I recently participated in a multidisciplinary seminar at the Jewish Hospital of Cincinnati. This was the third such seminar sponsored by the Ohio State Chiropractic Association. In attendance were DCs, MDs, and DOs. The subject was "Diagnoses and Treatment of Upper Extremity Syndromes." The speakers included chiropractors, orthopedists, radiologists, and neurosurgeons. The camaraderie and sharing between the representatives of the different healing arts was a pleasure to experience. I hope for the good of all of the professions and the public at large that this type of program may some day be sponsored by all 50 of our state organizations.
The conference was a learning experience that I would like to share with you. The following represents tidbits from the conference that you may find worthwhile:
Dr. Steven Skurow, D.C., presented a case with a possible suprascapular neuritis. The patient complained of a vague burning ache at the posterior lateral shoulder area. Testing revealed weakness and minimal or no pain on resisted testing of the supraspinatus and infraspinatus muscle. There was also atrophy of the infraspinatus muscle. Sometimes this condition is confused with a cuff rupture, and in this case EMG studies revealed a cervical radiculopathy as the cause.
Dr. Stewart Dunsker, a neurosurgeon stressed the importance of a case history. He stated that if the diagnosis is not made with the history, it is almost never made with the physical examination. He made very informative statements such as: bilateral paresthesias and bilateral carpal tunnel may be related to spinal cord involvement; pain caused by C2 spinal segment involvement, especially a fracture or dislocation, will describe excruciating mastoid pain especially on cervical rotation; and spinal cord tumors produce night pain. He remarked that when he is about to operate on a cervical radiculopathy and the patient is complaining of both pain and numbness, he tells the patient that the surgery is performed to eliminate the pain and not the numbness; "numbness is not a surgical problem."
Dr. Andrew Roth, an orthopedist, held that the most frequent cause of compression of nerve roots in the lumbar spine is due to herniation of the intervertebral disc while in the cervical region, the most common cause is osteophytic narrowing of the intervertebral foramina.
He described the elbow flexion test for entrapment of the ulnar nerve due to the cubital tunnel syndrome: "Sitting with both arms and shoulders in the anatomic position, both elbows are fully but not forcefully flexed, with full extension of the wrist to maximize both compressive and tensile forces on the nerve. The elbows are kept off all surfaces to avoid external compression during the exam, and pulses are checked to assure adequate tissue perfusion. Pain and numbness are usually the most anatomic in distribution, followed by tingling, then pain. The patients should experience a rapid resolution of symptoms with extension of the elbow."
Drs. Wells and Lenobel, radiologists, stated that MRI has replaced CT scan/myelography as the imaging method of choice for cervical spine disease. They felt that CT scan was probably better for acute trauma, but MRI was better for disc, cord, and soft tissue injury.
I spoke on functional evaluation of the shoulder and demonstrated friction massage on conditions that only friction massage could alleviate.
Timothy Smith, D.O., mentioned that an aneurysm of the thoracic aorta is inordinately painful and often unbearable. It may cause interference with circulation to the arms or legs and a patient may present with upper extremity pain. There would be a loss of arterial pulsations. It is important to rule out myocardial infarction. He also discussed a Pancoast tumor which may involve the brachial plexus causing a C7-T2 neuropathy with pain, numbness, and weakness of the arms. Chest x-rays with apical views are helpful in making the diagnosis.
This article cannot possibly do justice to the voluminous amount of information presented. I feel that all of the attending doctors gained increased respect for each other. Special thanks goes to Ron Fudala, D.C., who invited me and worked so hard to make this annual event a resounding success.
Warren Hammer, M.S., D.C., DABCO
Norwalk, Connecticut
Editor's Note:
Dr. Hammer will conduct his next soft tissue seminar on April 25-26, 1992, in New York City, and May 9-10, 1992, in Denver, Colorado. You may call 1-800-327-2289.
Dr. Hammer's new book, Functional Soft Tissue Examination and Treatment by Manual Methods: The Extremities, is now available. Please see the Preferred Reading and Viewing list on page xx, Parts #T126 to order your copy.
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