Study Design Case report. Background Thoracic spine thrust manipulation has been shown to be an effective intervention for individuals experiencing mechanical neck pain. Case Description The patient was a 46 year-old female referred to outpatient physical therapy 2-months following multiple-level anterior cervical discectomy and fusion (ACDF). At initial evaluation, primary symptoms consisted of frequent headaches, neck pain, intermittent referred right elbow pain, and muscle fatigue localized to the right cervical and upper thoracic spine regions. Initial examination findings included decreased passive joint mobility of the thoracic spine, limited cervical range of motion, and limited right shoulder strength. Outcome measures consisted of the Numeric Pain Rating Scale (NPRS), the Neck Disability Index (NDI), and the Global Rating of Change Scale (GROC). Treatment consisted of a combination of manual therapy techniques aimed at the thoracic spine, therapeutic exercises for the upper quarter, and patient education including home exercise program, over a 6-week episode of care. Outcomes Immediate reductions in cervical region pain (mean ± SD, 2.0 ± 1.1) and headache (2.0 ± 1.3) intensity were reported every treatment session immediately following thoracic spine thrust manipulation. At discharge, the patient reported 0/10 cervical pain and headache symptoms during all work related activities. From initial assessment to discharge, NDI scores improved from 46% to 16% with an associated GROC score of +7 “very great deal better”. Discussion This case report describes the immediate and short-term clinical outcomes for a patient presenting with symptoms of neck pain and headache following ACDF surgical intervention. Clinical rationale and patient preference aided the decision to incorporate thoracic spine thrust manipulation as a treatment for this patient. Level of Evidence Therapy, level 4. J Orthop Sports Phys Ther, Epub 10 May 2014. doi:10.2519/jospt.2014.5026.