Non-surgical relief of cervical radiculopathy through reduction of forward head posture and restoration of cervical lordosis: a case report.

[Purpose] To present a case demonstrating the relief of cervical radiculopathy following the dramatic reduction of forward head posture and restoration of the cervical lordosis by use of a multi-modal rehabilitation program incorporating cervical extension traction. [Subject and Methods] A 31-year-old male patient presented with severe cervical radiculopathy and muscle weakness as well as neck pain. The patient had limited neck range of motion, and multiple positive orthopedic tests. Radiography revealed excessive forward head posture with a cervical kyphosis.
[Results] The patient received a multi-modal rehabilitation protocol including mirror image extension exercises, cervical extension traction, and spinal manipulative therapy. After forty treatments over 17 weeks, the patient reported a complete resolution of radiculopathy and significant improvement in neck pain level. Post radiography demonstrated correction of the spine and posture alignment. The patient remained well and maintained corrected posture with limited treatment one year later.
[Conclusion] Our case demonstrates the relief of cervical radiculopathy resulting from the non-surgical correction of forward head posture and cervical kyphosis.

INTRODUCTION

The cervical lordosis has been demonstrated to occur as early as 7.5–9 weeks in utero1) and should be considered more a primary, rather than a secondary curve of the spine. A reversal of the cervical lordosis—a kyphosis, is abnormal and associated with a barrage of symptoms, including neck pain, headache, and radiculopathy2, 3).

The correction of cervical lordosis by surgical means has been the procedure of choice for cervical radiculopathy for many years4, 5). Traditional physiotherapy approaches in the treatment of patients with cervical radiculopathy have not proven to be more effective than surgical approaches6), and as a stand-alone treatment has been shown to be no better than wearing a neck brace7). Physiotherapy approaches in treating this disorder must improve; one means is for the non-surgical restoration of cervical lordosis.

The restoration of cervical lordosis by non-surgical means has been established in the manual therapy literature8,9,10,11), and recently it has been shown to be effective in treating patients suffering from cervical radiculopathy11). This new approach in the non-surgical treatment of cervical radiculopathy mirrors the achievement of surgical fusion for successful treatment of patients suffering with radiculopathy; that is, by re-establishing the cervical lordosis—only not surgically, but by extension traction11). This case presents the successful reduction in right arm radicular symptoms in a 31-year-old male by improving posture through use of a multi-modal rehabilitation program incorporating cervical extension traction. This case is novel as it demonstrates a dramatic correction in head and neck alignment in a short period of time, and was maintained at a years’ follow up.

SUBJECT AND METHODS

On September 28, 2015, a 31-year-old male presented with a chief complaint of right upper arm weakness and neck pain, both a 6/10 (0=no pain; 10=worst pain ever). The patient scored a 46% on the neck Bournemouth questionnaire (NBQ)12) and had reduced mobility in the neck and multiple positive cervical orthopedic tests.

Cervical spine antero-posterior and lateral radiographic images were taken, then digitized and analyzed using the PostureRay system (New Port Richey, FL, USA). This system uses the Harrison posterior tangent method for lateral spine images13, 14), and the modified Riser-Ferguson method for AP spine images14). These measurement methods are repeatable and reliable13,14,15). The patient had excessive forward head posture (FHP), measured to be 49 mm, and a cervical kyphosis of +16° (normal lordosis is −31°- −42°16, 17)) (Fig. 1). Patient was diagnosed with right cervical radiculopathy.

Fig. 1.

Lateral cervical radiographs

Left: Initial taken on 9/29/15. Right: Follow-up taken on 2/4/16.

Green line indicates normal alignment; Red line indicates patient

The patient was treated with a structural spine rehabilitation protocol18,19,20) at a frequency of 2–3 times a week, totaling 40 treatments over 17-weeks. Treatment consisted of cervical extension exercises, cervical extension traction and spinal manipulative therapy.

Ten to fifteen repetitions of neck extension exercises were done against resistance bands (Pro-lordoticTM: Circular Traction, Huntington Beach, CA, USA). The traction was done in an extension set-up designed to restore the cervical lordosis8) (Fig. 2) and performed for 15–20 minutes each session. Home cervical extension ‘Denneroll’ traction was also prescribed11) starting at 5 minutes, progressing up to 20 minutes maximum daily. The patient was also given full- spine spinal manipulative therapy, as well as paraspinal stimulation with a hand-held instrument (Arthrostim®: Impac Inc., Salem, OR, USA). The patient gave verbal and written consent for the presentation of this case.

Fig. 2.

Cervical extension traction set-up

RESULTS

On February 4, 2016, the patient was re-examined after 40 treatment sessions (17 weeks later) and reported complete alleviation of upper arm weakness and neck pain. The patient scored a 0% on the NBQ, and had a cervical lordosis of −30.6° and a reduced forward head posture to −5.6 mm (Fig. 1). A one-year follow-up exam with minimal treatment (i.e. up to 2x/month) showed the maintenance of cervical lordosis (lordosis: −19.5°; FHP: 0.5mm), no radiculopathy and a NBQ score of 10%.

DISCUSSION

This report documents the successful outcome in a 31-year-old patient suffering from cervical radiculopathy by reducing extreme forward head posture and re-establishing the cervical lordosis.

The structural correction of cervical lordosis is an emerging evidence-based practice. Contemporary cervical spine surgical approaches attempt to preserve and/or re-establish the cervical lordosis to avoid neurologic symptoms as well as adjacent segmental disc disease. The same goals should hold true for the non-surgical re-modeling of the cervical lordosis.

Advances in non-surgical, manual techniques involving cervical extension traction have demonstrated consistency in the structural re-modeling of the cervical lordosis in symptomatic patients8,9,10,11). Specifically, in cervical radiculopathy patients, Moustafa et al.11) were able to demonstrate that patients under a multimodal physiotherapy program were only able to have lasting (1 year) symptomatic improvements if the cervical lordosis was corrected.

Re-establishing the cervical lordosis and reducing forward head posture is presumed to relieve cervical radiculopathy by decreasing the spinal canal length and thereby reducing the tension in the pons-cord neurological tissue tract21). Relaxation of the neural elements with a simultaneous improvement in neurological function was long ago demonstrated by the ‘cervicolordodesis’ surgical procedure invented by Alf Breig in the 1970s, for many neurological illnesses22).

Since contemporary, non-surgical methods have evolved to show consistent improvement in cervical lordosis in patients with cervical symptoms including radiculopathy, these should be practiced before resorting to surgical approaches which have potential risks including reoperation23). Limitations to this study is that it is just a single case; we believe the results from this case warrant further study to the non-surgical approach to cervical radiculopathy.