J Manipulative Physiol Ther 2001 (Sept); 24 (7): 477Ė482 ~ FULL TEXT
Joel Alcantara, DC, Gregory Plaugher, DC,
Richard E. Thornton, DC, Chris Salem, DC
This study was funded by Life Chiropractic College West,
Hayward, Calif, Gonstead Clinical Studies Society,
Mount Horeb, Wis, and Palmer College of Chiropractic West,
San Jose, Calif.
OBJECTIVE: The chiropractic care of a patient with vertebral subluxations, neck pain, and cervical radiculopathy after a cervical diskectomy is described.
CLINICAL FEATURES: A 55-year-old man had neck pain and left upper extremity radiculopathy after unsuccessful cervical spine surgery.
STUDY SELECTION: Randomized clinical trials on chronic headache (tension, migraine and cervicogenic) were included in the review if they compared SMT with other interventions or placebo. The trials had to have at least 1 patient-rated outcome measure such as pain severity, frequency, duration, improvement, use of analgesics, disability, or quality of life. Studies were identified through a comprehensive search of MEDLINE (1966-1998) and EMBASE (1974-1998). Additionally, all available data from the Cumulative Index of Nursing and Allied Health Literature, the Chiropractic Research Archives Collection, and the Manual, Alternative, and Natural Therapies Information System were used, as well as material gathered through the citation tracking, and hand searching of non-indexed chiropractic, osteopathic, and manual medicine journals.
INTERVENTION AND OUTCOME: Contact-specific, high-velocity, low-amplitude adjustments (ie, Gonstead technique) were applied to sites of vertebral subluxations. Rehabilitation exercises were also used as adjunct to care. The patient reported a decrease in neck pain and left arm pain after chiropractic intervention. The patient also demonstrated a marked increase in range of motion (ROM) of the left glenohumeral articulation.
CONCLUSION: The chiropractic care of a patient with neck pain and left upper extremity radiculopathy after cervical diskectomy is presented. Marked resolution of the patient's symptoms was obtained concomitant with a reduction in subluxation findings at multiple levels despite the complicating history of an unsuccessful cervical spine surgery. This is the first report in the indexed literature of chiropractic care after an unsuccessful cervical spine surgery.
From the Full-Text Article:
The medical treatment of musculoskeletal neck pain, conservative
or surgical, remains largely based on empirical
evidence. For example, the efficacy of traction has not been
scientifically proven in a randomized controlled clinical
trial; however, it is thought to be effective, particularly in the
treatment of neck pain and associated radicular symptoms.
[7, 8] According to Grob,  70% to 80% of cases of cervical
radiculopathy symptoms could be treated by conservative
means. These include the use of oral medications, soft
collars, cervical traction, and other physical therapy modalities.
Patients with associated radiculopathy might also
achieve relief of neck pain with the use of corticosteroids.
Failure of the above conservative approaches may result
in cervical diskectomy and fusion for the patient. As such,
spine surgery ranks as one of the most common inpatient
surgical procedures in the United States. [10-14] In considering
only spinal fusions, there was a 310% increase from 36,000
in 1985 to 111,400 in 1996. In 1996, 48% of the spinal
fusions involved the cervical spine, and in 97% of these the
indication was because of degenerative changes.  Despite
the frequency of spinal fusions, there does not seem to exist a
standard outcome tool for measuring clinical success after
surgery. Using the status of the arthrodesis as an outcome
assessment is of great controversy among surgeons, particularly
when this measure of outcome does not necessarily correlate
with clinical measures of success. [16, 17] Reliable outcome
measures remain to be developed, and the effects of
fusion on any functional spinal unit continue to be studied. 
One of the supporting ideas behind this intervention is
that the achievement of fusion results in the prevention of
spondylotic spurs, the offending entity, whereas existing
spurs regress because of the stability of the fused segments.
However, degenerative joint disease, as evidenced on radiographic studies, has been found within the fused spinal
segments. In addition, the segments above and, to a lesser
extent, in the segments below also demonstrate degenerative
joint changes. [19-22]
A recent descriptive paper by Klein et al  examined the
health outcomes of 28 patients before and after cervical diskectomy
and fusion for radiculopathy. They concluded that this
procedure may improve a patientís self-reported health assessment,
especially for pain and physical function. Other studies
also report positive outcomes from similar surgical intervention.
 However, cervical spine surgery in general may lead to
such complications as bone graft failure, cerebrospinal fluid
leak, recurrent laryngeal nerve injury, nerve root injury, quadriplegia,
and death.  For the patient presented in this case report,
based on Odomís criteria, the surgical outcome can be described
as poor.  The patientís signs and symptoms remained
unchanged after surgery and eventually worsened.
This is the first description in the indexed literature of the
chiropractic care of a patient with vertebral and sacroiliac subluxations
with a history of unsuccessful cervical diskectomy of
the cervical spine. In our experience, allopathic practitioners
usually do not offer patients the option of chiropractic care
before surgery. Perhaps more rarely is chiropractic care considered
a viable option in instances of unsuccessful surgical care.
Since chiropracticís inception, chiropractors have for the
most part performed their clinical activities based on the
detection and removal of a patientís vertebral subluxations.
 Subluxation is defined as a partial dislocation, a
sprain.  Historically, chiropractors have described kinesiologic,
neurologic, and histologic manifestations of this
injury. The term vertebral subluxation complex (VSC) is
used to highlight the diverse tissues that are involved and the
impact of the lesion on the individualís ability to maintain
homeostasis. Several mechanisms and models have since
been proposed [24,29-31] reflective of the state of knowledge
encompassing the biopsychosocial sciences. For the purpose
of this writing, mechanical and neurologic components
of subluxation will provide the theoretical framework from
which we will discuss this case.
The patient consulted one of us for chiropractic care
approximately 3 years after surgical diskectomy. From a
biomechanical point of view, the cervical spine of this patient
had been compromised. Schulte et al  studied the
kinematics of the cervical spine after diskectomy and stabilization
and found that there were significant reductions in
mobility at fused segments. Motion palpation of the patientís
neck exhibited decreased left lateral flexion and
decreased spinous process rotation at the C5 vertebral level
in addition to the fused segments at C6-7. Early studies have
demonstrated a decrease in motion at the fused segments with
concomitant increase in motion segments above or below
the site(s) of cervical fusion.  This abnormal pattern of movement
(ie, hypomobility) at one or several functional spinal
units (including global and intersegmental malposition) is
referred to as kinesiopathology. A possible consequence of
this may be an increased rate of degenerative changes. [19-21]
As previously described, degenerative joint disease was
visible on the radiographs in the segments above the cervical fusion; particularly with the presence of anterior osteophytes,
which are more frequent in anterior cervical
fusions.  In addition to compromising activities of daily
living and contributing to the persistence of pain, the presence
of a cervical kyphosis after anterior cervical diskectomy/
fusion is correlated with a less successful outcome. 
This patient had a mild cervical kyphosis, most apparent in
the mid to lower cervical spine. This is associated with anterior
carriage of a patientís head, which may lead to further
compromise of osseous and soft tissue structures.
The neuropathologic component of the VSC involves
nerve root compression/irritation interfering with normal
nerve root function resulting in pain or other clinical
pathologies. The oblique views clearly demonstrated a
decrease in diameter at the C5-C6 left intervertebral foramen
(see Fig 1). Compressive radiculopathies are the result
of pressure on the spinal nerve roots caused by protrusion of
the intervertebral disk; retrolisthesis or Y-axis rotation of the
segment; spondylotic spurring of the vertebral body, the
uncovertebral joints, or the facet joints; or combinations
thereof. For example, at the most medial aspect of the nerve
root, osteophytic projections from the lateral aspects of the
vertebral body end plates can compress the nerve root without
resulting in clinical evidence of spinal cord compression.
The patient discussed in this case report did not have
spinal cord compression.
Mechanical compression combined with chemical mediators
of inflammation likely produced the neck pain and
radiculopathy experienced by the patient. Of interest in this
case report is the immediate relief of neck pain and radiculopathy
and the improved shoulder range of motion after
adjustments at the sites of vertebral subluxations. The comparative
radiographs (Fig 4) showed only minimal improvements
in the patientís posture, most notably in the upper cervical
spine. A comparative oblique radiograph was not
obtained on this patient. In our opinion, the intervertebral
foramen (IVF) would not likely have demonstrated an
increased diameter of the structure given the amount of
retrolisthesis at C5 on the comparative lateral radiographs.
Radiographs may not be sensitive to small changes in IVF
size or changes in the patientís outcome as a reflection of the
changes in the IVF.
It is important to remember that functional characterisitics
of nerve root compression are dependent, not only on
the patency of the IVF, but also on the presence or absence
of inflammatory products such as edema, interneural edema,
and connective tissue fibrosis/scarring. The fact that the
nerve root must telescope within the IVF during neck and
arm movements may play a role in its susceptibility to compression.
If nerve root adhesions are present, this may
increase susceptibility. Theoretically, an adjustment could
alter the mobility of an individual motion segment, the
mobility of the nerve root within the IVF, or both. This may
provide a possible explanation as to why functional
improvements in the patient were obtained despite minimal
changes to IVF architecture. The patientís cervical curve
became mildly more lordotic in the upper portions of the
neck. It is well recognized that alterations in cervical lordosis
can alter the function and/or circulation of the spinal
cord and nerve roots.  We acknowledge the speculative
nature of what putatively happened to this patient from a
There is a considerable body of literature that demonstrates
that patients who undergo spinal adjustments experience
relief of pain. According to Vernon,  hypoalgesia may
possibly be achieved through central facilitation from the
stimulation of spinal structures through a spinal adjustment.
This may result in changes of cutaneous and muscular pain
thresholds and the release of endorphins.
In a pilot study, Cassidy et al  examined the effects of
spinal manipulation on pain and range of motion in the cervical
spine. They found a significant relationship between a
decrease in pain and an increase in cervical range of motion.
In a further study, Cassidy et al  found that both mobilization
and manipulation increased range of motion; however,
manipulation was more effective in decreasing pain.
Hurwitz et al  performed a systematic review of the literature
on manipulation and mobilization of the cervical spine
and found that manipulation and mobilization provided
short-term benefits for some patients with neck pain and
headaches. The improvement in the patientís shoulder range
of motion may be attributed to the reduction of the components
of subluxations in the cervical spine, because the
glenohumeral articulation did not receive an adjustment.
The mechanism by which this occurred remains to be elucidated.
Concomitantly, the patientís complaints of myopathology
(muscle weakness and atrophy) were also alleviated. This
could be attributed generally to positive changes in nervous
system function associated with removal of subluxations. In
addition to spinal adjusting to sites of subluxations, the
patient was provided with arm exercises to increase his
shoulder range of motion, muscle strength, and muscle
hypertrophy. These adjunctive procedures played an important
role in ameliorating the muscle weakness and atrophy.
Many clinicians support the use of ancillary therapies to
improve the effect of the adjustment; however, scientific
evidence of any putative effect is lacking. 
We presented the chiropractic care of a patient with neck
pain and cervical radiculopathy after an unsuccessful surgical
diskectomy. This unusual case may challenge the
conventional allopathic clinical care pathways, as well as
opinions within some chiropractic circles about the appropriateness
of chiropractic care of patients with cervical
radiculopathy or unsuccessful cervical surgery.