruction of the C7 vertebrae with an obvious malignancy, probably secondary to carcinoma of the kidney removed five years previously.
Margaret B, aged 43, an American tourist, presented with an episode of severe vertigo, which she said had bothered her on and off for the past five years since a motor accident. After spells of being well, the bouts could be precipitated by actions such as collecting overhead luggage from a plane. She had associated headaches but no nausea or vomiting. She marvelled at the wonderful tests performed at the University of Birmingham (USA): scans, MRI, angiograms and so on, but they all showed zero. She produced Persantin tablets and Stemetil tablets for the treatment of alleged spasm of her cerebral arteries and inner ear inflammation respectively. On examination she had an extremely tender C2–C3 level of her neck and it appeared that the problem could be benign positional vertigo associated with cervical dysfunction. Since vertebrobasilar inefficiency tests were negative I performed mobilisation and a gentle rotational manipulation with resounding effects. Seven months later I received this letter from Goodwater, Alabama:
I have sung your praises to all who will listen. I have not been bothered with inner ear ever since you gave me that adjustment. I arrived at the conclusion that it isn’t inner ear in all cases.
DISCUSSION AND LESSONS LEARNED
Dysfunction of the cervical spine can cause many unusual symptoms such as headache and vertigo, a fact that is often not recognised. Despite teaching to the contrary from some consultants, the cervical spine is a common cause of headache, especially dysfunction of the facet joints at the C1–C2 and C2–C3 levels.
Expert mobilisation or manipulation of the cervical spine can be a dramatically effective technique, but it should be used with care and never used in the presence of organic disease and vertebrobasilar insufficiency. It should, therefore, be given only by skilled therapists. Two groups at special risk from quadriplegia are those with rheumatoid arthritis of the neck and those with Down syndrome because of the instability of the odontoid process.
If pain or anaesthesia in the arm involves more than one nerve root look for other causes (one disc = one nerve root).