Chiropractic Management of a Patient with Chronic Post-surgical Neck Pain: A Case Report
Shawn M. Neff, DC, MAS, FACO1, 2, Alec L. Schielke3
1 Staff Chiropractor, Martinsburg Veterans Affairs Medical Center, Martinsburg, WV
2Adjunct Faculty, Palmer College of Chiropractic
3 Student, Palmer College of Chiropractic
Published: September 2016
Journal of the Academy of Chiropractic Orthopedists
September 2016, Volume 13, Issue 1
This is an Open Access article which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The article copyright belongs to the author and the Academy of Chiropractic Orthopedists and is available at: http://www.dcorthoacademy.com. © 2016 Neff/Schielke and the Academy of Chiropractic Orthopedists.
Introduction: This paper presents a case report of chiropractic management of a patient with myofascial cervicalgia as a sequela to carotid endarterectomy.
Case Presentation: An 83 year old male presented with a chief complaint of chronic right anterior neck pain and an associated tender mass. His surgical history includes a right carotid endarterectomy performed 32 months prior to initial chiropractic consult.
Management and Outcome: The patient was treated weekly with Instrument Assisted Soft Tissue Mobilization (IASTM) of the right cervical spine musculature and instrument assisted manipulation of the right first costovertebral joint. The patient’s pain resolved after five visits without sustained soreness or other side effects following treatment.
Discussion: Post-surgical pain is a common problem with a high degree of morbidity and a high overall cost effect. Myofascial adhesions are a well-documented cause of postsurgical pain. IASTM was effective and safe in treatment of pain and adhesion in a patient with chronic pain following carotid endarterectomy.
Keywords: Fascia; Therapy, Soft Tissue; Chiropractic; Endarterectomy, Carotid; Chronic Pain
More than 140,000 individuals die from stroke every year, making it the third leading cause of death in the United States, behind heart disease and cancer . Patients with carotid artery disease may undergo a preventative surgery known as carotid endarterectomy (CEA) during which a surgeon will make a 5-10 cm incision on the carotid artery and remove accumulations of atherosclerotic plaque [Figures A-C]. Another common alternative treatment known as carotid angioplasty stenting (CAS) utilizes an inflatable balloon to displace the plaque and a stent to lower the risk of future blockage . It is estimated that 100,000 CAE procedures occurred in the United States in 2010 .
The utilization of CEA declined between 1997 to 2010 as the use of CAS increased  despite studies suggesting that CEA is the preferred procedure in symptomatic patients due to decreased postsurgical risk of stroke when compared to CAS . CEA has its own risks, specifically with regard to health related quality of life measures such as difficulty swallowing and persistent neck pain [5, 6]. The more invasive nature of the CEA increases the risk for and intensity of postsurgical pain. As with other open surgeries, myofascial pain with adhesion is a common postsurgical complication [7, 8, 9].
Instrument assisted soft tissue mobilization (IASTM) is an emerging treatment for conditions with myofascial components. Evidence indicates that soft tissue mobilization promotes healing by increasing fibroblast production  and instrument assisted cross fiber massage has been shown to accelerate early tissue level healing as well as the orientation and formation of collagen fibers in ligament injuries .
The patient is an 83 year old caucasian male with right anterior neck pain and an associated soft, tender, mobile mass measuring approximately 2 cm by 3 cm in size. His surgical history includes a right carotid endarterectomy 32 months prior to initial chiropractic consult. He reported that the pain began a year and a half ago without inciting event or injury. He described the quality of pain as a soreness which he rated at a 2-3 out of 10 on the Numeric Pain Rating Scale (NPRS) where 0 equals no pain and 10 equals the most intense pain imaginable. The patient reported some pain relief from prescription acetaminophen (325 mg tablet, two per os every 6 hours as needed for pain). The patient’s medical history includes right carpal tunnel release, right hip replacement, left quadriceps tendon repair, left forearm osteomyelitis surgery, and a bone marrow surgery. Two months prior, a computed tomography study showed signs of cervical degeneration. The patient also reports a history of transient ischemic attacks prior to, as well as several following the carotid endarterectomy. Patient consult was sent from an otolaryngologist who was seeing the patient for the neck discomfort and dysphagia as well as otitis externa and impacted cerumen.
Physical examination yielded mild to moderate palpatory tenderness at the right anterior cervical region as well as the right supraclavicular fossa. Palpation also revealed moderate to severe hypertonicity of the anterior cervical musculature including the right sternocleidomastoid (SCM) and anterior and middle scalenes. Cervical range of motion was normal in flexion, but decreased in extension, left rotation, right rotation, left lateral flexion, and right lateral flexion. Active cervical right rotation, left lateral flexion, and right lateral flexion were provocative for right anterior neck pain. Static and motion palpation revealed a tender superior prominence of the right first rib as well as a decrease in superior to inferior fluid motion of the right first costovertebral joint.
Management and Outcome
Following the consult evaluation, the patient’s costovertebral joint was adjusted by a chiropractor with an Impulse® Adjusting Instrument (NeuroMechanical Innovations, Chandler, AZ) with a superior to inferior and lateral to medial line of correction. Additionally, IASTM was performed utilizing a FAKTR® Instrument F4 and emollient (FAKTR-PM, Inc., Asheville, NC) on the right, hypertonic anterior cervical musculature. Following initial treatment the patient rated his pain at 0 out of 10 on the NPRS and noted on a subsequent visit that he remained without pain for three days.
The patient completed a short course of conservative care at a frequency of 1 visit per week for 4 weeks, during which he underwent the same intervention of instrument adjusting and IASTM as needed. Adjustment of the right first costovertebral joint was accomplished on visits 1-4 only. IASTM treatment progressed from visit to visit as follows: neutral cervical position; passive right and left rotation; active patient cervical motion of combined flexion and right lateral flexion and right rotation into combined extension left lateral flexion and left rotation; resisted cervical motion from combined flexion and right lateral flexion and right rotation into combined extension, left lateral flexion and left rotation. Patient pain presentation on the third visit was decreased to 1-2 out of 10 on the NPRS and 0 out of 10 on the penultimate visit. Patient reported feeling better following the first and second visit, and the patient stated that he had no pain or soreness following the care of the 3rd, 4th, and 5th visits.
During of the fifth and final visit of initial course of care, the patient presented with a pain intensity of 0 out of 10 on the NPRS and reported only three exacerbations since the fourth visit which he rated at 2 out of 10 in terms of pain intensity. Following active treatment on the fifth visit, a home exercise program was described, demonstrated, and observed with instructions regarding frequency provided to the patient for stretching of the anterior neck musculature, specifically the SCM. The patient was asymptomatic at the conclusion of the fifth visit and was discharged with self-care recommendations and the option to return to clinic on a symptomatic basis.
Fascia becomes important clinically when it loses stiffness, becomes too stiff or has decreased shearing ability . A surgical operation can cause adhesions that, regardless of the surgical procedure adopted, are traceable in the underlying layers, with fascial tissue failing to differentiate the adjacent structures effectively leading to entrapments [13, 14]. Fibrous adhesions are known to be painful, prevent normal muscle mechanics and decrease soft-tissue extensibility . This case presented the use of a minimally invasive treatment for chronic post-CEA neck pain of myofascial etiology and yielded a good outcome over 5 weeks, without negative side effect.
The mean follow-up cost for CAE for one year is over $1,000  and in 2012, the United States alone had an estimated 100,000 inpatient CEA procedures . This creates a cost burden that is substantial and post-operative adhesions are associated with substantial morbidity and present a risk over time that can run into decades . Due to the nature of many operations, fascial layers are often disturbed during surgery, but more often than not, little to no attention is given to the remodeling to this anatomy.
When providing care directly to an area of increased and delicate vasculature, especially with complications such as stroke, precautions such as a thorough history and physical examination are of a paramount importance. Although the results from one case cannot be generalized, further study is indicated to determine if this procedure could benefit other patients for whom chronic postsurgical pain is a problem.
The authors recognize limitations of this case study. Generalization of the diagnostic findings and outcomes represented in this case may not necessarily apply to other patients.
Written consent for publication was obtained from the patient.
Supported by the Department of Veteran Affairs. The contents of this paper do not represent the view of the Department of Veterans Affairs or the United States Government. Public domain image(s) provided courtesy of The National Heart, Lung, and Blood Institute (NHLBI) https://www.nhlbi.nih.gov/health/health-topics/topics/carend part of the National Institutes of Health and the U.S. Department of Health and Human Services.
The authors declare that they have no competing interests.
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Public domain image(s) provided courtesy of The National Heart, Lung, and Blood Institute (NHLBI) https://www.nhlbi.nih.gov/health/health-topics/topics/carend part of the National Institutes of Health and the U.S. Department of Health and Human Services.