Introduction: Prescriptions of manual therapy have been increasing in Korea. Although potential complications accompany with manual therapy, some physicians or non-medicals perform manual therapy without proper musculoskeletal assessment. This study reports on a case of serious complication of myelopathy after manual therapy without prior assessment in order to draw attention to the need for careful clinical and imaging assessment prior to manual therapy.
Case report: A 56-year-old female had the 1st tingling sensation at the right hand in 2018, which aggravated to both upper extremities on Oct. 2019. When the patient visited neighborhood clinic to treat abnormal sense, she was recommended to undergo manual therapy. Any imaging evaluation was not done before it, including simple x-ray, CT or MRI of C-spine. After the 3rd session in which thrust technique was performed, she immediately felt weakness in her upper and lower extremities. The symptoms had become severe from Dec. 2019 to Jan. 2020. She then admitted to Department of Neurology of our hospital on Feb. 5th, 2020. At the initial evaluation, the patient showed weakness of both upper and lower extremities grade 4 and 5. Fine motor of the patient deteriorated, so she could not write or use chopsticks well. Touch and proprioceptive sense were also decreased in all extremities, which made the patient difficult to gait. MRI of cervical spine showed erosion of dens and pannus formation and high signal intensity in the C1/2 joint, which indicates compressive myelopathy at the level of C1/2. The patient admitted to Department of Neurosurgery of our hospital on Feb. 26th, 2020. The symptoms worsened; she showed weakness of both upper and lower extremities grade 3 and 4, and restrictions in activities of daily living(SCIM-3 scored 70). She underwent occipito-cervical fusion operation for releasing spinal cord compression on Feb. 27th, 2020. After the operation and rehabilitation for a month, the weakness gradually recovered to the previous level except the numbness of both hands at April 11th, 2020.
Conclusion: While generally safe, various mechanisms of neurological injuries have been reported. In this case, weakness of all extremities occurred after thrust technique was done. MRI conducted after the event showed erosion of dens and odontoid process. The spinal canal at C1 level was narrowed due to hypertrophy of retro-odontoid soft tissue with high signal intensity of spinal cord at C1 level on the T2 weighted MRI. If the prior assessment had been performed to reveal the cause of the Rt. hand’s tingling sensation, devastating complication could have been prevented. If there are any underlying anatomical abnormalities like this case, the possibility of complication increases during manual therapy. Thus, prior assessment is necessary to distinguish the general contraindications of manual therapy especially in case of thrust technique, and it should be performed by relevant medical professionals. |
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Figure 1. Initial C-spine MRI (February 17, 2020). Initial C-spine MRI shows HCD in C5/6, erosion of dens(arrowhead), odontoid pannus formation(retro-odontoid pseudotumor, white arrow) and compressive myelopathy in the C1/2 joint (empty arrow)
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