Module 5 Case Study: Spinal Traction

Patient Information: 

• Name: Sarah Johnson

• Age: 45 

• Occupation: Administrative Assistant (spends long hours at a desk) 

• Presenting Complaint: Neck pain with radiating symptoms down the left arm 

• Diagnosis: Cervical Radiculopathy (left C6-C7 nerve root impingement due to a herniated disc) 

History and Symptoms: 

• Duration of Symptoms: 4 weeks 

• Pain Description: Constant neck pain, 8/10 intensity, aggravated by prolonged sitting, desk work, and head movements (especially when looking up). The pain radiates down the left arm, with occasional tingling and numbness in the left hand. 

• Medical History: Mild hypertension, no previous neck injuries or surgeries. 

• Physical Exam: 

Positive Spurling’s Test on the left (provokes arm pain). - Spurling's test is used to assess for nerve root compression in the cervical spine, typically due to conditions like cervical, radiculopathy, herniated discs, or stenosis.  
How it’s performed: The patient is seated and the clinician asks them to rotate and extend the neck to one side (the side being tested). The clinician then applies a downward compressive force to the top of the head.  
If the test reproduces the patient's symptoms (e.g., pain, tingling, or numbness radiating down the arm on the same side), it is considered positive and suggests nerve root irritation or compression at that level of the cervical spine 

• Decreased range of motion (ROM) in cervical flexion and extension. 

• Positive neck muscle spasms (trapezius, levator scapulae). 

• Reduced sensation in the C6 dermatome on the left (thumb and index finger area). 

Goals for Treatment: 

• Relieve pressure on the affected nerve root to reduce radiating arm pain. 

• Reduce muscle spasm in the neck. 

• Improve cervical ROM. 

• Promote disc rehydration and reduce herniation size if possible.