Introduction

Anomalies of vertebrae like a congenital fusion/block are always interesting to locate and evaluate. It is often an incidental finding detected by professionals during a radiologic examination [1]. A block vertebra is asymptomatic until adulthood and sometimes till young adolescence [2]. In literature, cervical spine anomalies such as block vertebrae have been well documented with most common levels found at the second cervical vertebra (C2)–C3 or C5–C6 [2]. The clinical manifestations can vary from simple neck pain or range of motion restriction to muscular weakness of one or both upper limbs and even complex neurological deficits or myelopathy [3].

Block vertebrae can result in hypermobility in adjacent vertebrae and biomechanical stress leading to symptomatic presentations in advanced age [4]. Neck pain as a common complaint is a leading cause of disability. Causes like congenital anomalies with neck pain and musculoskeletal changes should be dealt with caution during conservative as well as surgical management [5]. Clinically, an early diagnosis can help document changes in aging, the progression of degenerative processes, and lifestyle modifications to lead a pain-free life. The purpose of this case report was to highlight the presence of rare block vertebrae and how conservative intervention can bring improvement to the symptoms experienced by the patient.

Case report

A 21 years Asian male engineering student who was referred by an orthopedic specialist presented to the clinic with complaints of neck pain (non-radiating) for almost a week. He described his pain to be gradually increasing in intensity every time he sat on a chair and studied. The intensity of the pain had been intermittently increasing/decreasing for about a year and about 2–3 episodes in a month for approximately one year after he participated in a sports event. He presented with an X-ray cervical spine prescribed by the orthopedic surgeon which showed C3–C4 block vertebrae. Earlier, he had consulted a health care provider who had advised him non-steroidal anti-inflammatory drugs (NSAIDs) and rest before being referred to physiotherapy.

The patient was quite definite about the factors which increased his pain, studying on a chair for a prolonged duration and lying with a pillow. His numeric pain rating scale (NPRS) level ranged from 5 (minimum) at rest and 8 (maximum) post activity. He emphasized the inability to sit and study as his examinations were near and were anxious about the same. The most painful position was sitting for a prolonged duration followed by supine lying with a pillow, though a no pillow position helped. There were no red flags identified. For the assessment of the patient, both psychosocial factors as well as physical factors causing pain were identified. On physical examination, his cervical spine range of motion was restricted and painful. Left rotation was limited to 45 degrees and flexion/extension was equally painful and restricted. He had tenderness over spinous processes of C3, C4, and C5 vertebrae and gross tenderness over cervical facet joints, upper trapezius, and cervical flexors. Muscle weakness of deep neck flexors was assumed because of the theoretical concept and chronicity of the pain. On assessing the psychosocial factors, he was anxious and worried about the upcoming examinations as he was not able to focus on his studies. He was also concerned about his performance in the examination. He had a sedentary lifestyle and mainly focused on his studies. The international classification of functioning disability and health (ICF) health domains are described in Figure 1 for the patient.

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Figure 1. 

Description of international classification of functioning and disability health domains as per the assessment of the patient. ROM: range of motion

For diagnosis, physiotherapist must try to classify the case either into a pathoanatomic or impairment based. The case was referred by an orthopedic surgeon with a noted diagnosis of non-radiating neck pain. Based on X-ray findings, diagnosis of the patient was considered as a symptomatic block vertebrae. There was fusion at the level of C3/C4 vertebrae. The anteroposterior, lateral views of radiographs are depicted in Figure 2. The aim of the physiotherapists diagnostic process should be to find the divergence that exists between the level of function that is desired by any individual and the capacity of the individual to achieve that level. The patient demonstrated reduced functional capacity and muscle performance. Acknowledgment of pathoanatomical diagnosis and its interpretation into modifying the lifestyle of an individual (if applicable) is a must.

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Figure 2. 

Anteroposterior, lateral views of radiographs showing C3–C4 block vertebrae. (a) Anteroposterior view; (b) lateral view. R: right side of patient

Discussion

The case report demonstrated a significant decrease in the intensity of pain after 2 weeks of supervised physiotherapy management. The pain intensity decreased from 8 (NPRS) to 2 (NPRS) which shows a meaningful clinical change [6, 7]. The patient reported sitting duration without discomfort also showed a significant improvement. To our knowledge, this is the first study that describes physiotherapeutic intervention for neck pain associated with a block vertebra. Literature supports the findings of the case report and suggests that exercise alone or combined with manual therapy does result in significant pain reduction [8, 9]. However, clinical decisions must not simply rely on the radiological findings (ex block vertebra, spondylosis, etc.), these findings must always be correlated clinically.

The used of specific patient-reported issue as an outcome measure, for example, the sitting duration which showed improvement. This change can be attributed to improvement in muscle performance associated with prescribed exercises. Literatures suggest that individuals with neck pain have been found to have lower muscle strength compared to their healthy controls [10]. Although the hypothesis that improvement in sitting capacity may be due to enhance muscle performance there was no direct measurement of muscle performance in the study.

The protocol used demonstrates that an exercise regimen using strengthening exercises can be effective in reducing the patient’s pain and discomfort. The advice for not sustaining a posture prevented loading and helped in the reduction of pain. A recent study demonstrated the use of ergonomic advice combined with exercises improved the health productivity of individuals at their workplace [11]. Present case report has similar findings in terms of improvement in the patient’s ability to do his daily chores. As block vertebra is usually an incidental finding, the authors suggest more case reports and case series to further explain the therapeutic interventions that can be used for this specific subset of the neck pain population.

In conclusion, patient-reported pain was decreased significantly from the initial visit. In the current case report, patient education and structured exercise program demonstrated an improvement in self-reported function deficit. The patient was able to sit for a longer duration and had a considerable improvement in pain associated with prolonged sitting. A supervised exercise program combined with patient education should be the ideal physiotherapy management for the case of neck pain associated with findings of a block vertebra.