This putative case report reveals an underreported neuromusculoskeletal condition usually referred from primary care providers to dermatologists and then to a cadre of physicians including psychiatrists – but rarely chiropractic physicians.
History of Present Illness (HPI)
Subjective
Chief concern: "My back itches and my neck hurts." For the past three years, this 42-year-old female patient has experienced daily pain in the neck and back near her left scapula. There is also an itching sensation near the left scapula.
Ten years ago, she was injured in a rear-end motor-vehicle collision, which caused a whiplash injury. Prolonged sitting at the computer increases the neck and back pain. She does experience temporary relief of the itching with the use of a back scratcher or application of capsaicin. She describes the pain as an intermittent burning and tingling with numbness. She denies any radiation down the spine or extremities.
At this time, the pain is rated at 4/10 on an 11-point numerical rating scale. There are times when the pain and itching is worse at 7-8/10, in which case she must scratch or use the capsaicin to reduce the pain. Her primary care physician diagnosed pruritus and referred her to a dermatologist. She was prescribed topical medications that did not relieve the pain. Hence, the dermatologist referred her to a psychiatrist, who diagnosed her with psychogenic itch. Counseling did not reduce the pain.
She purchased a back scratcher and capsaicin at the local health food store, which provide her with temporary relief of the pain and itching in the thoracic spine. She has never seen a chiropractor. Her neighbor suggested the capsaicin and referred her to a chiropractor for neck pain treatments.
Objective
Observation: A 42-year-old female standing 65 inches in height and weighing 165 pounds, with a patch of hyperpigmentation along the border of the left scapula. She is attentive, kind and a dependable historian.
Vital signs: Oral temperature 97.8 F; BP 144/72; pulse 76, respirations 12.
Posture: Sitting, anterior carriage of the head is 3 inches with rounding of the shoulders; standing, posterior and inferior left ilium and anterior and superior right ilium.
Palpation: Pain at C5-6-7 midline ligamentum nuchae and left C5-6 facet capsules; T2-4 midline supraspinous ligaments and left facets. Myofascial trigger points located in the left levator scapular muscle and bilateral lower posterior cervical paravertebral muscles. Hypertonicity and pain in the left paravertebral muscles at T2-4, which increases the pain and itching at the left scapular border.
Active cervical range of motion within normal limits and without pain except for reduced range with pain at C5-6 left upon left lateral flexion and rotation. Cervical compression produces pain at C4-6 left; cervical distraction positive with reduced pain at C4-6 left.
Long sit test demonstrates left functional leg-length shortening supine and right functional leg-length shortening seated, indicating a functional leg-length inequality.
Posterior joint dysfunction at C5-6 and T2-4 with pain, reduced range of motion and hypertonicity of the paravertebral muscles.
3-Part Peripheral Neurological Exam:
- Sensory intact for pain and light touch in the upper extremities, but hypesthesia noted along the medial border of the left scapula
- Motor intact at 5/5 in the upper extremities bilaterally
- Deep tendon reflexes intact at 2+ and brisk in the upper extremities bilaterally
- Hoffman and Babinski signs absent
Cervical spine imaging revealed degenerative joint disease at C5-6.
Assessment
- Chronic pain syndrome, posttraumatic (G89.21)
- Notalgia paresthetica (G54.8)
- Cervical degenerative joint disease (M50.30)
Treatment Plan
- Soft-tissue treatments to reduce trigger points, hypertonicity and compression of the dorsal primary rami (cutaneous branches)
- Spinal manipulation to reduce joint dysfunction and pain; improve active cervical range of motion
- Prescribed 3-12 treatments over the next six weeks to reduce the pain and pruritis
- Prescribed specific postural exercises to reduce the forward head posture and rounding of the shoulders
Test Your Knowledge
Now let's augment your learning opportunity with three multiple-choice questions. How many can you answer correctly? [Answers at end of article]
1. The diagnosis of "notalgia paresthetica" is also known as ____________.
a. Itchy back syndrome
b. Spinal subluxation syndrome
c. Chronic spinal pain syndrome
d. Cervical radiculopathy
2. Which compressed nerves might cause notalgia paresthetica?
a. Brachial plexus because of scalene muscle compression
b. Dorsal nerve branches of thoracic roots at their passage through the multifidus spine muscle
c. C 5 nerve root due to neuroforaminal compromise
d. Spinal cord due to herniated nucleus pulposus
3. What objective finding would ind-icate the probability of the diagnosis of notalgia paresthetica?
a. Cervical joint dysfunction
b. Thoracic joint dysfunction
c. Hyperpigmentation over the area of sensory findings
d. Postural alterations of the cervical spine
Practice Pearls
It is my opinion that this putative case report will enable you to identify patients who present in your office with notalgia paresthetica. I believe you will be able to provide evidence-based, patient-centered care that will improve the quality of life for your patients.
I suggest you contact your local primary care providers and dermatologists, and share with them the diagnosis and appropriateness of chiropractic management of patients with this neuromusculoskeletal condition and its dermatological presentation. Please continue to investigate this condition and "scratch your itch" to learn more about notalgia paresthetica.
Quiz Answers: 1. A. 2. B. 3. C.
Recommended Reading
- Faye LJ, et al. Presumptive spondylogenic pruritus: a case study. J Can Chiropr Assoc, 2020 Aug;64(2):139-143.
- Akram A. Notalgia paresthetica: cervical spine disease and neuropathic pruritus. Cureus, 2021 Jan;13(1):e12975.
- Yosipovitch G, et al. Neuropathic and psychogenic itch. Dermatolog Ther, Jan 2008;21(1).
- Situm N, et al. Notalgia paresthetica. Acta Clin Croat, 2018;57:721-725.
- Low R, et al. Notalgia paresthetica relieved by cervical traction. J Am Board Fam Med, Nov-Dec 2017;30(6):835-837.
- Muir B. Dorsal scapular nerve neuropathy: a narrative review of the literature. J Can Chiropr Assoc, 2017 Aug;61(2):128-144.
Click here for more information about James Lehman, DC, MBA, DIANM.