THE AMELIORATION OF SYMPTOMS IN CERVICAL SPINAL
STENOSIS WITH SPINAL CORD DEFORMATION THROUGH
SPECIFIC CHIROPRACTIC MANIPULATION: A CASE REPORT
WITH LONG-TERM FOLLOW-UP
George W. Kukurin, DC a

ABSTRACT
Objective: To describe the chiropractic management of a patient with paresthesia on the entire left side of her body and
magnetic resonance imaging (MRI)-documented cervical spinal cord deformation secondary to cervical spinal stenosis.
Clinical Features: A 70-year-old special education teacher had neck pain, headaches, and burning paresthesia on the
entire left side of her body. These symptoms developed within hours of being injured in a side-impact motor vehicle
accident. Prior to her visit, she had been misdiagnosed with a cerebrovascular accident.
Intervention and Outcomes: Additional diagnostic studies revealed that the patient was suffering from cervical
spinal stenosis with spinal cord deformation. Two manipulative technique systems (Advanced Biostructural Therapy
and Atlas Coccygeal Technique) unique to the chiropractic profession and based on the theory of relief of adverse
mechanical neural tension were administered to the patient. This intervention provided complete relief of the patient’s
complaints. The patient remained symptom-free at long-term follow-up, 1 year postaccident.
Conclusion: There is a paucity of published reports describing the treatment of cervical spinal stenosis through
manipulative methods. Existing reports of the manipulative management of cervical spondylosis suggest that traditional
manual therapy is ineffective or even contraindicated. This case reports the excellent short-term and long-term response of
a 70-year-old patient with MRI-documented cervical spinal stenosis and spinal cord deformation to less traditional,
uniquely chiropractic manipulative techniques. This appears to be the first case (reported in the indexed literature) that
describes the successful amelioration of the symptoms of cervical spinal stenosis through chiropractic manipulation.
More research into the less traditional chiropractic systems of spinal manipulation should be undertaken. (J Manipulative
Physiol Ther 2004;27:e7)
Key Indexing Terms: Chiropractic; Cervical Spine; Stenosis

INTRODUCTION

S

tenosis or narrowing of the central vertebral canal was originally described in the lumbar spine by
Verbiest1 in 1949. Although stenosis of the central
canal can occur anywhere along the length of the spine, this
condition is considered more ominous with greater potential
for serious neurological sequelae when it occurs in the
cervical spine.2-4 Depending on the nature and location of
the neurological insult, symptoms associated with cervical
spinal stenosis (CSS) may be radicular or myelopathic. Any

a

Private practice of chiropractic neurology, Pittsburgh, Pa.
Submit requests for reprints to: George W. Kukurin, DC,
DACAN, 2415 Sarah Street, Pittsburgh, PA 15203 (e-mail:
dacan@alt-compmed.com).
Paper submitted October 8, 2002.
0161-4754/$30.00
Copyright n 2004 by National University of Health Sciences.
doi:10.1016/j.jmpt.2004.04.009

combination of upper and lower motor neuron syndromes
and sensory symptoms ranging from unilateral, bilateral, or
with a Brown-Sequard-like presentation have been described.2 A neurological condition that is associated with
impingement of the spinal cord secondary to CSS is cervical
spondylotic myelopathy (CSM). There are several theories
concerning the development of the neurological signs and
symptoms associated with CSS. The most obvious would
appear to be direct spinal cord compression.5,6 Compression
and deformation of the normal oval shape of the spinal cord
can be readily visualized on axial computed tomography
(CT) or magnetic resonance imaging (MRI) of the cervical
spine.5,6 However, there are other potential mechanisms that
may explain neurological compromise and resultant signs
and symptoms. In addition to direct nerve fiber compression, neural ischemia secondary to compression of neurovascular structures has also been proposed.7,8 There are
several studies which suggest that tensile forces transmitted
366.e1

366.e2 Kukurin
Amelioration of Symptoms

Fig 1. Axial T2-weighted MRI image at a relatively normal level.
Note the bright white cerebrospinal fluid ring (CSF) surrounding
the cord.
to the cord through its dural and dentate ligament attachments play an important role in the generation of the
neurological signs and symptoms seen clinically.9-11 It is
likely that all of these mechanisms play a role in the
neurological compromise and that symptoms are generated
through multifactorial pathophysiology.6
Given the lack of understanding about the cause and
mechanisms that generate symptoms in CSS, it is not
surprising that there is also controversy and a lack of data
concerning the natural history of CSS, as well as the longterm benefits of treatment.12-14 There are even fewer
reports in the literature of the utility of manipulative
management of CSS. A computer search of Medline and
a hand search of the Chiropractic Research Archive Collection produced a paucity of data concerning the appropriateness of spinal manipulation for CSS. Several reports
suggest that manipulation is contraindicated in patients demonstrating compromise of the neurological elements.15-17
Another published report of 2 cases of cervical myelopathy suggested modest improvement following spinal
manipulation.18

IMAGING OF CERVICAL STENOSIS
Cervical stenosis is defined as a narrowing of the central
canal of the vertebral column. This narrowing becomes

Journal of Manipulative and Physiological Therapeutics
June 2004

Fig 2. Sagittal T2-weighted MRI of the cervical spine. Note the
areas of stenosis.

clinically important when impingement of the neurological elements results. There are many grading systems designed to classify the neurological insult seen in cases of
CSS.5,6,13,19 One such system for the grading of neurological insult depends on the findings of the axial magnetic
resonance (MR) image at the level of impingement (stenosis) visualized on the sagittal MR image.19 In a normal axial
image of the cervical spine, the cord appears ovoid and a
bright ring of cerebrospinal fluid (CSF) can be readily
visualized surrounding the neural tissue (Fig 1). If the
CSF ring surrounding the spinal cord is broken or discontinuous, a finding of thecal sac effacement is suggested.19 If
the stenosis deforms the spinal cord but preserves the CSF
ring on the posterior aspect of the spinal cord, spinal cord
effacement is suggested.19 A significant degree of spinal
cord effacement will alter the appearance of the spinal cord
on axial imaging, changing the normal cross-sectional
appearance from ovoid to ‘‘banana-like.’’6 Finally, if in
addition to impingement of the CSF anteriorly and deformation of the cord proper, the CSF ring is broken on the
posterior aspect of the axial image, actual spinal cord
compression is suggested.19 The degree of change seen in
cross-sectional images of the spinal cord appears to offer
some value in predicting both the development of neurological compromise and the response to decompressive
surgical treatment.5,13

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Fig 4. Axial MRI slice demonstrating areas of ischemia (i) in the
patient’s brain that originally led to the diagnosis of CVA.

CASE REPORT
Fig 3. Axial T2-weighted MRI image at a stenotic level. Note the
loss of CSF signal (V V V) surrounding the cord. See text for more
information.

I discuss a case of cervical spinal stenosis with frank
spinal cord compression, treated with manipulative techniques that have several unique characteristics. Most notably,
the manipulative treatment of this patient was limited to
chiropractic techniques that are not generally seen in other
professions that practice manual therapy. The manipulative
methods employed in this case are derived from the
chiropractic techniques known as Advanced Biostructural
Therapy (ABT)20 and Atlas Coccygeal Technique (ACT).21
Additionally, the extent and nature of the spinal cord
compression seen in this patient is well documented
through magnetic resonance imaging (Figs 2 and 3).
The patient’s MRI images in this case illustrate the
concept of spinal cord compression described above.19
The axial image in this case taken at the stenotic level
clearly demonstrates loss of the normal CSF ring on both the
anterior and posterior aspect of the spinal cord, with gross
deformation of the neural elements into a ‘‘banana-like’’
shape (Fig 3). These 3 findings suggest a ‘‘pincher’’ effect
on the spinal cord. Under these circumstances, the cord is
thought to be migrated and deformed away from the anterior
impingement, only to have secondary compromise and
encroachment posteriorly.

The patient is a 70-year-old female special education
teacher who was injured in a side-impact motor vehicle
accident (MVA) that occurred in July of 2000. Within hours
of the accident, she developed headaches, neck pain, and a
burning sensation on the left side of her face and the entire
left side of her body, including her extremities. She was
taken to the emergency room where an MRI of her brain
was obtained. She was diagnosed with a cerebrovascular
accident (CVA) based on her symptoms and areas of
ischemia (marked i) as visualized on MRI (Fig 4). She
was later seen by a neurologist who felt that her signs and
symptoms did not correlate with the ischemic changes seen
on the MRI scan of her brain. She had a magnetic resonance
angiography (MRA) procedure that demonstrated that the
arterial supply to her brain was not compromised. Figure 5
is a representative image of her MRA study demonstrating
the patency of the distal ends of her vertebral arteries (VA),
intact basilar artery (BA), circle of Willis (COW), and
internal carotid arteries (ICA). An MRI study of the cervical
spine was then obtained. This revealed significant spinal
stenosis with spinal cord deformation as described above.
Her diagnosis was changed from CVA to cervical myelopathy, and she was referred for surgical decompression.
She came to my office less than 2 weeks later. Her stated
goal was to avoid spinal surgery. At that time, she complained of headaches, neck pain, and an ‘‘odd sensation like
my left face, body, arm, and leg are hot and burning.’’
Neurological assessment revealed normal gait and station.
Her cranial nerves were intact, and she communicated well

366.e4 Kukurin
Amelioration of Symptoms

Fig 5. MRA image that demonstrates relatively normal vascular
anatomy of the patient’s vertebrobasilar system.

with no evidence of cognitive impairment. She did not
exhibit dysphasia, dyslalia, dysphonia, or any other sign
of CVA. Her deep tendon reflexes were globally and
symmetrically reduced and rated 1 over 4. She had no
weakness, no pathological reflexes, or other signs of an
upper motor neuron syndrome. Her sensory complaints were
subjective, but her orthopedic evaluation was remarkable in
that cervical compression tests exacerbated her burning
paresthesia and cervical spine distraction relieved these
symptoms. She had the usual paracervical muscle spasms
seen commonly in post-MVA patients. Chiropractic assessment was based on the clinical models of ABT and ACT
manipulative systems.20,21 From a chiropractic perspective,
she had gross anterior head translation (sagittal plane
subluxation) and a noticeable head tilt with the high side
on her left (coronal plane subluxation).

Intervention
There are many styles and theories of application of
spinal manipulative techniques. A number of generic spinal
manipulative maneuvers are practiced across the various
disciplines that make up the manual therapy professions.
Many chiropractic, orthopedic, osteopathic, and physiotherapy spinal manipulative procedures are indistinguishable.
Some are identical with only the theory of application
differing. This case employed 2 systems of spinal manipulation (ABT and ACT) that are distinctly associated with the
chiropractic profession. Part of the theory of their application is based on the concept that global spinal orientation
(posture) is related to tension or insult within and along the
neuroaxis.20,21 One of the treatment goals of the ABT
chiropractic technique system is to restore the patient to a
more neutral resting head posture in the sagittal plane.20 In

Journal of Manipulative and Physiological Therapeutics
June 2004

the ACT technique, tilting of the head in the coronal plane
(as visualized by a line representing the transverse plane of
the foramen magnum) is believed to transmit tension to the
spinal cord through dural attachments to the rim of the
foramen magnum and upper cervical vertebrae.21 ACT
practitioners postulate that reduction of tension on the
neuroaxis is accomplished by restoring the patient to a
neutral head posture in the coronal plane. The mechanisms
of both these chiropractic techniques are based on theoretical models derived from basic science studies of the
biomechanics of the nervous system.
However, there is at least some evidence that suggests
that changes in the posture of the cervical spine in the
sagittal plane can alter the degree of compression of the
spinal cord seen in some patients with CSS.22-24 Muhle22,23
demonstrated through dynamic MRI investigation that a
neutral head posture can reduce the deformation of the
spinal cord when compared with more flexed or extended
postures. Muhle’s22,23 dynamic MRI studies offer at least
some support to the theory that a neutral resting posture
offers the greatest potential for cord decompression in cases
of cervical spinal cord impingement.
Resting posture can be measured on radiographs or can be
visualized as postural deviations from a plumb line. In the
case presented here, head forward posture and head tilt were
determined by plumb line assessment. This postural examination revealed a clinical presentation consisting of an
anterior head translation (head forward posture/anterior
translation subluxation) and head tilt, with the line representing the foramen magnum higher on the left (right lateral
flexion subluxation of the head on the neck). The manipulative techniques were employed in such a way as to reverse
the observed spinal distortions with the hope of reducing
spinal cord insult.

Description of the Manipulative Techniques
The Advanced Biostructural Therapy approach to correcting head forward subluxation involves adjusting or manipulating the first rib.20 The standard first rib adjustment
utilized by practitioners of ABT was modified as follows.
In this case, the patient was placed supine on an adjusting
table equipped with an upper thoracic drop mechanism. The
medial aspect of the first rib was palpated with the thumb.
The thumb remained in contact with the first rib. The
pisiform area of the opposite hand was placed over the
palpating thumb. A thrust was directed inferiorly to
superiorly and anteriorly to posteriorly. The thrust was
high-velocity, low-amplitude and delivered with enough
penetration to cause the drop mechanism of the table to
release. This manipulative procedure was repeated 3 times
each visit (a number of repetitions arbitrarily determined by
the author) on both the right and left first rib. It is my
experience that this maneuver causes a rapid reduction of
abnormal head forward subluxation. This maneuver was

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applied to the patient on each office visit for 18 sessions
over 55 days at a frequency of 3 times per week for the first
2 weeks and then once per week for the duration of the
treatment period.
The Atlas Coccygeal Technique adjustment is designed
to reduce head tilt subluxation in the coronal plane. It
consists of placing the patient in a side-posture position.
The drop mechanism of the adjusting table was elevated
slightly so the patient’s head and neck were in a neutral
position (no left or right lateral flexion). With the patient on
her side, the inferior (low) side of the foramen magnum
plane (as determined by upright postural assessment) was
placed superiorly. The patient was placed in what resembles the left decubitus position. The region of the right
mastoid process of the skull was palpated with the doctor’s
thumb. The mastoid process served as a landmark with
which to identify (and remain in contact with) the transverse process of the C1 vertebra. Contact of the transverse
process was maintained, while the pisiform region of the
author’s opposite hand was placed in contact with the
palpating thumb. A thrust was delivered with a line of
drive superior to inferior (right atlas transverse process
toward the left atlas transverse process). The penetration
was deep enough to cause the cervical drop mechanism to
release. This procedure was repeated 3 times. The application of the ACT atlas adjustment was performed only on
those visits where the patient demonstrated a head tilt in the
coronal plane as observed by postural assessment using
plumb line analysis. This varied from visit to visit.
Within 2 weeks of treatment utilizing the spinal manipulative methodologies described, the patient reported that
her burning paresthesia had diminished by about 90%. The
improvement in symptoms seemed to parallel her improvement in sagittal and coronal plane alignment, and her
treatment frequency was reduced to 1 session per week.
The patient did experience 1 episode of spontaneous exacerbation of her burning sensory symptoms. This rapidly
returned to preexacerbation status with increased frequency
of treatment (3 times per week for 1 week). Her associated
muscular aches and pains also quickly resolved under this
adjustive approach. The time frame from initial presentation to complete resolution of symptoms was just under
2 months and encompassed 18 manipulative sessions. She
was discharged without residual signs or symptoms from the
accident. The patient was most recently reevaluated 2 years
later. She remained asymptomatic at this long-term followup evaluation.

transmitted from the spinal column to the neural tissues
through various soft tissue supporting structures.10 The
clinical picture is further complicated because the neurological insult may be from direct pressure on the neural
elements or produced indirectly through compression of
vascular elements.8 The emerging model is one of a
multifactorial causation, with each patient having a unique
combination of neural pressure and tension, as well as
vascular compromise. The 2 manipulative procedures administered to this patient are based on theories derived from
the known interrelationship between the bony spinal column (posture) and the response of the neural elements to
these postures. Based on the MRI data of Muhle,23 it does
seem plausible that in at least some patients with CSS, an
abnormal resting posture may increase compression of the
neural elements. Unfortunately, without a posttreatment
MRI in this case, it is impossible to determine if the
chiropractic procedures employed actually reduced neural
element impingement. Other explanations for the clinical
recovery seen in this patient, such as effects of mechanoreceptor stimulation, are possible. Reflex pain inhibition
following mechanoreceptor stimulation has been well documented.25 However, unlike its known effects on pain
modulation, it is unclear if mechanoreceptor stimulation
can alter what appears to be, in this case, centrally generated paresthesia. Furthermore, it is doubtful that a short
course of mechanoreceptor stimulation (if it can modulate
paresthesia) could provide the long-lasting suppression of
symptoms seen in this case. Spontaneous recovery is
another possibility; however, even with surgical intervention, it appears that the long-term prognosis of patients with
CSS is only modest. A large number of patients tend to
deteriorate after an initial phase of improvement.12,14 However, a controlled trial with a larger number of patients
would be needed to rule out spontaneous recovery. The
growing availability of weight-bearing and dynamic MRI
studies like the ones described by Muhle23 may provide the
technology needed to better understand the pathophysiology of CSS. These imaging techniques may also provide a
valuable tool with which to assess various chiropractic
techniques. Further study utilizing emerging imaging and
other noninvasive technology may help to explain the
clinical improvement frequently reported in chiropractic
patients and help to identify the mechanisms responsible
for this improvement.

CONCLUSION
DISCUSSION
The exact mechanism by which the signs and symptoms
in CSS are generated is controversial. The 2 most prominent theories are direct compression of the neural elements
at the stenotic spinal level and tension within the neuroaxis

Resolution of the signs and symptoms of cervical stenosis
with MRI-documented spinal cord compression through
chiropractic techniques is reported. This case suggests the
need for more research into the less traditional chiropractic
techniques. More research is needed to identify the exact
mechanisms of neurological insult seen in cervical spinal

366.e6 Kukurin
Amelioration of Symptoms

stenosis. Better understanding of the pathophysiology of
this condition may lead to novel conservative approaches
to treatment.

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