Detecting space occupying lesions in the thoracic and cervical spine. By Hector Wells DO BSc(Hons)

Detecting space occupying lesions in the thoracic and cervical spine. By Hector Wells DO BSc(Hons) Summary As far as the author can establish, the tes...
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Detecting space occupying lesions in the thoracic and cervical spine. By Hector Wells DO BSc(Hons) Summary As far as the author can establish, the test reveals any “bottlenecks” in the spinal canal caused by space occupying lesions before any classical clinical test would reveal canal compromise. The observations described below have not been reported before and are therefore unknown and new at present, in the clinical osteopathic and wider medical setting. When combining abdominal compression, with lumbar flexion, on the supine (exhaling) patient. A sufficient raise in cerebro-spinal fluid (CSF) pressure can be created to be carried as a dynamic fluid change, towards the upper thoracic and cervical spinal canal. This dynamic flow can cause the CSF to display a segmental dysfunction at the approximate level of a spinal canal narrowing caused either by a space occupying lesion or spinal stenosis. Conclusion The cases reviewed, support the concept of provocative testing for space occupying lesions within the spinal canal. It is of interest that spinal stenosis and space occupying lesions both provide similar positive results. However the test show there is dural/spinal canal compromise at a particular level, but the test will not pick up a secondary higher lesion above the first restriction.

Introduction Increasing clinical safety is always an interest with the clinical setting in osteopathy. It is proposed that previously undetected space occupying lesions within the spinal canal could be more easily detected. By using the fluid dynamics of the cerebral-spinal fluid surrounding the spinal cord, a provocative could be established.

The test when used in osteopathic practice, would help to differentiate if clinical signs are of peripheral nerve origin or from dural compression within the spinal canal which could potentially have more serious outcomes. If the proposed test were found to be reliable then clinical osteopathic treatment would be able to provide appropriate intervention, avoiding procedures that may be higher potential risk than expected. At present the osteopath uses a number of clinical methods to incriminate neurology that may be compromised • Reflex testing • Muscle testing • Peripheral signs, muscle wasting, trophic change. • Referred pain display patterns • Dermatome testing • Long tract signs and tests. • Lhermitte’s sign (barber’s chair sign in the USA) (see Pattern 2000) Presently there is no test that can establish if pain display is caused by a narrowing of the spinal-canal function, either by stenosis or a space occupying lesion. Where test are used the clinical scenario usually is much more serious, as the clinical picture has deteriorated significantly to give long tract signs. Observation It has been observed by the author that by using the fluid dynamic of the CFS in the spinal canal a fluid pulse can be generated within the spinal canal. If this pulse is directed towards the neck the client will complain of increased pressure at the level a spinal narrowing occurs.

• • • • •

“I feel a tight band in my neck” “There is feeling of the blood getting stuck” “There is a throttling pain in my neck” “I’ve got that pain in my shoulders” “There is an explosive feel in my neck”

Where this observation has been followed up by MRI there appears to be a 100% correlation between the test and finding a restriction at the level of the increased CSF pressure complained of by the patient. No other test is available to incriminate a space occupying lesion within the spinal canal at the sub-clinical setting. Patient one

Female D of B 08/10/1951 Recurrent neck and shoulder pain, reflex and power normal CSF test suggested disc at level C6/C7 MRI: There is multi-level spondylosis with posterior osteopytes from level C3 toC5 and loss of disc height at C4/C5 Axial images show discogenic bar at C4/C5 narrowing the canal particularly on the left side but not significantly compromising the cord. Several of the nerve roots canals are slightly narrowed particularly the C5 and C6. There are no disc prolapse or nerve root compression Patient Two Female D of B 25/09/65 Complaint: Stiff left shoulder with pain the whole time, no pins and needles, not aggravated when coughing. Elevation of left shoulder increases left arm symptoms. Neck rotation to left increases symptoms. Shrug of shoulders hurts. Radicular pain in left arm CSF test level of C6/C7 left increased tension and tightness MRI: Disc dehydration affects all of the cervical discs. There is straightening of the normal cervical lordosis. Small disc/osteophyte bars are seen at each level between C3/C4 and C7/T1. These indent the thecal sac but do not appear to cause direct neural compromise. There is mild bilateral foraminal narrowing at C5/6. The spinal canal and the other neural foramina are capacious. There is a very slight dilatation of the canal within the spinal cord between levels C7 and T2. In my experience this is usually an incidental finding with no clinical significance.

Patient three Male D of B 16/4/72 Complaint: funny neck! Pain shooting into jaw and ears. Mild neck pain for over 5 years and recently hurting for a week. CSF test suggests tension at upper thoracic level T5 to T6

MRI findings: C5/C6 a moderate sized postero-lateral disc bulge is present with anterior contact and mild indentation of the cord. No evidence of cord compression or signal abnormality is detected. The C6/C7 disc also demonstrates a postero-central and left parasagittal disc bulge with cord contact. Conclusion, no evidence of neural compression demonstrated within the cervical spine. Thoracic spine; Normal thoracic kyphosis noted. At level of T7 to T9 the central canal within the spinal cord is rather prominent but no evidence is seen of cord expansion or other abnormality. Mild prominence of the canal is also demonstrated at T5/T6 level. The prominent central canal is noted within the thoracic cord (hydromyelia) and this is likely to be normal variant. Patient four Male D of B 15/06/79 Complaint; stiff neck and right shoulder stiff for the last 5 years CSF test: tightness at level C6/C7 level on the right. MRI At level of C5/C6 there is a small posterior paramedian right disc protrusion which indents the anterior theca, but does not quiet contact the surface of the spinal cord. The right neural foramen is not compromised. Conclusion: Small right sided disc prolapse, but no features of neural compromise.

Patient five Female D of B 11/1/63 Complaint: Right arm pain down to the elbow C5 distribution, and pain up the back of the neck right CSF Test Positive, pain in tips of shoulders bilaterally, test result was difficult to evoke. MRI: Cervical disc height and signal is within normal limits. No evidence of neural compression. Normal cord appearances. No cause of symptoms found. Osteopath could see thecal sac touching at C4/C5 level right, no distortion of thecal sac.

Discussion The MRI reports identify anatomical changes at the level where the CSF test gave a reaction, however the reports do not see the MRI findings as clinically significant in a medical context. So this suggests the CSF test can pick up restrictions within the spinal canal before they are severe enough to give gross MRI findings and gross neurological symptoms. Where the CSF test does give a positive finding in the clinical setting, it will help to give a better prognosis for treatment as treatment out-comes in these situations are invariably more slow to respond and potentially carry higher risk with treatment. Therefore the osteopath would be justified to treat the patient with more caution and presumiably more treatment visits. The CSF test appears to be pressure sensitive; if a positive test result is achieved with light abdominal compression then it is likely the space occupying lesion likely to be larger. Where the pressure requires for a positive sign is much larger and/or a number of attempts are needed to elicit a positive then the lesion is more likely to be smaller and less obstructive in the spinal canal. The Procedure It is assumed the patient has no pathology in the lumbar spine and the practitioner is able to discern clinical safety before the test. Clients who have not had any vascular accidents recently from sneezing and violent coughing are assumed to be safe to treat as the compression should not generate any greater force than this. Tendency to haemorrhage The author does not want to deal with any other clinical detail. It is assumed the reader will be a practitioner trained to a recognised clinical standard and safety. The CSF test is not seen to stand alone from a good case-history and examination.

• The patient lies supine • Patient is told a feeling of change of sensation is being looked for on compression of abdominal contents with expiration. • The patient bends the knees which are then rolled onto the patient’s chest/abdomen. • If the abdomen is very large then the quads rest on this • If the abdomen is thin then some augmentation will be needed, like a pillow, cushion, rolled up blanket. • The practitioner places a towel/cushion on the posterior thighs • The practitioner places his chest on the covered thighs • The Lumbar spine is mildly flexed, (pulled up).

• The patient inhales and the exhales, with the practitioner chasing the exhalation wave down and into the thorax.

The client is placed with knees flexed and abdomen padded to ensure abdominal compression on exhalation.

The client breaths in maximally The lumbar spine is flexed and rocked ready for the expiration compression The client expires and the practitioner chases the exhalation wave down to the abdomen and towards the thorax.

The practitioner compresses the thighs onto the abdomen as quickly as the exhalation allows. This creates a CSF compression wave up the spinal canal and test any increase to the CSF velocity due to spinal canal diameter reduction. Client reports level of discomfort.

John Pattern; Neurological Differential Diagnosis 2nd edition Springer-Verlag Berlin Heidelburg New York (2000)

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