Case Study #2: Cervical Disc Herniation

At Tri City Disc and Nerve Center, Spines Are Our Specialty

Which means our healthcare staff is specially trained to diagnose and treat the source of your back pain. All of our treatment options are all-natural, so you can benefit from your treatment without the risks and recovery time associated with more invasive procedures, such as back surgery.

 

Case Study 2: Cervical Spine Disc Herniation

Patient Name: Janet, L  

Age: 53 year old Female

Janet presented in our office complaining of chronic right side neck pain that spread into her right shoulder, arm and even into her hand. She stated that she had been suffering with neck pain for the last 10 years and that after a work injury that caused a shoulder and rotator cuff tear she has had neck pain since. She noted that at times, when it becomes too intense, her neck pain radiates into her forehead and causes her to have a migraine. She is currently taking OTC Exedrin pain reliever and that her Pain Specialist also prescribed her Oxycodone. She rates her neck and shoulder pain as a 9 out of a possible 10 score. Her rates her migraine headaches as a 10 out of 10 when she experiences them. She stated that she usually has 1-2 Migraines per week.

Previous Medical Treatment:

2 Right Shoulder/ Rotator Cuff Trigger Point Injections

Physical Therapy

Ice / Heat

OTC Pain Relievers (Exedrin for Migraines)

Prescription Pain Relievers : Oxycodone

Examination Findings:

Janet has a severe decrease in her cervical spine flexibility with an overall 70% loss in Cervical ROM. Upon palpation of the cervical spine, she had severe pain (9 out of 10) in the C5-C7 region, right paraspinal cervical musculature. In addition, bilateral upper cervical trigger points and muscle spasm were noted and upon palpation, they produced pain at a level 8 out of 10. Trigger points were palpated and noted on right side upper trapezius muscle and right side rhomboid muscles. Right rotator cuff and right shoulder had a reproduction of pain upon palpation. Cervical orthopedic tests for nerve impingement were all positive indicating cervical intervertebral disc herniation.

 

 

Diagnostic Tests:

Cervical Spine Radiographs

Cervical Spine MRI

Treatment Plan:

Based on Exam and MRI Findings, Janet was given a treatment program that included an initial 1-3 week intensive phase designed to relieve her inflammation and pain.

Manual Therapy which included soft tissue and manual massage to relieve tender trigger points and inflamed paraspinal musculature.

A Class 4 Deep Penetrating Laser was used to increase immune cell activity, oxygenation of injured tissues and lower pain and inflammation. 5-7 Minutes each session.

Non-Invasive Disc Decompression was used to decompress the herniated spinal segment and relieve pressure off the nerves radiating into her right arm. Initial Janet started with 7 minutes of NIDD therapy and gradually increased to 20 minutes per session.

Home Care of light cervical stretches, and shoulder ROM exercises were prescribed. Ice in the evenings for 15 minutes and proper amounts of sleep each night, 8 hours minimum.

 

 

 

Re-exam Findings and Progress Report:

After 8 sessions of care (2 1/2 weeks) Janet noted improvement. The first thing she noticed was a dramatic decrease in her migraine headache intensity and duration. During the initial 8 sessions, she only noted 2 migraines, both of which lasted 50% less in intensity and duration. Her pain levels in her right arm and shoulder decreased to a 5 out of 10. She noted that her neck was starting to relax and she can feel that her flexibility was starting to come back. She also noted that she has reduced the amount of medication she is taking and that she feels much better as a result of the care.

After 1 month of care:  Janet rates her pain levels as a 3 out of 10. She has noted a significant improvement in the amount of neck and shoulder pain she is experiencing. She has not experienced a headache or Migraine in 2 weeks. She mentioned how thrilled she was to not be experiencing migraines anymore. She has noted that her range of motion has improved and that she can turn her head again when backing up her car. She is currently only taking exedrin a few times a week, when she starts to feel some of the soreness come back. She is doing her home stretches and icing each evening and is getting 7-8 hours of sleep each night.

After 2 months of Care: Janet is pain free. She rates her pain level as a 0 out of 10. She has not had a headache in almost 2 months. She has noted that her energy levels have been much higher than normal and that she’s sleeping great at night. She is no longer taking any medications for pain relief and that she has no more shoulder pain or neck pain.

 

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