Radicular Arm Pain in a Patient on Anticoagulation
A 58-year-old man presents with 3 weeks of right neck and arm pain radiating to the thumb and index finger, with intermittent numbness. He has hypertension and atrial fibrillation and takes apixaban 5 mg twice daily. He denies trauma. On exam: right cervical rotation is limited to 40 degrees with reproduction of arm pain, Spurling's maneuver on the right reproduces radicular symptoms, and there is mild weakness of the right biceps (4+/5) with a diminished right biceps reflex. Sensation is decreased over the right thumb. He has no bowel or bladder changes, no gait difficulty, and no bilateral symptoms. He asks for "the neck adjustment that fixed his brother's."
1. How do the examination findings localize the lesion, and what does that imply about urgency?
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Localization: right C5-C6 level.
- Biceps weakness (4+/5) and diminished biceps reflex point to the C5-C6 myotome/reflex arc.
- Decreased sensation over the thumb is the C6 dermatome.
- Positive Spurling's and pain with ipsilateral rotation/extension are consistent with cervical foraminal narrowing or disc herniation at that level.
Urgency assessment:
- No myelopathic signs (no gait disturbance, no bilateral findings, no bowel/bladder dysfunction, no hyperreflexia or Babinski reported).
- Mild (4+/5) weakness is a soft sign; progressive or severe weakness (≤3/5), or any myelopathic sign, would escalate to urgent imaging and neurosurgical referral.
- At present, this is a radicular syndrome without myelopathy, which can be managed conservatively with imaging if symptoms progress or fail to improve.
Teaching point: Localize by dermatome, myotome, and reflex together; a single finding is not enough. Then screen for myelopathy, which changes the timeline entirely.
2. Given his anticoagulation, how do you counsel him about manipulation versus other OMT, and what is your treatment plan?
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Counseling on anticoagulation and manipulation:
- High-velocity thrust to the cervical spine is relatively contraindicated in a patient on a direct oral anticoagulant because of bleeding risk, particularly with the vascular structures of the neck and the potential for hematoma. Many practitioners avoid cervical thrust entirely in this population.
- Non-thrust OMT is reasonable and preferred: soft-tissue/myo-fascial release, muscle energy, counterstrain, and gentle traction to reduce muscle guarding and improve mobility.
- Avoid vigorous end-range rotation/extension maneuvers that could provoke the radicular symptoms.
Plan:
- Non-thrust OMT to the cervicothoracic region; home cervical traction and a structured home exercise program.
- Imaging (MRI cervical spine) if weakness progresses, if symptoms persist beyond 4-6 weeks, or if any myelopathic sign develops.
- Coordinate with his primary care/neurology if weakness worsens; consider referral for EMG/NCS if the diagnosis is unclear.
- Document the anticoagulant, the decision to avoid thrust, and the informed-consent discussion.
Teaching point: Anticoagulation is a relative, technique-specific contraindication, not an absolute bar to all OMT.