Enlarged c1 transverse process?

I have an 8 year old female patient that I need a bit of advise with.
Parents noticed a hard lump that correlates to her c1 transverse process on palpable. The left transverse process is largervthan the right. It's painful with too much poking and seems to be limiting her rom partially. Her dr ordered an ultrasound to check glands etc as 2 drs thought it could have been a gland. The ultrasound indicated that it was a bone and that nothing seemed amiss and that no further examinations would be necessary.
She does not like gentle mobs due to pain and doesnt seem to limited by it. Her parents want it resolved.
Send her for further tests ie. Xray before commencing treatment with mobs/exercises/posture training? Anyone had any experience with an enlarged c1 transverse process?
Thoughts would be greatly appreciated!

Eight years old??? are you sure of the age??

Esther

Yes she's definitely 8 years old. Why?

As a paediatric physio, having been around for a while, I have never had a child come in with such a complaint.

And, is there a complaint? What is the real problem?
Does the child have any problems?
I can imagine that her parents are worried a little...
What do they percieve as the problem? What is their biggest concern?

You say the bone seems to be limiting her ROM partially. Could you be more specific?
Is it hurting her in rest or only after your handeling?
I think that your action of sending them back for further assessment is a very good idea.

I wouldn't surprised, that if it is a bone asymmetry, there is nothing you can do.
I have seen children with asymmetric cervical ROM because of spinal deformities and skull deformities. In these cases treatment
was deemed necessary only if the child had some kind of trouble as a result.

Keep us informed please.

Esther

Quote:

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Originally Posted by Anarion

I have an 8 year old female patient that I need a bit of advise with.
Parents noticed a hard lump that correlates to her c1 transverse process on palpable. The left transverse process is largervthan the right. It's painful with too much poking and seems to be limiting her rom partially. Her dr ordered an ultrasound to check glands etc as 2 drs thought it could have been a gland. The ultrasound indicated that it was a bone and that nothing seemed amiss and that no further examinations would be necessary.
She does not like gentle mobs due to pain and doesnt seem to limited by it. Her parents want it resolved.
Send her for further tests ie. Xray before commencing treatment with mobs/exercises/posture training? Anyone had any experience with an enlarged c1 transverse process?
Thoughts would be greatly appreciated!

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Is the lump bone or soft tissue so yes further exam verifying the either would be great to give a guide how you should treat it? You need to verify that if it is tissue then you will have to "iron it" with any possible hands on tools you have. Posture wise is also a reliable assessment for treatment guide look at Kendal book if availble. Mobs or manips are not my favorite tool if the muscles are tight and you dont adreess that the bone will be displaced again in time.

Hi Anarion,
Interesting problem. The other posts are providing good feedback. If the child has only recently reported soreness then I suspect that she was born with a Left Right transverse process variability.
Such variations are not uncommon in the human body and can be completely assymptomatic until another minor injury / irritation draws attention to them. If the child has previously had full Cx range of movement (and I suspect this to be the case given no previous medical investigations) and the child is otherwise well, it would be best to advise mild heat (hot packs) and let the child get on with her life. Massage may just aggravate the problem and cause the child to 'play' to the problem, possibly creating a learned protective muscle splinting that will reduce range of movement. When the soft tissue soreness ceases then the parents can be taught how to have their daughter stretch the soft tissue - only if necessary.

Obviously I am assuming that scans are ruling out bone tumour - MRI or CT to be undertaken should plain x-ray be unhelpful.

Just my thoughts. Hope the info provokes further discussion.
MrPhysio+

My first question is what is the presenting problem. Is it a limitation of ROM or is she presenting with pain or headaches?

There are a number of good suggestions above as to what an "enlarged" C1 might be, but in my experience, more often than not, an "enlarged" lateral arch of C1 is more commonly a slightly rotated, and hence, more "prominent" with associated spasm/thickening of tissues over the top giving an enlarged feel. In the absence of red flags of course, heat would be a sensible start, and maybe palpate C2 centrally. If the sp process of C2 is deviated towards the same side then it is more likely the inf oblique has spasmed, pulling the two closer to one another. Just be wary with your C2 palapation as its sp process is bifid and not always uniformly. Another good way to check this is to apply a tranverse pressure to C2 from the left and from the right. Is the resistance equal? Is the tenderness equal? If not, again you may have some muscle spasm of the oblique.

If, as you say, she isn't bothered by it at all, I'd be looking to re assure the parents that nothing is wrong, we aren't all symmetrical and probably let sleeping dogs lie.

Cheers,
BB

Wow thanks so much for the great advice everyone!
On further examination I believe that her C1 is substantially rotated creating the impression that her (L) side is 'enlarged'. US confirmed the tissue to be bone with normal blood flow and no associated mass.
She has no neurological signs/symptoms except complaining of the occasional head ache and neck soreness.
She appears to have a mild scoliosis which is prob exacerbating the issue, and has quite a poor posture and weak trunk stabilisers.
I'll ease off the mobs as it seems to increase her discomfort (and annoy her :)) so will focus on strengthening/stretching and posture correction.
Thanks again for the great posts! Any further ideas will certainly be appreciated.

If the hands on approach is too uncomfortable you might try using some sustained (20sec) cervical retraction, which you can easily link up with your posture re-ed. I'd also use sustained mobilisation techniques along the lines of the Dean Watson headche stuff, but again, what is the goal? If treatment is more to appease the parents anxiety I'd give her heat then 3-4 x 20 sec sustained and end of range Cx retraction...........good luck.

The Cx retraction is particularly powerful for headache, so if she has one next time you see her it would be worth trying and see if it changes her symptoms. If headache is a significant issue for her it may be worth seeking out a Watson headcache technique trained physio.

dear Anarion,
As you see, your question has been answered by a number of others as well.
I think your idea to ease off the mobilisation is is very wise decision.
Do not forget that she is EIGHT years old....skeletal and articular structures are still developing.

In chapter 6 of Physical therapy for children (S.K.Campell, D.W. Vanderlinden and R.J. Palisano3rd edition)
under musculoskeletall development and adaptation I found some relevant information regarding bone development.
At birth the diaphyses are almost ossified whereas the epiphyses are still cartilaginous. Timing of complete ossification varies.
Most bones are fully ossified by 20 years of age.
Most rapid bone periode of bone growth is prenatal. A midgrowth spurt occurs at age 7 and in puberty.
Basic structures of joints are formed during the 6th-8th week of gestation, but the final shape develops through
early childhood under the influences of forces of movement and compression.

If there are signs of a scoliosis it is certainly wise to monitor this during her growth.
I would personally avoid passive stretching... there are many other ways to actively stretch in play...
I am also not in favor of using techniques that work for adults on a child without having a very very good reason.
Children are not mini-adults.

kind regards and I wish you both well.

esther

Forgive me for interupting a very interesting thread. I'm a long term C/S patient and feel I must say that I'm so glad that some Physios are now tending towards 'hands off ' therapies. My experiences tell me that most C/S symptoms (headaches, stiff neck, etc.) are associated symptoms caused by the neck trying to readjust to a percieved threat of nerve compression. As such, any interference can easily hamper or aggravate the problem. Any applied therapies should really be concerned with how the patient sleeps, because sleeping postures create the default associated symptoms for the next day. Good sleeping conditions can greatly relieve associated symptoms and allow the neck to readjust rapidly to it's best functioning mode, which is what it's trying to do all along. I don't know if this is of any help to the problem posted in this thread, but as a general overview of neck problems I think it shouldn't be overlooked.

Hi Gerry the Neck,
It is true that some conditions require hands off treatment and rest. However not all conditions respond in this way, requiring therapists to be knowledgeable, good assessors and capable of deciding the best course of action for individual cases.
Restful sleep is necessary for healing and requires comfortable conditions - disturbed sleep is a pointer to problems and improving sleep demonstrates that a condition is heading in the correct direction.

Therapists in this discussion agree that care is required for children and that techniques suitable for some conditions may not be suitable for other conditions or ages. Sometimes the body mounts an inappropriate reaction to a condition or continues a reaction as a learned response despite the original condition having healed a long time previously. Therapist directed retraining to return correct biomechanics is often necessary to alleviate problems.
The trick or art is in the way a therapist interacts with a patient to detect sufficient information, adds this to training experience luck and the healing craft, reassesses then fine tunes the responses to such interaction until the patient is satisfied with the functional / sensory outcome.

As a therapist I aspire to achieve the abovementioned description and share the joy of the patient when successful. Failures spur me on to improve my knowledge and technique.

Anything worth doing is worth doing well. Your experience and comments are welcome.
Regards,
MrPhysio+

Hi MrPhysio+
Thanks for your response. I would hope that my views aren't seen as a criticism of the integrity or good intentions of the profression. No problem there. However, I am aware that, as a science, it is necessary to work off the same template, apply the same recommended textbook therapies, and compare results, in order to progress towards better solutions. If the textbook advice has been badly designed, then we are all groping in the dark. I still have uncomfortable memories of neck collars, mechanical traction, osteos, chiros, and even failed medications, so perhaps I feel entitled to be a little sceptical of textbook advice. However, progress, with it's litany of failures trailing behind, has been made and we are now hopefully entering an era of user-friendly therapies.

Because of it's exposure, the neck is probably the most protected organ in the body. It must always ensure some flexibility to guarantee survival. It must also protect the nerve roots before distribution to the body general etc. etc. As such, it comes with advanced integrated protective processes which allow functioning, even in critical situations. Understanding and accommodating these processes is the basis for all neck therapies. With Cervical Spondylosis, the neck is repeatedly and naturally overworked, trying to adjust itself for optimum, but limited, functioning. Adding additional exercises to this process, if in conflict with what is already happening, can delay symptom healing or exacerbate symptom intensity. As a patient, why would I want to risk such experimental or unproven methods. Doesn't make sense.

Regarding sleeping therapies, I realise how difficult it becomes to monitor home based therapies and arrive at accepted conclusions about their effect. However, I would ask one question to support any enquiries into their usefulness...." How come the duration of, and the intensity of different C/S symptoms can be altered by adopting different sleeping / napping postures ?" I know that I, as an individual patient, vouching for this is pretty worthless, but I have to ask if differing sleeping postures have ever been explored as a possible suitable therapy. In my small world it seems to work better than many less effective therapies I've experienced. A seemingly preposterous claim today might, in 20 years time, seem like common sense.

I appreciated your comments regarding being sensitive to the patients concerns because such interaction helps to empower the patient to rationalise their distress and perhaps begin a journey of self therapy. Most patients spend 99% of their time away from direct professional help, and it's important they don't get to view their condition as a repetitive 'crisis/must get treatment' condition. If good home therapies are advised, this cycle of dependancy can be broken.

I hope my posts aren't read as 'disgruntled with physios' (even if it reads like that sometimes !). I'm merely trying to add ideas to the equation which might help with less failures in the future....for us all.

Gerry

Hi Gerry the Neck
I have no problem with people expressing an opinion and do not take offence against comments made about the physiotherapy profession - heaven knows I make my own opinions known on such topics at various times, including within this forum. The scientific method is a way of progressing knowledge within a framework of ongoing assessment. For all its faults (some alluded to by you) it is better than no system at all. The method can be slow, cumbersome and mistakes occur due to the human frailities of system overseers. The human body has a limited number of ways to convey ill health or dysfunction but a myriad of causes for the few presentations given. Assessment is a detection process only as good and experienced as the detective and their current knowledge base. Sometimes it is necessary to test the assessment and wait to see what occurs before a new idea is formulated that better fits the presentation, then treating on that basis. The most elegant treatment is the simplest one that works, remembering that a lot of effort may be required before the 'simple' end result eventuates.
Having said all the above, the human body is so complex that no one knows enough to be correct all the time in relation to treatment interventions. Does that mean that we do not take educated and calculated risks in treatment provision? Of course we do, but within an accepted framework of judgemental peers that tend to be conservative (unlike the non scientific disciplines) and try to temper the excesses of exuberant practitioners theories.

There is so much information being generated these days and despite internet searches linking to new information and validations of old treatments there can be a disconnect between implementation or discovery and the tried and true past (which can be less true knowledge than assumtion based upon longevity eg use of cortisone to treat tennis elbow by reason of it being an anti inflammatory medication when the tendon was not inflamed but rather a tendinopathy). Overall an open mind attached to the generally accepted knowledge base is the best combiination - although as stated previously this does not always work eg Look up 'Miasma and the Houses of Parliament' to do with Londons water supply;infection control in hospitals / midwifery; Joseph Listers story; as well as the English medical response to a nurse discussing polio rehabilitation. All mistakes that the scientific community learnt from and incorporated - such as your comments regarding ideas unaccepted today being mainstream in 20 years.

Cervical spondylosis is but one area where treatments can be improved.

Anyway, these are my comments, for what they are worth.
Cheers,
MrPhysio+

Hi MrPhysio+

Thanks for your enlightening comments. They're worth a lot, because I can see you retain some flexibility in your approach to therapy, and you are not wary of exploring the ethical issues involved. That's very reassuring from the patient's perspective. Your comments re the conservative nature of progress v the exuberance of snake oil peddlers does encourage me to think, in nothing but an instinctive way, that there exists an ever increasing vacuum between accredited and unaccredited practices, into which disappointed patients regularly fall and become vulnerable to confused decision making when considering best ways forward. Perhaps this is the story of C/S where discontent with therapies seems the order of the day. At the same time, I understand that the accredited professions must ring fence their professions from dubious practices which could undermine public confidence. I accept that reaching beyond the textbooks is highly restricted for these reasons, but that, in itself shouldn't stop a bit of 'outside the box' thinking when textbook recommendations don't quite fit their purpose.

The best therapy I received in 30 years happened 2 years ago, when I was called to the Physio for a report on my neck MRI. She explained the details...degeneration from C3 to C7, possible nerve infringement at C5/C6 and minor stenosis in the root canal. Pretty much what I expected, so I asked a question...."Does this mean that all my whingeing over the years has had substance". She replied.."Yes. For many years". In three words she blew away all the self doubting, all the angst, and all the repercussions from feeling that I was always dealing with a 'sub-text of disbelief ' when dealing with others, even therapists, which was gnawing at my resolve to meet the problem head on. So, therapy can work on many levels, I think you alluded to this previously.

I would love to get involved in an ethics v risky therapy discussion, but as that is veering away, again, from the original thread on this page, perhaps it is better consigned elsewhere.

Again, thanks for your clarifications of your purpose.

Gerry