Neck and shoulder stiffness and pain for 3 years in a 57-year-old patient with nuclear magnetic diagnosis of cervical disc herniation

(Disclaimer: This article is for scientific purposes only. To protect the patient’s privacy, the relevant information in the following content has been processed) Abstract: In this case, the patient had stiff neck and cervical spine pain for 3 years prior to the consultation and the pain was discharged to the scapulae and occipital region, and the symptom was gradually alleviated after resting. After coming to the clinic, an MRI examination confirmed a cervical disc herniation compressing the nerves. In order to alleviate the clinical symptoms and improve the quality of life, the patient was admitted to the hospital for conservative treatment, and his symptoms were relieved after cervical spine braking and massage physiotherapy. Basic information] Male, 57 years old [Disease type] Cervical disc herniation [Hospital] Harbin No.1 Hospital [Date of consultation] April 2022 [Treatment plan] Cervical spine braking + cervical spine traction + wax therapy + hydrogen iontophoresis + massage + medication (flurbiprofen ester injection) [Treatment cycle] Hospitalization for 1 week, outpatient follow up for 3 months [Effect of treatment] Pain relief, cervical spine activities Recovery I. Initial Consultation The patient was a 57-year-old man who came to the hospital with radiating pain in the neck, scapula and occipital area, and there was no abnormality in the muscle strength of the upper limbs. Based on the symptoms and examination results, it was considered that cervical disc herniation only had mild radicular symptoms, and there was no serious compression of the spinal cord or spinal nerve roots. Therefore, non-surgical treatment should be chosen to relieve clinical symptoms. During the treatment period, the patient should be closely observed for changes in condition, and if there are symptoms of spinal cord compression, the patient should be changed to surgical treatment. Communicate with the patient that the choice of treatment for cervical disc herniation is usually based on clinical presentation, not imaging, and that the patient’s condition is amenable to non-surgical treatment. The patient needed to correct bad working or living habits to prevent excessive stress on the cervical spine, which could aggravate the cervical disc herniation. Cervical collar braking was used during the non-surgical treatment to limit the excessive movement of the cervical spine. Since the patient did not have a severe centralized cervical disc herniation, cervical traction was tried to promote cervical disc retraction and reduce the pressure on the nerves. At the same time, wax therapy and hydrogen iontophoresis were used to eliminate inflammation and relieve pain symptoms. With the assistance of rehabilitation doctors, massage therapy can improve the spasm and tension of cervical muscles and promote the restoration of the physiological curvature of the cervical spine, and the clinical symptoms of the patients will be further relieved. And short-term treatment with non-steroidal anti-inflammatory drug flurbiprofen ester injection eliminates nerve inflammation and relieves the symptoms of radiating pain in the neck, shoulder and occipital region. After 1 week of comprehensive non-surgical treatment, the patient’s cervical, shoulder and occipital radiating pain symptoms were significantly relieved, and the patient was able to ensure normal sleep quality and sleep time at night. The stiffness of the cervical spine and the restriction of movement were also improved to a certain extent, and the patient was able to resume flexion, extension and rotation of the cervical spine, and the cervical spine movement did not cause the clinical symptoms to aggravate. Under the guidance of the rehabilitation doctor, cervical spine muscle strength training was carried out, which significantly improved the stability of the cervical spine, and the patient was discharged from the hospital. At the same time, the patient was asked to follow up in the clinic after 3 months and consciously correct the bad habits such as playing with the cell phone for a long time with the head down. Precautions It is gratifying that the patient’s symptoms were relieved after conservative treatment, but the patient was still advised to pay attention to the fact that cervical collar braking usually takes 4 weeks, and after 4 weeks, the cervical collar can be removed, and the patient should persist in cervical flexion and extension and lateral flexion exercises for a long period of time. The patient is advised to assist elastic band for resistance training after discharge, which can promote the effect of exercise, thus enhancing the stability of the cervical spine and preventing the recurrence of cervical disc herniation, which leads to cervical spine pain and activity limitation. Regular neck activities are also needed in work and life to avoid excessive cervical spine fatigue and cervical degenerative disc changes. If there is a recurrence of clinical symptoms, it is necessary to go to the orthopedic clinic for review and timely treatment. Not all cervical disc herniation requires surgical treatment. Early and stable patients can usually consider non-surgical treatment, as in the case of this patient, after comprehensive non-surgical treatment, clinical symptoms have been significantly reduced, and at the same time, the development of the lesion has also been controlled. However, if spinal cord compression occurs, such as limb weakness, unsteady walking, hyperreflexia, ankle clonus and other clinical symptoms, then timely surgical treatment is needed to protect the spinal cord nerves.