Concussion-Type Symptoms After Head Trauma in a Patient With No Apparent Neck Signs or Symptoms: A Case Report of Cervicogenic Concussion and Response to Targeted Cervical Adjustments/Manipulation

Abstract

In two head trauma events occurring 38 years apart, the same male patient presented to the same chiropractor with concussion-type symptoms, including headaches, dizziness, visual disturbances, and cognitive slowness (brain fog), but no neck pain and normal standard orthopedic neck test results. The chiropractor initially diagnosed the patient with concussion/mild traumatic brain injury (mTBI). A diagnosis of cervicogenic concussion (CGC) was made in both 1985 and 2023 after the patient reported the immediate and lasting resolution of all symptoms following what became a diagnostic-therapeutic trial (DTT) of cervical adjustments/manipulation. The DTT targeted cervical segmental joint dysfunction (CSD), also characterized as vertebral subluxation (VS) in the nature of hypomobility/fixations, identified by the chiropractor on further cervical motion palpation examination (CMPE). On both occasions, the chiropractor confirmed improvement in CSD/VS on post-DTT adjustment CMPE. Cervical pathology constituted by CSD/VS and/or cervical segmental degenerative joint disease was considered the probable cervicogenic etiology of the patient’s concussion-type symptoms and CGC diagnosis rather than a brain etiology and concussion/mTBI. This case report illustrates how cervical dysfunction/pathology can mimic the symptoms of concussion/mTBI, highlighting the importance of recognizing CGC in the differential diagnosis of concussion/mTBI.

Introduction

Concussion/mild traumatic brain injury (mTBI) is commonly diagnosed after head trauma. It is defined as a complex pathophysiologic process affecting the brain, induced by traumatic biomechanical forces secondary to direct or indirect forces to the head, with the duration of symptoms being highly variable and lasting from several minutes to days, weeks, months, or even longer in some cases [1].

Cervical spine pathology (trauma or cervical dysfunction in the neck), especially dysfunction in the upper cervical segments, is increasingly recognized as a contributor to symptoms attributed to concussion, particularly headaches [2-4], dizziness, balance and visual disturbances [5-8], and cognitive slowness/brain fog, and should be considered in the differential diagnosis of concussion/mTBI because cervical dysfunction shares a similar symptom profile. Several narrative reviews and prospective descriptive studies have identified cervical pathology as a contributor to persistent post-concussion symptoms and recommend targeted cervical assessment, including upper cervical interventions or cervical alignment rehabilitation, as part of multidisciplinary care [9]. Although controlled trials of spinal manipulation specifically for acute concussion are lacking, case reports and small case series suggest that targeted cervical manual therapy may provide symptomatic benefit in selected patients [10]. Mechanistically, aberrant proprioceptive afferent input from dysfunctional upper cervical joints may perturb vestibular and brainstem processing and may generate headache, dizziness, and cognitive complaints, providing a pathway for cervicogenic dizziness (CGD), neck-related headache (cervicogenic headache), and a possible cervical biomechanical dysfunction pathway from which these concussion-type symptoms may arise concurrently [11-15]. Vertebral subluxation (VS) is described as “a biomechanical and functional spinal lesion characterized by altered joint motion, associated muscular imbalance, and potential neurological effects, and may contribute to adverse health effects through disrupted spinal and neural integrity” [16].

Cervicogenic concussion (CGC) is a clinical syndrome in which concussion-type symptoms arise from cervical spine dysfunction with a cervicogenic etiology rather than a brain etiology, as in concussion/mTBI. The cervicogenic source in this case report appeared to be cervical pathology constituted by cervical segmental joint dysfunction (CSD)/VS, in the nature of hypomobility/fixations, and cervical degenerative joint disease (DJD) at C5/6 and C6/7, as revealed on cervical radiographs obtained in 1983 and 1991. Given this, the chiropractor conducted what became a carefully controlled diagnostic-therapeutic trial (DTT) of cervical adjustments/manipulation targeting the CSD/VS identified on more detailed cervical motion palpation examination (CMPE). The patient reported the immediate resolution of all concussion-type symptoms following the DTT, which was key to distinguishing the probable cervicogenic etiology and CGC diagnosis from a brain etiology and concussion/mTBI diagnosis.

Case presentation

1985 event

A 30-year-old otherwise healthy male patient presented to his chiropractor in April 1985, three days after a head injury caused by a falling brick. Signs and symptoms included a small laceration and bruising of the scalp and severe headaches that were worsening and interfering with his sleep. He also complained of visual acuity disturbances, dizziness, cognitive slowness (brain fog), and an inability to concentrate but reported no neck pain or stiffness. He had sustained previous sports-related concussions in 1973 and 1976, had no other health issues, was not taking any medications, and had no history of vestibular problems.

The neurological screening examination was unremarkable. Standard orthopedic cervical examination revealed full and painless active and passive ranges of motion. A more detailed motion palpation examination (MPE) of the cervical spine revealed CSD/VS in the nature of hypomobility/fixations at C1/2 (right) and C5/6 (left). Cervical radiographs (AP/lateral/flexion/extension) obtained in 1983 revealed a mildly alordotic lateral cervical curve, moderate C5/6 intervertebral disc narrowing (about 40%), and associated posterior C5/6 endplate osteophytosis (Figure 1A-1C).

Figure 1. (A-C) Cervical lateral/extension/flexion radiographs obtained in 1983. (D) Cervical lateral radiograph obtained in 1991.

(A) Lateral cervical radiograph obtained in 1983 showing an alordotic lateral cervical curve, moderate C5/6 intervertebral disc narrowing (about 40%), and associated moderate posterior C5/6 endplate osteophytosis. (B) Lateral cervical extension radiograph obtained in 1983. (C) Lateral cervical flexion radiograph obtained in 1983. (D) Lateral cervical radiograph obtained in 1991 showing a normal lateral cervical lordotic curve, mild to moderate C5/6 intervertebral disc narrowing (about 30%) with associated mild to moderate C5/6 endplate osteophytosis, and moderate C6/7 intervertebral disc narrowing (about 50%).

The treating chiropractor, with decades of experience treating the patient, made a provisional diagnosis of concussion/mTBI based on the history of head trauma, progressively worsening headaches, the absence of reported neck pain, and normal standard neck test results. It was noted that the patient was on his way to the local hospital ED because he believed he had sustained a potentially serious head injury when he met the chiropractor at a seminar.

Before the patient left, the chiropractor asked whether he would like the identified CSD/VS to be treated, and, with the patient’s consent, conducted a carefully controlled, low-force, high-velocity, low-amplitude (HVLA) cervical adjustment/manipulation in the supine position. The patient reported immediate relief of his headaches, visual focusing disturbances, dizziness, and cognitive brain fog and stated that his head “felt clear,” that “he could concentrate again,” and that he “felt incredible.” The chiropractor noted improvement in the CSD/VS on post-adjustment CMPE.

The patient agreed to follow up with the chiropractor and remained symptom-free; therefore, it was decided that there was no longer a need to attend the hospital ED. The cluster of concussion-type symptoms did not recur for 38 years.

2023 event

At age 68, in 2023, the same otherwise healthy patient tripped, fell, struck his head, experienced a transient loss of consciousness, and sustained acute right shoulder and arm pain but no neck signs or symptoms. He attended the local hospital ED, where he was examined by two orthopedic specialists who applied a removable splint for a fractured right proximal humerus before he was discharged. Within a couple of days, the patient again developed headaches, visual acuity disturbances, dizziness, and cognitive slowness (brain fog), a symptom cluster similar to that of the 1985 episode, again without neck pain. On day 7, the patient presented to the same treating chiropractor for assessment, reporting no neck pain.

Standard orthopedic neck tests on cervical examination were normal. The chiropractor then conducted a more detailed MPE, identifying CSD/VS in the nature of hypomobility/fixations at C1/2 (right) and C6/7 (left). Cervical radiographs obtained in 1991 were reviewed and compared with those obtained in 1983 and revealed a more normal lordotic lateral cervical curve, mild to moderate C5/6 intervertebral disc narrowing (now about 30%) with associated mild C5/6 osteophytosis, and moderate C6/7 intervertebral disc narrowing (about 50%) (Figure 1D). Neurological examination revealed a sluggish pupillary response and some oculomotor/eye-scanning disturbances, and the chiropractor, with decades of experience treating the patient, again made a provisional diagnosis of concussion/mTBI.

The patient again consented to a carefully controlled DTT of HVLA cervical adjustments/manipulation targeting the CSD/VS identified on CMPE, this time in the sitting position. The cervical adjustment/manipulation was accompanied by a very audible joint release, particularly during adjustment/manipulation of the right C1/2 segment. The patient again reported immediate resolution of his headaches, visual disturbances, dizziness, and cognitive slowness (brain fog), and the chiropractor confirmed improvement in the CSD/VS on routine post-adjustment CMPE. The patient reported, “What fantastic relief” and “I had no idea it was my neck causing the problems” and stated that the improvement had lasted.

The clinical findings, interventions, and outcomes of the 1985 and 2023 events are summarized in Table 1.

Table 1. Clinical findings, interventions, and outcomes.

CMPE, cervical motion palpation examination; CSD, cervical segmental joint dysfunction; DTT, diagnostic-therapeutic trial; HVLA, high-velocity, low-amplitude; VS, vertebral subluxation

Parameter	1985 event	2023 event
Age	30	68
Mechanism of injury	Brick falling onto the head	Trip and fall with head impact and transient loss of consciousness
Symptoms	Headaches, dizziness, and cognitive slowness (brain fog)	Headaches, dizziness, cognitive slowness (brain fog), and visual disturbances
Neck pain and standard neck examination	No reported neck pain and normal standard orthopedic neck examination	No reported neck pain and normal standard orthopedic neck examination
Neurological signs and symptoms	Neurological screening normal/inconclusive	Sluggish pupillary response, visual acuity/focusing disturbances, brain fog, and slow response to questioning; mildly abnormal
CMPE	CSD/VS; hypomobility/fixations at C1/2 (right) and C5/6 (left)	CSD/VS; hypomobility/fixations at C1/2 (right) and C6/7 (left)
Intervention (DTT)	Supine HVLA cervical adjustment/manipulation at C1/2 (right) and C5/6 (left)	Sitting HVLA cervical adjustment/manipulation at C1/2 (right) and C6/7 (left)
Outcome	Immediate and lasting resolution of all concussion-type symptoms and improvement in CSD/VS on post-cervical adjustment (DTT) CMPE reexamination

Discussion

These two case studies involving the same patient, managed by the same chiropractor 38 years apart, with concussion-type symptoms following head trauma but no neck signs or symptoms, highlight the probable diagnosis of CGC. The cervicogenic source of the patient’s symptoms appeared consistent with asymptomatic and latent cervical pathology constituted by cervical dysfunction (CSD/VS) and/or cervical segmental DJD at C5/6 and C6/7, as revealed on cervical radiographs obtained in 1983 and 1991 (Figure 1).

The cited research supports a cervicogenic etiology for all of the patient’s concussion-type symptoms, including cervicogenic headache, CGD, cervicogenic-related visual disturbances, and cervicogenic-related cognitive slowness/brain fog [2-14]. A cervicogenic source is further supported by the patient’s clinical observations and his report of the immediate and lasting resolution of all symptoms following what became the DTT of cervical adjustments/manipulation.

The patient’s response to the DTT provided key evidence supporting a cervicogenic source of all symptoms, inconsistent with a brain source and the initial diagnosis of concussion/mTBI and post-concussion syndrome (PCS). The patient’s response was also consistent with the cited research on cervicogenic vestibular-ocular dysfunction and post-traumatic headache of cervical origin (cervicogenic headache) and inconsistent with a vestibular or brain injury etiology. Although a placebo response cannot be excluded, it is also inconsistent with the chiropractor’s observations following the DTT and with his decades of experience treating the patient. Spontaneous improvement is likewise inconsistent with the patient’s rapid and lasting response following the DTT, including in 1985, when the patient’s severe headaches had progressively worsened over the three days between the head trauma and presentation to the chiropractor.

This case report provides the following clinical insights. First, it highlights the clinical overlap between the symptoms of concussion/mTBI and CGC and emphasizes that clinicians should maintain a high index of suspicion for potential CGC in patients presenting after head trauma with concussion-type symptoms, no neck pain, normal standard orthopedic neck test results, and inconclusive neurological findings.

Second, it supports the utility of a carefully controlled DTT of HVLA cervical adjustments/manipulation when no red flags are present, targeting CSD/VS as a differential diagnostic test for a potential cervicogenic source of concussion-type symptoms.

Third, it illustrates the importance of a collaborative multidisciplinary approach to diagnosing and managing concussion/mTBI and the important role of the chiropractor in identifying a potential asymptomatic latent cervicogenic source (CSD/VS) and conducting a safe and controlled DTT of cervical adjustments/manipulation.

Fourth, it underscores safety and screening considerations, as cervical adjustments/manipulation carry rare but serious risks. Before intervention, red flag assessment, including vascular and neurological screening and shared decision-making with the patient, is mandatory.

Finally, it suggests avenues for future research into nonpharmacologic, manual therapy-based approaches to post-traumatic head injury care.

Future directions

There is a need for larger case series to establish a database of similar cases and capture comparable clinical experiences from clinicians. The exact mechanism underlying the observed improvement remains unclear and warrants further research to better understand CSD, VS, their interaction with cervical DJD, and the neurophysiological and mechanical pathways linking CSD/VS and cervical DJD to concussion-type symptoms. A randomized or controlled DTT of cervical adjustments/manipulation could be designed with the assistance of chiropractors to further evaluate the differential diagnostic insights demonstrated in these cases, including the reproducibility and reliability of interexaminer CMPE as a baseline assessment and its association, if any, with cervical CSD/VS and cervical DJD. Future studies should also incorporate standardized concussion symptom scales, VOMS (vestibular/ocular motor screening), and cervical joint position error testing.

Limitations

This is a single-subject observational case report and cannot establish causality. Objective baseline and post-treatment concussion metrics were limited in 1985 and incomplete in 2023. Diagnostic uncertainty regarding the inability to definitively exclude true concussion/mTBI and PCS was addressed by the patient’s immediate and complete response to the DTT, which has persisted and was consistent with a cervicogenic source and inconsistent with a brain injury source, concussion/mTBI, or PCS, all of which are predicated on an initial diagnosis of concussion/mTBI. Concussion/mTBI and PCS are also inconsistent with the patient’s rapid and complete response within a short period after head trauma (three days in 1985 and seven days in 2023) following the DTT of cervical adjustments/manipulation. Confounding factors, such as spontaneous recovery and placebo effects, cannot be excluded but are mitigated for the reasons outlined above.

Conclusions

Across two head trauma events separated by 38 years, the same male patient presented to the same chiropractor with concussion-type symptoms, including headaches, dizziness, visual disturbances, and cognitive slowness (brain fog), but no neck pain and normal standard orthopedic cervical examination findings. On both occasions, an initial diagnosis of concussion/mTBI was made until a DTT of cervical adjustments/manipulation was conducted targeting the CSD/VS identified on further MPE, after which the patient reported immediate resolution of all symptoms, which has persisted. Both events involved a similar pattern of CSD/VS in the nature of hypomobility/fixations. Neurological examination was normal in 1985 and mildly abnormal but inconclusive in 2023. On both occasions, the clinical findings were more consistent with a cervicogenic etiology and CGC than with a brain etiology and concussion/mTBI. This case report illustrates how cervical dysfunction/pathology and CGC can mimic the symptoms of concussion/mTBI and highlights the importance of recognizing CGC in the differential diagnosis of concussion/mTBI.