Post-Fall Neck Pain in an Anticoagulated 72-Year-Old Who Wants the Same Adjustment as Always
72-year-old woman presents 5 days after a backward fall onto her buttocks, with new occipital headache and neck stiffness. She has atrial fibrillation on apixaban 5 mg twice daily, hypertension, and a transient ischemic attack 3 years ago. She denies syncope, diplopia, dysarthria, or weakness. Blood pressure 148/86, pulse 78 and irregular. Examination: marked restriction and pain at C1-2 rotation bilaterally, tenderness of the suboccipital muscles and upper cervical facets, no focal neurologic deficit, cranial nerves intact, no nystagmus, Dix-Hallpike negative. She asks you to 'crack her neck like before' -- she has had manipulation elsewhere for years.
1. Stratify her risk and identify what must be excluded before any high-velocity cervical thrust.
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Two separate questions, and they must not be merged.
A. Is there structural injury that must be imaged before any manual care? Age 72, a fall onto the buttocks 5 days ago, therapeutic anticoagulation, and new occipital headache with upper cervical tenderness. Each factor alone is modest; together they raise the probability of occult fracture meaningfully. The headache pattern plus upper cervical point tenderness is the specific trigger. My threshold for imaging is deliberately low here: I would not deliver high-velocity manipulation before fracture is excluded, and cervical CT is the practical study in this setting because it is fast and sensitive for bone.
B. Even if imaging is negative, is thrust manipulation appropriate? Her vascular risk is not baseline -- recent TIA, age, hypertension, irregular pulse. The TIA history is not an absolute contraindication to cervical manipulation in itself, but combined with recent trauma and anticoagulation it makes a thrust technique a poor trade when effective alternatives exist.
Conclusion: image first, then use low-risk manual care. The fact that she has been manipulated for years without incident is not evidence about this episode; her risk profile has changed.
2. Assuming imaging excludes fracture, design and justify a treatment approach.
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- Cervical mobilization, grades I-II, supine or seated -- provides mechanical input without pre-manipulative positioning, rotation, or end-range thrust loading of the vertebral artery.
- Drop-table or instrument-assisted contacts at the thoracic and upper cervical regions -- light, controlled force with no rotational cervical loading.
- Soft tissue: suboccipital release, upper trapezius and levator inhibition, ischemic compression of the posterior cervical musculature.
- Home program: chin tucks, scapular retraction, graded cervical range work, sleep and workstation positioning.
- Defer high-velocity cervical thrust until fracture is excluded, she is stable on reassessment, and she has given informed consent specific to that risk.
Justification logic: the therapeutic goal is restoration of motion and reduction of pain, not the delivery of a thrust. Every technique above achieves the first without incurring the second's risk. Choosing the low-risk path costs a small amount of short-term specificity and buys a large reduction in catastrophic-risk exposure.
Also state plainly: manual care is adjunctive. New headache after a fall in a patient with vascular risk factors needs medical evaluation regardless of how well she responds to treatment.
3. What must the informed consent cover, what should be documented, and which findings would prompt urgent referral?
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Disclose:
- The diagnosis the technique is intended to address.
- That the evidence for cervical manipulation in her presentation is modest and that alternatives exist and are being offered.
- The serious-but-rare risks -- vertebral artery dissection and, in her case, fracture -- in absolute rather than alarmist terms.
- That she may stop at any point, and that a thrust technique is being deferred and why.
Document: her own words, not merely a signature; the specific risks discussed; the imaging result and its date; the techniques chosen and the ones declined; the reasoning for deferral; the referral plan.
Stop and refer urgently for:
- New or worsening headache with neck pain, especially thunderclap onset.
- Diplopia, dysarthria, dysphagia, ataxia, new vertigo, or any new cranial nerve finding.
- Focal weakness, sensory level, hyperreflexia, or new upper extremity numbness.
- Worsening pain despite appropriate care, or any fracture identified on imaging.
- A change in anticoagulation status or a new fall.