By Thomas V. Giordano, D.C.
This case deals with the chiropractic treatment of an anesthesiologist,
who was referred to my care by a neurosurgeon for an acute phase
lumbosacralgia. An interesting, long-standing cervical syringomyelia
was treated concomitantly, with very satisfying results. The patient
has had no major complaints in over 6 months from his release
from care. A follow-up MRI of the cervical spine is still pending,
but deemed superfluous by the neurosurgeon.
On Friday, the 15th of March, 1996, Dr. Carmelo C., a married
42 year old, was accompanied (possibly forcibly!?!) to my chiropractic
office by Dr. Antonio M., a local neurosurgeon. Dr. Carmelo, specialized
in both orthopedic surgery and anesthesiology, was suffering from
an acute phase lumbosacralgia. He reported that he had a chronic,
intermittent central lumbalgia with no sciatic radiation for at
least 8 years. An underlying, chronic, gastroduodenitis prevented
the use of NSAIDS. Although Dr. M. suggested to his colleague
to seek chiropractic care, PT (US, TENS and axial mechanical traction)
was attempted for two weeks with a progressive increase in the
subjective complaint, as Dr. Carmelo was admittedly ignorant of
and unsure about chiropractic. The non-surgical nature of the
case was verified by Dr. M. prior to their consultation with me.
An added complication, was a 7-year (minimum)*, MRI-confirmed,
syringomyelia extending from C1 to C3. The doctor reported subjective
complaints of low-grade cephalgia, unilateral left cervicobrachial
paresis and formication and numbness of the left arm and hand
(globally manifested). Intermittent exacerbations were followed
immediately with MRI studies over the years, but Dr. M. refused
to intervene surgically for this complaint - for reasons I'll
discuss later in the conclusion of this report.
This, however, was not the chief complaint and was reported to
me with a certain resignation and acceptance. The low back complaint
was of primary concern to both men, as Carmelo was entering his
third week of sick leave from his hospital duties as chief anesthesiologist
in the neurosurgical division.
(* - That is to say, confirmed by MRI 7 years past. The lesion
is probably from a much earlier date.)
(N.B.: The examination was a relatively brief screen and performed
in the presence of the referring neurosurgeon.)
INSPECTION: Dr. Carmelo presented with an antalgic scoliosis with
a severe contracture of the right, lumbar paraspinal musculature.
Static postural analysis was not performed due to the severity
of the myospasm (this is my habit until the severity of the algic
state subsides). The left side of the face was slightly reddened
with some lacrimation to the left eye.
PALPATION: Myospasms were also palpated along the piriformis muscles
bilaterally, as well as both biceps femorii. Pain was elicited
upon deep palpation to the SI joint bilaterally and to the L5/S1
interval on the right. Trigger point tenderness was also reported
in the left supraspinatus, levator scapula and trapezius ridge.
Slight fasciculations were also palpated in the left biceps brachii
and left supinator.
PERCUSSION: Not Performed.
INSTRUMENTATION: Not performed.
ROM: Cervical Spine - Flexion: reduced and painful; Extension:
normal with limited discomfort; Left Lat. Bending: reduced with
limited discomfort; Right Lat. Bending: limited with severe discomfort.
Lumbar Spine - Forward Flexion: extremely limited with lancinating
pain to the SI Joint; Extension: Limited with minor discomfort;
Left Lateral Bending: severely reduced with strong, contralateral
pain; Right Lateral Bending: Limited and with slight discomfort.
(N.B.: For brevity, precise measurements were not performed, as
the patient was being screened for adjustment purposes only.)
ORTHOPAEDICS: Lumbar - Lasegue's: + @ 55 deg.; Braggard's: + @
50 deg. Contralateral Lasegue's: + @ 65 deg.; Contralat. Braggard's:
+ @ 60 deg.; Patrick's: -/-; Iliac Compression: + ; Ely's test:
+/+; Cervical - Sotto-Hall's Test: (+/-) ; George's Test: performed
with difficulty, but negative; Cervical Distraction: (+/-) on
the left, + on the right (but with difficulty); Maximum Cervical
Compression: +/+, but the pain provoked was local to the C7/T1
LUMBAR - DTRs: Patellar (L4/L5): present and hyperreflexive bilaterally;
Achilles' + Medio Plantar (L5/S1): present and hyperreflexive
- Muscle Testing: Hip Flexors (L1-L3): 5/5; Dorsiflexors (L4/L5):
5/5; Ext. Hallicus Longus (L5/S1): 5/5.
- Pathologics: Babinsky's: -/-; Valsalva's Maneuver: -; Rhomberg's
- Sensory: Pin prick, vibration, light touch: present and normal
in all areas tested.
CERVICAL - DTRs: present and normal on the right in all areas;
present and slightly hyperreflexive in all areas on the left.
- Muscle Testing: Deltoids/Biceps Brachii: 5/4; Wrist Ext.: 5/3;
wrist Flex.: 5/4; Finger Flex.: 5/3; Interossei: 5/3. (On Right/On
- Pathologics: Hoffman's and Tromner's: Negative bilaterally;
Naffziger's Test: Negative.
- Sensory: On the right, pin prick, light touch and vibration
were readily appreciated; on the left, the 128 Hz tuning fork
was readily discernible, but the light touch and pin prick was
only truly appreciable in the deltoid area (C5), all other areas
were practically obliterated.
CRANIAL NERVES - the only noteworthy abnormality was a temporal
nystagmus of the left eye, Chvostek's was difficult to interpret,
but deemed negative.
RADIOLOGICS: Lumbosacral Plain Films taken in AP and LL in Clinostasis.
The films were not dated nor were they accompanied with a report,
but were reported to have been shot in the radiology department
of the hospital on March 2, 1996.
AP: Evidenced a left convex, non-rotatory scoliosis. The SI joints
showed signs of exostosis at the inferior aspects bilaterally.
The lower lumbar SPs were irregular and suggestive of Baastrup's
in orthostatsis. The Psoas Major shadows were readily apparent.
Zygopophyseal remodeling was apparent. There were no signs of
fracture, gross pathology, anomaly or dislocation.
LL: Osteophytosis of the anterior margins of the vertebral bodies
was noted at L3/L4 and L4/L5 and at the inferior aspect of L5.
Loss of L4 and L5 disc spacing suggestive of degenerative discopathy
was also noted. The zygopophyseal joints were widely spaced, suggestive
of inflammation of the joint capsules at L4/L5 and L5/S1. No other
signs of anomaly, dislocation, fracture, listhesis or gross pathology
A MRI of the brain and cervical spine without contrast medium,
dated February 24, 1996, was also presented. Dr. M. and I evaluated
the images together. They clearly revealed the presence of an
Arnold-Chiari Malformation and the presence of a centrally-located,
cystic formation (syrinx) in the cord beginning at C1 and descending
down to the level of the inferior aspect of C3. There were no
signs of ependymoma or any other tumor formation present. The
fourth ventricle showed a slight enlargement, but was reported
to me to be unaltered from previous investigations. Some effusion
into the arachnoid membrane space was also noted at the C1/C2
level. Dr. M. (also a neuroradiologist), interpreted the images
as that of a communicating syringomyelia secondary to the Arnold-Chiari
Malformation, which partially compromised the CSF flow from the
From the above findings, we concurred that the lumbosacralgia
was due to a sacroilitis and not directly related to the syringomyelia.
I proceeded to prepare Dr. Carmelo for the lumbosacral adjustment.
Prior to the adjustment, the doctor was placed on intersegmental
traction for 12 minutes.
The listings palpated on the adjustment table were recorded as
a PIL Sacrum, an AS Right Ilium, an L5:PRS-M and an L1:PLI. The
side-posture technique was employed. The immediate reaction was
a reduction of the antalgic posture and a moderate reduction in
pain. We decided upon a treatment plan to commence the next day,
even though it was my day off.
On Saturday, the 16th, Dr. Carmelo came to the office and reported
that the pain had been considerably reduced since the previous
day. His antalgic posture had returned slightly, but he rated
the discomfort at about 20% of what it was. Only the PIL sacrum
and the AS Right Ilium were adjusted. The antalgic posture was
On Monday, the 18th, the doctor presented and was no longer in
antalgic posture. The pain was still as it was on Saturday, but
he reported that he had gone to the shore to "breathe some
fresh air" on Sunday, and may have overdone it a bit. A brief
Static postural analysis was performed.
The results were as follows:
Pes Cavus (Grade II) in pronation (bilaterally); Genu Valgum on
the right; apparent left leg dismetria; PI Left Ilium; AS Right
Ilium; Left convex lumbar scoliosis/right convex dorsal compensation
(intersection at T12); Left convex cervical deviation with a high
Adam's Test was Positive, implying a functional scoliosis secondary
to the heterometry of the lower extremities and pelvic obliquity.
A podometric study was performed to quantify the pedal deformity
and a 5mm Heel lift was provided for the left leg dismetria as
a temporary measure.
Dr. Carmelo was again adjusted in the lumbosacral area. At his
request, he asked if he might also benefit from cervical adjustments
for the other complaints. I related to him that I would only attempt
a supine cervical adjustment of the lower vertebrae first, to
see how he'd respond.
The listings found on palpation were recorded as - C1: ASRA; C2:
CPBR; C6: PL; C7: PL. C6 and C7 were adjusted.
On Wednesday, the 20th, Dr. Carmelo returned to the office and
reported the L/S complaint had gone into complete remission. He
also reported a slight improvement in the cervicobrachial complaint
and was eager to attempt an upper cervical adjustment. On this
visit, only C1 and C2 were addressed. (Nota bene: Seated Rotary
Breaks were NOT EMPLOYED at ANY TIME in this case.) The doctor
rose from the table with a slight vertigo. This sensation subsided
in a few moments.
On Friday, the 22nd, a very enthusiastic Dr. Carmelo reported
to the office to report that his cervicobrachial complaint had
all but disappeared. The only remaining effect was a slight numbness
to the superficial radial nerve distribution on the left. His
cephalgia was gone for the last day and a half and he felt the
sensation pain upon pinching his left hypothenar and fingertips.
He also reported an increase in grip strength. His plantar orthotics
(semi-rigid and corrected for the left leg dismetria) were provided
and another adjustment to the upper cervicals was performed.
Dr. Carmelo returned to work on the following Tuesday. That afternoon,
Dr. M. called to thank me for the handling of his colleague's
case. Carmelo's reaction to the cervical adjustments were the
topic of discussion among the neurosurgeons that day; one after
the other ran a cursory physical examination on the doctor and
were delighted with the results. The consensus among them was
that the upper cervical manipulations had effectively reduced
the CSF pressure at or below the Arnold-Chiari Malformation, and
were responsible for the attenuation of the symptoms. I suggested
a follow-up MRI to verify this hypothesis, but Dr. M. deemed it
unnecessary for the time being.
Carmelo came back to the office on the following Friday. He was
quite satisfied with the results of his treatment. The upper cervicals
were again adjusted and he was checked for any imbalances in the
hips. He reported no difficulty adapting to the orthotics. He
was dismissed from care, but told to report in two months for
another podometric study (which he did) or if there were any changes
in his physical state.
I met Carmelo at the shopping center last week. He told me that
he experienced a slight cephalgia three times in the last six
months, but each time it lasted less that two hours.
Syringomyelia is a relatively rare disorder, generally appearing
in young adults and probably developmental in origin. It is defined
as a fluid-filled neuroglial cavity - syrinx - within the substance
of the spinal cord or brainstem.(1)
"The Merck Manual" suggests that about 50% of these
cases are congenital and the other 50% arise secondary to intramedulary
tumor or trauma.
To answer Dr. Morgan, the congenital forms are often associated
with the Arnold-Chiari Malformation or other neurologic defects,
such as encephalocele or myelomenigocele. Also, about 30% of all
spinal tumors present with a syrinx.(2)
Alterations in the cord are usually confined to the cervical area,
but may extend cephalad into the medulla, reported as a 'syringobulbia'.
Macroscopic examination reveals swelling and thickening of the
meninges at the site of involvement.
The syrinx is defined as a cyst and has no connection to the central
canal and no ependymal lining.(3) The formation suggests that
the gliosis precedes the cavitation.
According to Dr. M., who has had much experience with these cases,
at times, the effusion into the arachnoid membrane spaces actually
forms a ring around the cord and gradually constricts it, but
the major problems arise because of the central location of the
The fibers of pain and temperature which cross the cord and pass
up the lateral spinothalamic tract are interrupted, as well the
fibers of touch of the anterior spinothalamic tract, but the posterior
columns transducing light touch and vibration sense are unaffected
- resulting in a 'dissociated' sensory loss in the early stages
of the condition. As the cyst becomes larger, pressure on the
long tracts, such as the pyramidal tract, demonstrate signs of
upper motor neurone lesions in the lower extremities. The anterior
horn cells also become involved in the affected segmental levels
and produce lower motor neurone lesions in the upper extremities.(4)
Over the course of many years, the progressive neurologic deficit
and disability ensue. The anesthesia predisposes these unfortunate
people with trophic ulceration of the hands and neuropathic arthropathy.
No specific therapy has proved of benefit in these cases. Radiation
has been employed with doubtful results, in association with intramedullary
tumor. Dr. M. either employs posterior fossa decompression; basically,
the removal of the posterior rim of the foramen magnum and the
posterior arches of C1 and C2, or a syringotomy - that is, the
surgical drainage of the syrinx. In any case, no really effective
treatment has been demonstrated.
It can be argued that the remarkable findings do not necessarily
support the chiropractic tenet, as it was a medical subluxation
that was reduced using a chiropractic technique! Not to get into
semantics about VS, VSC or subluxation in medical terms, this
may be a viable modality to treat a medically defined condition,
not our VS.
No soft tissue work was employed, other than intersegmental traction
and moist heat to prepare for the adjustments.
In this particular case of Communicating Syringomyelia secondary
to an Arnold-Chiari Malformation, non-rotary, supine chiropractic
cervical adjustments proved of benefit in the reduction of associated
signs and symptoms. The neurosurgeon's option for syringotomy
was not considered justified due to the lack of gross neurologic
deficit or pathologic reflexes (Babinsky's, Hoffman's and Tromner's
Negative). Although there was evidence of dissociated sensation
(loss of pain and maintained vibration sense) in the upper left
extremity, no upper motor neurone effects in the lower extremities
Due to the lack of effective medical treatment and unproved surgical
protocols in these cases, chiropractic adjustment (or osteopathic
manipulation) should be investigated as a viable approach to selected
patients afflicted with communicating syringomyelia unrelated
I'd like to openly thank Drs. Guebert, Deutsch, Miller, Morgan,
Seutter, Stockwell, Cockburn, and Green for their kind words and
assessments, as well as Joe Ierano - a colleague in the making!
- "The Merck Manual of Diagnosis and Therapy", 16th
Edition; Merck Research Laboratories; Rahway, NJ, 1992; pg. 1506.
- "Lecture Notes on Pathology"; Thompson, A.D. and
Cotton, R.E.; Blackwell Scientific Publications, 3rd. Edition;
Alden Press, Oxford UK, 1983; pgs. 615-616.
- "Merritts Textbook of Neurology"; 8th Edition; Lea
and Febiger, Philadelphia, PA, 1989; pgs. 687-690.