The patient is a 55-year-old right-handed female with a history of concussion and neck injury, sustained in a motor-vehicle accident when her stopped car was rear-ended by a two-door passenger vehicle.
She reported immediate pain on the right side of her head and neck; her pain issues have since improved, but four months later, she still suffers from headaches, poor concentration, difficulty multitasking, and soreness in the back of the neck and on any prolonged neck bending. She has noted slowness in speech. She cannot focus. She has some sleep disruption.
Vital Signs: blood pressure 130/90, pulse 72.
Chiropractic spinal listings detected at vertebral levels C0/1, C5/C6. There is some cervical facetal tenderness. No Adam's sign (scoliosis) noted. Testing sensory discrimination in right upper extremities C4 dermatomes demonstrates heightened sensitivity.
Radiological findings: Cervical lordosis is non-maintained and mensuration reveals 18 degrees with room for a radiological disparity of +/- 7 degrees. There is a mild loss in disc height, sclerosis and osteophytes projection involving cervical fifth and sixth levels. Radiographic impression includes loss in cervical lordosis.
Neurologic Findings: Cranial nerves tested and outlined as follows:
- CN I is not tested.
- CN II normal fields of vision, fundus exam normal disc appearance.
- CN III, IV, and VI reveal normal movement, no ptosis or nystagmus. Pupils are equally reactive to light and accommodation.
- CN V reveals normal symmetric sensation.
- CN VII reveals normal symmetric facial movements without evidence of weakness.
- CN VIII reveals equal and normal hearing distance of 6 feet.
- CN IX / X reveals normal elevation and movement of palate and uvula.
- CN XI reveals shoulder elevation and adduction of scapula normal.
- CN XII reveals normal tongue midline movement without either deviation or atrophy.
Strength is normal (5/5 in all extremities), with some pain production of cervical spine on PROM with normal muscle bulk. Noted that suboccipitals reveal some hypertonicity. Reflexes are 2+ in the extremities. Sensation is normal on light touch and to vibration and light prick. There is a negative Romberg's. Tandem gait intact.
Pain and discomfort on digital exam in region of dermatome C4-5 right-sided. Tingling and scalp paraesthesias on digital examination. Coordination is normal on heel-shin, finger-nose and rapid alternating. Remaining spinal exam is normal.
Summary and Impressions
This is a 55 year-old right-handed female who suffered a closed head injury from a motor-vehicle accident with subsequent traumatic brain injury and concussion. She is suffering from post-concussion syndrome and residuals of cervical facetal injury (whiplash-associated disorder), psychomotor retardation and slowing of cognition.
Mild traumatic brain injury (MTBI) represents 70-90 percent of all treated brain injuries.1 Today, the combination of high-resolution MRI with specifically tailored scanning protocols provides evidence of microstructural abnormalities in MTBI patients.2 Umile, et al., recently reported that participants with post-concussion syndrome performed more poorly in neuropsychological tests and showed structural abnormalities in high-resolution MR scans after MTBI without loss of consciousness.
Case management included specialty referral for diagnostic imaging, neurology, and physical medicine and rehabilitation behavioral specialists. The patient's care concluded uneventfully after the sixth month of chiropractic and medical co-management.
- Cassidy JD, et al, Incidence, risk factors and prevention of mild traumatic brain injury: results of the WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury. J Rehabil Med, 2004 Feb;(43 Suppl):28-60.
- Umile EM, et al, Dynamic imaging in mild traumatic brain injury: support for the theory of medial temporal vulnerability. Arch Phys Med Rehabil, 2002 Nov;83(11):1506-13.
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