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OMM Question of the Day: Left neck pain

Osmosis Team
Published on Nov 10, 2021. Updated on Nov 9, 2021.

Today's OMM question involves a 28-year-old woman who was recently brought to the emergency department with six days of neck pain and arm numbness. MRI of the cervical spine shows a minimal herniation of the nucleus pulposus below the C7 vertebra. What is the correct treatment for this patient's symptoms? 

A 28-year-old woman presents to the emergency department with six days of neck pain and arm numbness. She describes the neck pain as a sharp sensation localized to her lower left neck and clavicle and without radiation. Her past medical history is non-contributory, and she takes no medications. Her vital signs are within normal limits. On physical examination, her left first rib does not move fully during exhalation. Reflexes are 2/4 at the left biceps, brachioradialis and triceps. There is decreased sensation at the left lateral arm and forearm. Muscle strength in finger flexors, and wrist flexors and extensors is 5/5 on the left. MRI of the cervical spine shows a minimal herniation of the nucleus pulposus below the C7 vertebra. Which of the following is the correct treatment for this patient’s symptoms?

A. Corticosteroid injection of facet joint at C7-T1

B. Anterior cervical discectomy and fusion at C7-T1

C. Physical therapy

D. Supine high-velocity low-amplitude (HVLA) thrust at the 1st rib on exhalation

E. Oral naproxen

Scroll down for the correct answer!


The correct answer to today's OMM Question is...

D. Supine high-velocity low-amplitude (HVLA) thrust at the 1st rib on exhalation

Before we get to the Main Explanation, let's look at the incorrect answer explanations. Skip to the bottom if you want to see the correct answer right away!

Incorrect answer explanations

The incorrect answers to today's OMM Question are...

A. Corticosteroid injection of facet joint at C7-T1

This patient’s MRI does not mention any spinal stenosis or facet hypertrophy.

B. Anterior cervical discectomy and fusion at C7-T1

Although she has a herniated nucleus pulposus, it is mild and asymptomatic. Symptoms from this would affect the C8 nerve dermatome (5th digit and medial forearm), not the C5-C6 dermatome.

C. Physical therapy

Although this could potentially help, there is an obvious somatic dysfunction of the 1st rib. Treating that first may completely resolve her symptoms.

E. Oral naproxen

This could potentially help if there were obvious signs of nerve root irritation. However, this patient’s symptoms are likely related to her 1st rib dysfunction which should be treated first.

Main Explanation

Thoracic outlet dysfunctions can cause signs and symptoms mimicking cervical spine pathologies. 1st rib somatic dysfunctions can contribute to thoracic outlet dysfunctions, and can be easily treated with muscle energy, HVLA, and other techniques. Remembering the dermatomes and corresponding muscles can help differentiate between cervical spinal cord pathologies and more peripheral causes of neuropathy/radiculopathy. This patient has issues in her C5-C6 dermatome, and the mild herniated nucleus pulposus does not explain these symptoms (it would affect the C8 dermatome and muscles).

Treatment of 1st rib dysfunction with HVLA can be performed in a supine, prone or seated position. For the supine position, sidebend their head/neck toward the dysfunction side and rotate away. Engage the 1st rib with your second MCP and direct a caudal and medial thrust to the 1st rib at the end of exhalation. For this patient’s left-sided 1st rib dysfunction, she should be sidebent left and rotated right.

Major Takeaway

Treatment of 1st rib inhalation dysfunctions in the supine position involves sidebending the head/neck toward and rotating it away from the dysfunction side. The physician then thrusts with the 2nd MCP into the 1st rib at the end of exhalation.

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