ABSTRACT Rolfer™ Flynn Vickowski reaches out to Certified Advanced Rolfer Jeffrey Burch for advice on managing clients who present with cervical stenosis. One of Vickowski’s clients has anonymously shared an MRI and neurosurgical consultation report detailing long-term neck pain and related symptoms. Burch’s recommendations include emphasizing the importance of medical imaging, understanding the nature of stenosis, the value of individual assessment for locating the primary cause of pain symptoms, and surgical considerations that the client may need to consider with their physicians.
Editor’s note: Rolfer Flynn Vickowski has given Structure, Function, Integration permission to publish their original question, and their client has permitted us to print the notes from a 1992 neurosurgical consultation, the 2023 MRI of the cervical stenosis, and the written report.
Notes by MD, Neurosurgical Consultation, 1992
To Whom It May Concern,
[This client] is a thirty-three-year-old computer software salesman who has a long history of neck pains. He also has intermittent cervical spasms. Occasionally, he will wake up with numbness in his hand. Additionally, on occasion, he gets soreness in his left buttock. The numbness in his hand is noted to be in the hypothenar eminence. He rubs his hand, and in a short period of time, this improves. He has used various cervical pillows.
He has previously played multiple sports, most particularly baseball and basketball, and he participated in a junior football program. On one occasion he had a ‘stinger’. He described this as a pain radiating from his neck up along the distribution of the occipital nerve bundle. He states that when he doesn’t exercise, jog, or workout, he still has the same discomfort. In addition, any kind of stressful situation exacerbates similar neck discomfort.
An MRI study in October 1992 revealed multiple-level degenerative changes C3 through C7, with significant foraminal narrowing, most particularly on the left at C7.
His past medical history and examination are otherwise unremarkable. There is, however, a restriction of cervical extension. His strength, reflexes, and sensory examination are also unremarkable.
In summary, the [client] relates a long history of recurrent cervical pain and spasms, generally but not necessarily exacerbated by increased activities. His MRI test revealed multiple-level degenerative disease. He is a young man who suffers from significant cervical degenerative disease. It is impossible to predict the future course. There is, to the best of my knowledge, very little that he can do to prevent the current disabilities other than learning to live with them and avoid what might exacerbate this discomfort. Generally, as one ages, the process tends to burn itself out. Many years from now, he may be a candidate for decompressive surgery, but at present, I do not believe there is any specific treatment.
Since this process obviously starts from biochemical intradiscal changes, similar diskogenic abnormalities can be assumed in the lumbar and thoracic spines. I gave him a pamphlet describing the treatment of neck pain.
Thank you for this most interesting consultation.
The Question
Monday, August 26th, 2024.
Hi Jeff,
I hope you’re doing well. I am looking for tips and more information about working with cervical stenosis. A couple of clients with this condition have come to me recently. One sent me a recent X-ray with its accompanying report and also a description of a neurosurgical consult they had in 1992. They told me that they were in a lot of pain and had been for some time. Do you have any resources or recommendations you could send or point me toward?
Warmly,
Flynn Vickowski
Certified Rolfer™
2023 MRI Report
History:
Cervical spondylosis without myelopathy, neck and upper extremity pain.
Technique:
Multiplanar multisequential imaging of the cervical spine obtained with IV gadolinium.
Alignment Findings:
There is reversal of the normal cervical lordosis, apex at C4. There is mild degenerative retrolisthesis of C4-C5, C5-C6, and C6-C7, with mild anterolisthesis also present at C3-C4.
Intervertebral Disk Findings:
Multilevel degenerative disc disease as further detailed below although greatest at the C4-C5, C5-C6, and C6-C7 levels.
C2-C3:
Disc space narrowing and mild disc desiccation, probably at least in part congenital in etiology. No focal disc herniation. Mild bilateral facet hypertrophy with relatively mild bilateral foraminal narrowing.
C3-C4:
Severe facet hypertrophic changes are noted on the right with moderate facet hypertrophy on the left. There is mild degenerative anterolisthesis with mild disc desiccation and a diffuse disc bulge. There is severe right and moderate to severe left neural foraminal stenosis.
C4-C5:
There is degenerative disc disease with diffuse disc bulge, endplate spurring, and bilateral uncovertebral joint hypertrophy. There is mild to moderate bilateral facet arthrosis. There is high-grade bilateral neural foraminal stenosis. There is a more focal left subarticular disc protrusion noted, flattening the ventral aspect of the thecal sac. There is ample CSF [cerebrospinal fluid] dorsal to the cord. Anterior-posterior diameter of the spinal canal is estimated at 7mm.
C5-C6:
There is degenerative disc disease with diffuse disc bulge, endplate spurring, and bilateral uncovertebral joint hypertrophy. There is bilateral facet arthrosis and severe bilateral neural foraminal narrowing. There is severe spinal stenosis with compression of the cervical cord. No definite abnormal cord signal is visualized. Anterior-posterior diameter of the thecal sac measures approximately 5.6mm at the midline.
C6-C7:
There is moderate degenerative disc disease with diffuse disc bulge, endplate spurring, and a broad-based disc protrusion, asymmetric on the right. There is also compression of the ventral aspect of the cord, with the anterior-posterior diameter of the thecal sac roughly estimated at approximately 7mm at the midline. There is severe bilateral neural foraminal stenosis.
C7-T1:
Mild disc desiccation but no disc herniation. Mild facet hypertrophic changes. No significant spinal canal or foraminal stenosis.
Impression:
1. Multilevel cervical spondylosis with reversal of the normal cervical lordosis.
2. Multilevel spinal stenoses, severe at the C5-C6 and C6-C7 levels. There is mild compression of the cervical cord at C5-C6 greater than C6-C7. There is no abnormal cord signal identified however.
3. Severe multilevel neural foraminal stenoses from the C3-C4 through the C6-C7 levels.
The Answer
By Jeffrey Burch
To start, I advise clients with any kind of spinal stenosis to have medical imaging done before any manual therapy treatment. Cervical spinal stenosis has been found to have a prevalence of 4.9% in the general adult population, 6.8% in adults fifty years or older, and 9% of adults seventy years of age or older (Lee, Cassinelli, and Riew 2007). While those are the figures in the general population, the incidence of cervical stenosis in people with cervical and upper limb chronic pain is higher. As structural integrators, we have a role in treating people with cervical stenosis. It is imperative to prioritize medical data specific to our individual client’s presentation to guide interventions.
Stenosis by definition is a narrowing or constriction of a body passage. When it comes to a spinal stenosis, or a cervical stenosis specifically, the narrowing is due to bone growth. In other words, stenosis is a fancy term that means bone spurs. Spinal stenosis is distinguished into two geographic groups. (1) Bone spurs can be in the neural canal, potentially impinging on the spinal cord. This is called central stenosis. (2) Bone spurs on the perimeter of the neural foramina may press on nerves as they exit the spine. This is called foraminal stenosis.
Stenotic bone spurs can point in many different directions and have varying lengths, from tiny nubs to incredible stalactites. Stenotic bone spurs become important when their direction and length impinge on a nerve of the spinal cord. Shorter bone spurs and certain directions of bone spurs, which do not contact neural tissue, cause no symptoms. Larger spinal bone spurs can be quite disabling. And while the likelihood of cervical stenosis increases with age, it can occur in young people. It is important neither to discount the possibility of stenosis just because a person is young, nor to assume it is a big problem because a person is older. As always, epidemiology statistics are useful for describing populations, not individuals. As I mentioned earlier, the only way for a person to know if they have a stenosis is MRI imaging.
If you have a client present with a cervical bone spur that has been confirmed by radiology, and this client also has neck pain, keep in mind, the bone spur may or may not be contributing to the pain. The pain could be a result of multiple possibilities: the bone spur may be the whole source of the pain, one of several contributors to the pain, or not contributing to the pain experienced. There are ways to distinguish this and gathering this information to guide treatment is essential.
Plane X-rays can show some but not all stenotic bone spurs. They are better at showing foraminal stenosis and close to useless for central stenosis, but they don’t usually show the full extent of the foraminal stenosis in the first place.
Oblique X-rays do a better job of showing foraminal stenosis than anterior-posterior and lateral X-rays. Today, oblique spinal X-rays are rarely done; MRI does an even better job than oblique X-rays at distinguishing foraminal stenosis, so MRIs have largely replaced oblique X-rays for this purpose. An MRI will also disclose central stenosis, while both plane and oblique X-rays cannot show central stenosis.
X-rays cannot show soft tissue, including the nerves and spinal cord, they show one angle of the bones, and the bone spur if there. The presence of a bone spur seen on an X-ray does not tell us if the bone spur is pressing on a neural structure. MRI will fully show this. If the MRI shows no nerve impingement, then the source of the pain is something else, and our work will likely help. If a stenotic bone spur is pressing on a nerve or the spinal cord, surgery must come first. After the person has healed from surgery, our work will help clean up the region and relieve older strains present in the person’s neck.
Apply Caution with Diagnosed Cervical Stenosis
One feature of cervical stenosis presentation is that, if the bone spur is pressing on the nerve or the spinal cord, then time becomes important. The longer the pressure lasts, the more likely there will be permanent nerve damage even after the bone spurs are surgically removed. Therefore, it is in your client’s best interest to promptly discuss the potential benefits of an MRI with their doctor. Then, if the MRI shows bone spur pressure on a neural structure, your client should have a prompt surgical consultation.
Currently, surgical removal of stenotic bone spurs is usually done endo-scopically. Compared with older open-surgery methods, healing time is dramatically shorter. A friend recently had endoscopic surgery done for lumbar stenosis. He was on his feet the next day and fully recovered in a month, all with little pain.
Over time, the size of stenotic bone spurs will increase. They never decrease on their own. The rate of increase cannot be predicted and may include episodes of pauses in growth, but never regression. I am not aware of any therapeutic process that can shrink bone spurs.
With our manual therapy work, we can improve neck mobility and alignment. Concerning stenosis, particularly foraminal stenosis, improving mobility and alignment will sometimes reduce pressure on a nerve. However, the body will often have compensation to reduce the pressure on a nerve. As an example of such compensations, an increased cervical curve can open the neural foramen, reducing pressure on a nerve root. In that case, restoring a more normal curve and mobility could remove the compensation, thereby increasing nerve pressure and symptoms.
This potential to sometimes increase symptoms and nerve damage is one reason the client should seek prompt further imaging to clarify the situation.
Follow Up
In the end, Flynn Vickowski took Burch's advice. She wrote an email to the client advising against Rolfing Structural Integration at this time due to the severity of his cervical stenosis. Vickowski let him know that, given the bone spur compression on the spinal cord, she recommended that he consider the option to have surgery as soon as advised by his doctor. She offered that once his body had done some essential healing after surgery, Rolfing Structural Integration would be safe and beneficial in restoring mobility and alignment. While Vickowski could appreciate the client's preference to avoid surgery, with the information Burch provided, in this case, delaying surgical intervention may lead to lasting disability. Only a surgical consultation would be able to determine this risk. Vickowski and the client had a follow-up phone conversation where the client expressed gratitude for all the information and caution. Interestingly, he did not know that bone spurs caused the stenosis. No one had used the term with him. He offered to pay Vickowski for her time on this consultation, which she declined. The client appreciatated her diligence, integrity, and professionalism in this matter.
Jeffrey Burch received bachelor’s degrees in biology and psychology, and a master’s degree in counseling from the University of Oregon. He was certified as a Rolfer in 1977 and completed his Advanced Rolfing® Structural Integration certification in 1990. Burch studied cranial manipulation in three different schools, including with French osteopath Alain Gehin. Starting in 1998, he began studying visceral manipulation with Jean-Pierre Barral, DO, and his associates, completing the apprenticeship to teach visceral manipulation. Although no longer associated with the Barral Institute, Burch has Barral’s permission to teach visceral manipulation. Having learned assessment and treatment methods in several osteopathically derived schools, he developed several new assessment and treatment methods that he now teaches, along with established methods. In recent years, he has developed original methods for assessing and releasing fibrosities in joint capsules, bursas, and tendon sheaths. He is also beginning to teach these new methods. Burch, as the founding editor of the IASI Yearbook, regularly contributes to it, as well as to other journals.
References
Lee, Michael J., Ezequiel H. Cassinelli, K. Daniel Riew. 2007. Prevalence of cervical spine stenosis. Anatomic study in cadavers. The Journal of Bone and Joint Surgery 89(2):376-80.
Keywords
degenerative disc; cervical; stenosis; MRI; structural integration; bone spur. ■
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