LETTER TO THE EDITOR

Spinal myoclonus after cervical spine extension procedure:case report

Svetlana Tomic • Mirjana Cubra • Stjepan Juric •

Tea Mirosevic Zubonja • Tamer Salha

Received: 13 January 2014 / Accepted: 5 February 2014

� Springer-Verlag Italia 2014

Introduction

Cervical spine extension is a kinesitherapeutic procedure

where traction of cervical spinal cord is performed manu-

ally. It is most commonly used in treatment of degenerative

spine diseases [1]. Myoclonus is a brief (less than half a

second long) contraction involving agonist and antagonist

muscles, leading to a sudden jerk [2]. We present a patient

who developed spinal myoclonus after cervical spine

extension procedure.

Case report

A 27-year-old male patient came to our emergency

department presented with brief, irregular muscle con-

tractions on the arms and legs. The attacks repeated, lasted

less than a minute and ended with hyperextension of the

neck and the back (opisthotonos). In this period the patient

was conscious and complained of a headache and muscle

pains. In between the attacks he had normal neurological

status. The myoclonic jerks were induced mostly by

movement but also occurred when the patient laid down

calmly. They began a few minutes after cervical spine

extension procedure where the patient went due to neck

and back pain. This was his second neck extension treat-

ment performed in a non- medical institution. Few days

before he had also extension therapy for the lumbar spine

that was completed successfully. We performed extensive

examinations which resulted in normal findings (CT scan

of the brain, MRI of the brain and cervical spine, electro-

encephalogram, color Doppler of the carotide and vertebral

artery, somatosensory evoked potential of median and

tibial nerve). In the laboratory only increase in creatine

kinase level was reported and the rest of the findings were

unremarkable (thyroid hormones, liver and renal parame-

ters, electrolytes, red and white blood count). All toxicol-

ogy findings in serum and urine were negative

(benzodiazepines, tricyclic antidepressant, amphetamines,

metamphetamines, ecstasy, cocaine, methadone, opiates).

The patient was treated with benzodiazepines and baclofen

and after 2 h the myoclonic jerks completely ceased. The

patient recovered completely and during the remainder of

his stay on the ward he complained only of muscle pains.

In his past medical history he had streptococcal inflam-

mation of the hip and febrile convulsions in infancy.

Otherwise, he was healthy. He does not smoke, does not

drink and does not take drugs.

Discussion

Time-related association between spinal myoclonus and

cervical spine extension procedure points that myoclonus

was induced with this procedure. All examinations

revealed normal findings excluding other causes for

myoclonus. 2 h after admission and therapy, myoclonic

jerks completely ceased and the patient recovered com-

pletely. Spinal myoclonus appeared probably as a post-

hypoxic reaction of cervical spinal cord with suppression

of descending inhibition pathways that led to hyperexcit-

ability of alpha motor neurons.

S. Tomic (&) � M. Cubra � S. Juric � T. M. Zubonja

Department of Neurology, University Hospital Center Osijek,

J. Huttlera 4, 31000 Osijek, Croatia

e-mail: svetlana.tomic@vip.hr

T. Salha

Department of Radiology, University Hospital Center Osijek,

Osijek, Croatia

123

Neurol Sci

DOI 10.1007/s10072-014-1675-y

Probably inadequate procedure of cervical spine exten-

sion led to a spasm of paravertebral muscle with the con-

sequent compression of the vertebral artery.

According to the origin, myoclonus can be classified

into cortical, subcortical, spinal and peripheral. Spinal

myoclonus may be segmental or propriospinal. Segmental

spinal myoclonus persists during the sleep, can be present

at rest, and may or may not be stimulus sensitive. Propri-

ospinal myoclonus is present with axial flexion jerks

involving the neck, trunk and hips [2]. Spinal myoclonus

may be caused by structural cord lesion (syringomyelia,

myelitis, spinal cord trauma, vascular lesion or malig-

nancy), but also by no evident lesion of the spine (physi-

ological, posthypoxia, toxic-metabolic disorders, reactions

to drugs, storage disease, and neurodegenerative disorders)

[2, 3].

Cervical spinal cord extension method is a passive

kinesitherapeutic method where a therapist, using a

mechanical grip, stretches the neck. This treatment can

increase intervertebral space by 1.5–2.5 mm, unblocked

apophyseal joints, and streched ligament apparatus. Trac-

tion force should be increased gradually, otherwise it can

stimulate proprioceptors with consequent spasms of para-

vertebral muscles [1].

There are multiple reports on serious and sometimes

fatal complications after cervical spine manipulation. The

most frequent injuries involve artery dissection or spasm,

lesion of the brain stem and Wallenberg syndrome [4].

Neck pain, headache, vertigo, vomiting, and ataxia are

typical symptoms of vertebral artery dissection, but this

vascular injury can also be asymptomatic [5]. Visual def-

icits, hearing loss, balance deficits, and phrenic nerve

injuries are less frequently reported symptoms after cervi-

cal manipulation [4].

Conclusion

Spinal myoclonus in our patient is probably related to

cervical spinal cord extension procedure. Due to possible

serious adverse events, this procedure should not be rec-

ommended for routine treatment, especially for mild

cervicalgia.

References

1. Milivojevic M (2006) Ekstenziona terapija, http://www.ticma.iz.rs/

milojevicmedic/ekstenzivna_terapija.html. Accessed Dec 10 2013

2. Kojovic M, Cordivari C, Bhatia K (2011) Myoclonic disorders: a

practical approach for diagnosis and treatment. Ther Adv Neurol

Disord. 4:47–62

3. Campos CR, Limongi JC, Machado FC, Brotto MW (2003) A case

of primary spinal myoclonus: clinical presentation and possible

mechanisms involved. Arq Neuropsiquiatr 61:112–114

4. Di Fabio RP (1999) Manipulation of the cervical spine: risks and

benefits. Phys Ther 79:50–65

5. Leon-Sanchez A, Cuetter A, Ferrer G (2007) Cervical spine

manipulation: an alternative medical procedure with potentially

fatal complications. South Med J 100:201–203

Neurol Sci

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