Undiagnosed Atlas Subluxation in Patient with Pain and Poor Myofascial Function
This article explores the case of a patient with myofascial dysfunction who underwent years of myofascial trigger point injection to improve pain and range of motion (ROM). The patient would improve immediately after treatment, but then pain would return.
The authors suspected a diagnosis of atlas subluxation (misalignment of the top cervical vertebrae), and pursued the diagnosis and treatment aggressively. Part of the delay in diagnosis came down to a “turf battle” between chiropractors, physical therapist, and myofascial trigger point therapists. The specific training of each of these specialties can sometimes prevent the diagnosis of unusual cases. But working together, the four clinicians unraveled the underlying cause of dysfunction in this difficult case.
A 33-year-old man presented in 2010 complaining of pain and reduced ROM in his neck, shoulders, and low back that was worse on his left side. His occupation as a stock-
broker involved 12- to 14-hour days of sitting at a computer terminal. He noted that his activities of daily life (ADLs) were severely limited, despite the fact that he had previously been active in sports, including coaching baseball and playing golf.
His past medical history included a fall on his right hip and buttocks, with resulting sharp sacroiliac pain, and a head-trauma injury, both occurring 3 years previously. Physical therapy and work with a personal trainer had not produced any improvement in his pain or dysfunction.
Physical examination revealed a well-developed man whose neck was tilted to the right and shoulders hunched forward. There was loss of thoracolumbar lordosis, his left shoulder was higher than the right, and his left hip was lower than the right. His feet were flat. He had taut bands and muscle spasm in his neck and entire back.
Laboratory findings included a low vitamin D level. No imaging examinations were performed.
Initial Treatment Plan
The patient was started on vitamin D therapy and embarked on a weekly program of myofascial trigger point therapy (MFTPT) to release taut bands and to provide pain relief and increase ROM.
Although the term “myofascial dysfunction” in not addressed in current medical school curricula and does not appear in International Classification of Diseases coding manuals, it is present in virtually all patients with neck, torso, back, and extremity pain. Fascia is connective tissue (woven like a web) that surrounds and connects every muscle and organ. “Traditionally, fascia has been thought of as a passive structure. However, it is now evident that fascia is a dynamic tissue with complex vasculature and innervation.”1 In fact, fascia is finally recognized as a body system and is one of “ most important sensory organs in body perception.”2
Myofascial trigger points are inflamed,tender areas caused by excessive acetylcholine released at numerous motor end points, resulting in calcium accumulation, hypoxia, and acidosis. This results in the release of inflammatory mediators, causing swelling and edema that eventually leads to fibrosis between muscle and fascia, and between fascia and skin.3
Untreated myofascial trigger points result in traction on tendons and ligaments, both of which are confluent fascial bands. Muscle shortening, traction of tendons (ie, tendonitis), and eventually periosteal elevation, bone spurs, and tendon ruptures occur. The solution to avoiding these complications is to lengthen the fascia and disrupt the adhesions between fascia and other tissues.
Sarapin is an FDA-approved sterile solution of the soluble salts obtained from the botanical pitcher plant (Sarracenia purpurea). Widely used for over 70 years in veterinary medicine, mostly in race horses, as an anti-inflammatory agent, Sarapin’s mechanism of action in humans has not been systematically studied in the laboratory or in controlled clinical trials.
Clinical use today is limited largely to chiropractic and podiatric practices. Manchikanti and others, however, have shown that caudal epidural injections with either steroids or Sarapin are effective for persistent low back pain for up to 3 years after treatment.4 Therapeutic cervical medial branch blocks with Sarapin have been found to be as effective as steroids in controlling neck pain up to 1 year after treatment.5
Despite Relapse of Pain, Treatment Continues
For the next 4 years, the patient would receive MFTPT. Virtually every muscle group in his neck, back, anterior chest, anterior abdomen, buttocks, and thighs were treated depending on his pain findings each week. The treatment sessions allowed him to perform most of his daily activities without significant pain, but he had not resumed coaching or playing golf.
In early 2014, a program of trigger point injections with Sarapin combined with a small amount of 0.25% bupivicaine (less than 20% of the injectate volume), followed 20 to 30 minutes later by MFTPT was begun. At each session, he received between 10 and 20 injections of approximately 1 mL each. In spite of the large volume of injections, adding the bupivacaine allowed for much deeper tissue work in each painful area.
Over the following 6 to 12 weeks, the patient’s pain decreased from a 7 to a 2 or 3 out of 10 and ROM improved in all muscles groups except his neck flexors and extensors. Routine x-rays were interpreted as normal, but we observed that his cervical curve was almost absent and flexion views were incomplete.
On examination, his neck remained locked in extension at –15°. In August 2014, he sustained a twisting injury of his low back while golfing. This resulted in low back pain score of 8 out of 10. His acute injury was remedied within 10 days after 3 combined treatments of Sarapin and MFTPT.
Aggressive Therapy Started
Subsequently, an aggressive approach to improve his neck ROM was undertaken. We focused on the following muscles: levators, splenius cervicis, splenius capitis, multifidi, rotatores, scalenes, and rectus capitus muscles. After 3 months, he could flex his neck to +20° with extreme effort. In the spring of 2015, he resumed golfing and coaching high school baseball.
Because his neck flexion remained limited, the patient’s x-rays were sent to a chiropractor known for advanced interpretation of spinal pathology. The chiropractor diagnosed mildly decreased cervical lordotic curve (27°), dextroscoliosis (scoliosis to the right), forward head carriage, and atlas subluxation (locking of C0-C1 causing atlas misalignment: Figure 1).
Based on this diagnosis, the patient was referred to a certified cervical chiropractor for atlas realignment. Examination by the chiropractor was remarkable for palpable taut bands in the cervical and upper thoracic musculature and restricted cervical ROM.