Basilar impression presenting as intermittent mechanical neck pain: a rare case report

Abstract

BackgroundNeck pain is one of the most common musculoskeletal disorders in clinical practice. However neck pain may mask more serious pathology. Although uncommon in most musculoskeletal physiotherapy practices, it is possible to encounter rare and extremely life-threatening conditions, such as craniovertebral congenital anomalies. Basilar invagination is an abnormality where the odontoid peg projects above the foramen magnum and is the commonest malformation of the craniocervical junction. Its prevalence in the general population is estimated to be 1 %. Furthermore, it is a well-recognised cause of neck pain insomuch as it can be easily overlooked and mistaken for a musculoskeletal disorder. Diagnosis is based on the patient’s symptoms in conjunction with magnetic resonance imaging (MRI). If life-threatening symptoms, or pressure on the spinal cord are present, the recommended treatment is typically surgical correction.Case presentationThis case report describes the history, relevant examination findings, and clinical reasoning used for a 37 year old male who had the chief complaint of neck pain and occipital headache. After the history and the physical examination, there were several key indicators in the patient’s presentation that appeared to warrant further investigation with diagnostic imaging: (1) the drop attack after a triggering event (i.e., heading a football), (2) several episodes of facial numbness immediately and shortly after the trauma, (3) the poorly defined muscle upper extremity muscle weakness, and (4) the modification of symptoms during the modified Sharp-Purser test.Therefore, the decision was made to contact the referring neurosurgeon to discuss the patient’s history and his physical examination. The physician requested immediate cervical spine MRI, which revealed a “basilar impression”.ConclusionThis case report highlights the need for more research into a number of issues surrounding the prevalence, diagnosis, and the central role of primary care clinicians such as physiotherapists. Furthermore it underlines the importance of including Basilar invagination in the differential diagnosis. Physiotherapists working within a direct access environment must take a comprehensive history and be capable of screening for non-musculoskeletal medical conditions (on a systems, not diagnosis level) in order to avoid providing potentially harmful musculoskeletal treatments (e.g., cervical mobilization or manipulation, stretching, exercise) to patients with sinister medical pathologies, not benign musculoskeletal disorders.

Importance of screening in physical therapy: vertebral fracture of thoracolumbar junction in a recreational runner

“…Among the athletes that the physical therapist regularly evaluates, runners, both recreational and competitive, enjoy running as it is one of the most popular sports activities practised all over the world 1 2. Physical therapists routinely assess patients and athletes whose primary complaint is back pain alone,24–30 but when the clinical presentation is not clear other clinical conditions must be considered, with attention to an accurate process of clinical reasoning and screening for referral 25 31…”

“…In summary, this case report describes the clinical condition of a recreational runner presenting with post-traumatic thoracolumbar fracture, thus highlighting the importance of appropriate screening for physical therapists to facilitate the identification of potential pathologies that masquerade as a musculoskeletal condition by performing a thorough clinical examination 31…”

“…Noteworthy, in some cases, the clinical presentation of signs and symptoms is confusing and may mimic more serious conditions; thus, clinicians have to pay special attention when factors arise, such as the presence of red flags (RFs). For these reasons it is necessary to adopt a careful process of clinical reasoning and of decision-making to screen for potential RFs, and eventually direct these patients towards an appropriate diagnostic-therapeutic pathway 25 31. As reported in this case report, patients can present with LBP as a primary problem, mimicking an RF such as a fracture of the spine.…”

“…No loss of function was detected during the neurological examination; thus, on the basis of the anamnestic report (trauma, night pain, unable to lie supine sign,43 pain over 9 out of 10 on the NPRS) and the results of the clinical examination, a clinical diagnosis of specific LBP was made considering a possible vertebral fracture in the thoracolumbar junction. In accordance with the literature and clinical best practice,3 24–27 29 31 44 45 the patient was referred to the emergency unit for consultation. The patient was asked to inform the physical therapist about the outcome of the emergency unit visit or any change in their symptoms of LBP.…”

Osteochondritis Dissecans of the Radial Head in a Young Athlete: A Case Report

“…Physical therapists are capable of screening patients in need of medical referral for further examination or investigation of conditions. [33][34][35][36][37][38][39][40][41][42][43][44][45][46]47…”