Descended Sacrum in association with Headache Complaints following a Motor Vehicle Accident: A Case Report
Author: Marianne McGreevy, MA PT
Abstract: In this case report, the patient is a 20 year old woman who was in a motor vehicle accident. Symptoms included headaches, back and neck pain, and bilateral upper extremity paresthesia. The patient reported increased pain during specific activities, including forward bending and sitting for longer then ten minutes. The patient presented with decreased spinal range of motion and postural deviations. She received treatment with Integrative Manual Therapy focusing on her vascular system and musculoskeletal system including biomechanics. After the therapy was completed, patient presented with significant increases in spinal range of motion. She reported total elimination of her headaches and numbness in both upper extremities. The patient was able to return to her regular activities.
Key Words: Motor Vehicle Accident, Headache, Descended Sacrum
Introduction
A 20-year-old female was involved in a roll over motor vehicle accident. This occurred in July 1999 and the patient presented in the clinic March 2000 with complaints of headaches, back and neck pain since the time of the accident. The headaches and mid back pain increased with any forward bending activities, sitting longer than 10 minutes or while maintaining any prolonged posture. The headaches were constant and started at the base of the skull and would progress to the back of her eyes causing pressure and pain ranging from 3-8/10 on a pain scale. There was numbness of bilateral upper extremities (UE’S) occurring primarily in supine and was most intense first thing in the morning. Low back and mid back pain were constant and described as aching and sore. Sleep was disturbed 3-4 times per night secondary to pain and she was unable to participate in her normal activities including general weight lifting and horseback riding. She had difficulty with reading and work at the computer. Since her accident, she had been receiving chiropractic manipulation 1-3x/week. She had also participated in physical therapy for two months with only temporary relief of symptoms from either discipline.
Evaluation Results
|
Foward Bend (FB)
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Side Bend Left (SBL)
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Side Bend Right (SBR)
|
Rotation Left (RL)
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Rotation Right (RR)
|
Backward Bend (BB)
|
|
|
Cervical Spine
|
15%
|
20%
|
10%
|
40%
|
20%
|
20%
|
|
Thoracic Spine
|
30%
|
50%
|
50%
|
40%
|
40%
|
5%
|
|
Lumbar Spine
|
20%
|
30%
|
30%
|
10%
|
10%
|
0%
|
.
Myofascial mapping (9) in the transverse plane (see fig 1.)
Longitudinal Pressure Scan (10) x 5: Left side at region of tentorium cerebelli
figure 1. Myofascial mapping in the transverse plane
Treatment
Based on techniques and principles of Integrative Manual TherapySM (11).
March 29th (1 hour ):
Treatment: A Disruption of Membrane (DOM) was present at the region of the left medial aspect of the tentorium cerebelli, and was treated with a Disruption of Membrane Technique. This was followed by Muscle Energy and ‘Beyond’ Techniques for a bilaterally descended sacrum and a right upslip. The 5 Point Longitudinal Pressure Scan (LPS) then indicated DOM’s at the region of the aorta. Strain and Counterstrain techniques were done at all diaphragms, Disruption of Membrane Technique along the region of the length of the aorta followed by Compression Syndromes of the aorta.
April 6 (1 hour):
Subjective: Patient had no headache for 5 days after initial treatment. The headache had returned over the last 2 days but intensity was less and it no longer increased with forward bending. Patient complained of lower thoracic spine pain and numbness of UE’s if lying on her side.
Objective: Treatment: Frontal, parietal, temporal and occipital dural releases. Compression syndromes at bilateral tentoral arteries and great cerebral vein of galen. DOM at left medial portion of tentorium cerebelli, at left tentoral artery and at spinal artery at T8 level. Type III technique at T8, and further DOM of dura mater at T8 level. Type III respiratory diaphragm and DOM of the lesser curvature of the stomach.
April 12th (1 hour):
Subjective: No headaches since last treatment. Continues to have bilateral UE numbness if she lies on her side at night. Stiffness present in low back when waking in the morning.
Objective: Treatment: LPS at left brachiocephalic vein, DOM here as well as at bilateral brachial veins. MFR at bilateral clavipectoral regions and thoracic inlet, Advanced Strain and Counterstrain at thoracic inlet with defacilitated facial release, Compression Syndrome of right ulnar nerve with DOM and Neural Tissue Tension Technique of that nerve. Compression Syndrome and Strain Counterstrain of left axillary lymph nodes.
Outcomes
Patient failed to return for her next appointment. During a phone conversation a month later she stated she continued headache free, no longer had UE numbness and continued to have stiffness in her low back when waking. She was back to full participation in her desired activity level and no longer had any pain complaints as mentioned during her initial visit.
ROM (at last treatment):
Cervical spine: 90% in all planes
Thoracic spine: 80% in all planes
Lumbar spine: 80% in all planes
Discussion
After 3 hours of Integrative Manual TherapySM this patient had large range of motion gains through her full spine and an elimination of pain complaints. The key factors of her dysfunction were 1) the descended sacrum. 2) The DOM’s at the tentorium cerebelli, left tentorial artery and great cerebral vein of galen. 3) DOM’s at the aorta, left brachiocephalic vein and brachial veins. 4) A type III dysfunction at T8 and respiratory diaphragm. 5) A DOM of the spinal artery. A literature review supports the hypothesis that the impact from the car accident contributed to these dysfunctions.
Literature Review:
Both Lindenberg (1) and Mosberg & Lindenberg (3) describe a caudal shift of the cerebral hemispheres, secondary to a blunt force to the head. Lindenberg (1) states that "The vertex becomes flattened or indented at the site of the impact and, accordingly, the vertical axis of the skull becomes shortened, whereas the axis between the temporal regions becomes elongated. This produces a sudden stretching of the corpus callosum which at the same time moves with the other adjacent structures of the hemispheres towards the base of the skull". Weiselfish-Giammatteo continues on this thought recognizing the effects of the impact force as it continues down the kinetic chain. She describes a biomechanical dysfunction called a descended sacrum, resulting from a head-on injury (6, 7). The descended sacrum causes a tractioning of the dura due to its attachment to the sacrum (6). Lindenberg (1) also recognizes the translatory affect of force impact through the kinetic chain. The patient in this case study was found to have a descended sacrum.
Lindenberg (1) and Vielvoye (4) describe traumatic injuries resulting in tears and contusions related to the tentorium. Vielvoye (4) states that "Tentorial tears almost invariably occur just below the junction with the falx on one side or both sides. There may be separation of the superficial layer of fibers only, or a full thickness tear which usually involves the free margin." Lindenberg (1) describes the parameters necessary for a cerebral contusion as; Impact of an accelerating head striking a firm stationary object, impact at the forehead or the base of the head near the foramen magnum, and force directed towards the tentorium. Mosberg & Lindenberg (3) further describe the ill affects of force on the tentorium and neighboring structures when impact occurs through the top of the head. Details of how impact occurred with this patient are not available due to the nature of her roll over car accident, however it is probable that she hit both the frontal and top portion of the skull. Palpatory diagnostics indicated a tear in the tentorium most prominent on the left aspect near the junction of the falx.
Lindenberg (2) discusses secondary lesions caused from an increase in intracranial pressure especially at the supratentorial location. The faster the rate at which pressure increases, the more significant the arterial compression (2). "Compression of an artery might be related to its failure to adapt itself to acutely developed, abnormal stress. The artery may react with spasm or paralysis causing a localized lowering of the blood pressure which facilitates compression."(2) Compression of the intracerebral vessels results in hypoxia which in turn increases the permeability of the vessel and may lead to necrosis.(2) Weiselfish-Giammatteo (5) describes the increased permeability of a vessel as a disruption of membrane (DOM) and has developed techniques that release the protective compression around the disrupted membrane as well as a treatment called facial cohesion therapy that facilitates healing of the DOM. Palpatory diagnostics indicated a DOM of the left tentorial artery, and great cerebral vein of galen in this patient.
The blunt force of the seatbelt as it impacted the patients torso may be the contributing factor towards the DOM’s that were found on the aorta, brachial veins, left brachiocephalic vein and spinal artery at the T8 level. It was not surprising to find type III dysfunction’s in this patient at the respiratory diaphragm and T8, considering the mechanical forces present as the seatbelt presses posteriorally while the torso is moving anteriorally. Weiselfish-Giammateo (8) describes type III dysfunction’s as a shearing mechanism of the tissue.
Summary
Integrative Manual TherapySM principals for diagnostics and treatment were effective in altering this patient’s range of motion and pain symptoms. The combination of a descended sacrum, type III dysfunction at the respiratory diaphragm and T8, as well as the DOM’s at the tentorium, left tentorial artery, great cerebral vein of galen, aorta, left brachiocephalic vein, left brachial vein and spinal vein were significant in this patients ongoing headache complaints and range of motion limitations. Using the Integrative Systems Approachã provided her the opportunity to resume full participation in her desired activities in a pain free manner.
References