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Posterior disk displacement: morphologic assessment and measurement reliability--cervical spine.

BACKGROUND: Magnetic resonance imaging (MRI) is often used to assess for disk displacement after manipulation, but limited information about the true incidence of iatrogenic herniations exists. Preliminary data must be obtained concerning the size of different types of displacement to further assess this relationship. The reliability of chiropractic radiologists in assessing disks, and a comparison of measuring devices should be evaluated. OBJECTIVE: To identify average measurements for normal and displaced disks and to assess the reliability of measurements by chiropractic radiologists. STUDY DESIGN: Intraobserver and interobserver reliability study assessing cervical disk displacement on MRI scans. METHODS: Three evaluators assessed the disks on 106 MRI scans. Six categories were assessed and compared. Thirty-seven scans were reassessed for intraobserver comparisons. Interobserver and intraobserver variations and measurement-device correlations were determined. RESULTS: Interexaminer measurement reliability for the 2 devices was 0.80 to 0.84. Intraexaminer reliability ranged from 0.58 to 0.94. Interexaminer and intraexaminer agreement for the presence of disk displacement was 86% (kappa = 0.69) and 78% to 85% (kappa = 0.50-0.67), respectively; for the presence of osteophytes, 92% (kappa = 0.54) and 86% to 95% (kappa = 0.60-0.80); and for the classification of disk displacements, 76% (kappa = 0.53) and 73% to 80% (kappa 0.44-0.61). Distinguishing between normal versus bulged disks demonstrated the greatest classification disagreement. Clear size differences between the types of disk displacement were noted. The ruler and digitizer correlation coefficient was 0.96. CONCLUSIONS: Interexaminer and intraexaminer agreement were good to very good concerning measurements and fair to good concerning disk assessments. Different disk displacement types demonstrated obvious mean size differences. No significant mean difference in measurements between the ruler and the digitizer was noted.

Adolescent↗
PubMed2002

Uneventful upper cervical manipulation in the presence of a damaged vertebral artery.

OBJECTIVE: To discuss a case in which a patient with a previously injured vertebral artery underwent manipulation in the upper cervical spine without alteration of her symptom pattern. The literature concerning the relative safety of specific upper cervical manipulative techniques is reviewed. CLINICAL FEATURES: A 42-year-old woman had a 3-week history of unilateral suboccipital pain that she related to a sudden twisting of her head and neck that occurred while she was putting sheets of drywall on top of her car. Subsequent examination by a neurologist 2 weeks later was unremarkable, and a tension-type headache was diagnosed. Approximately 10 days later (3 weeks after injury), a single high-velocity upper-cervical manipulation (incorporating slight rotation and full lateral flexion) was performed with no change in her symptom pattern. Two weeks after that, the patient had development of a lateral medullary syndrome (also known as Wallenberg syndrome) after she briefly extended and rotated her upper cervical spine while painting a ceiling. INTERVENTION AND OUTCOME: The patient was treated with anticoagulant therapy, and the lateral medullary infarct healed without incident. The spinocerebellar and subtle motor symptoms also resolved, but the ipsilateral suboccipital headache and the loss of temperature sensation associated with the spinothalamic tract lesion were still present 9 months later. CONCLUSION: This case report demonstrates that vigorous manipulation of the upper cervical spine is possible without injuring an already damaged vertebral artery. It is suggested that the line of drive used during the single manipulation, almost pure lateral flexion with slight rotation, was responsible for the apparent innocuous response. Guidelines for the evaluation and management of vertebral artery dissection are reviewed. Because it is currently impossible to identify patients at risk of having a dissected vertebral artery with standard in-office examination procedures, rotational manipulation of the upper cervical spine should be abandoned by all practitioners, and schools should remove such techniques from their curriculums.

Adult↗
PubMed2002

Chronic low back pain: a study of the effects of manipulation under anesthesia.

OBJECTIVE: The objective of this project was to evaluate the efficacy of using self-reported questionnaires to study manipulation under anesthesia (MUA) for patients with chronic low back pain. Self-reported outcome assessment instruments were used to evaluate changes in patients receiving MUA versus those not receiving MUA. SETTING: Two ambulatory surgical centers and 2 chiropractic clinics. SUBJECTS: A total of 87 subjects participated in this study. The intervention group consisted of 38 patients and the nonintervention group consisted of 49 patients. Selection was made from a convenience sample of patients selected from doctors who perform MUA at 2 centers participating in the study. INTERVENTION: Patients in the intervention group received MUA. Patients in the nonintervention group received traditional chiropractic treatment. OUTCOME MEASURES: A Numeric Pain Scale and the Roland-Morris Questionnaire were administered at baseline evaluation, after the procedure, and 4 weeks later. Results were documented and compared. RESULTS: The average Numeric Pain Scale scores in the MUA group decreased by 50%, and the average Roland-Morris Questionnaire scores decreased by 51%. The average Numeric Pain Scale changes in the nonintervention group decreased by 26%, and in the Roland-Morris Questionnaire group mean scores decreased by 38%. CONCLUSIONS: In this sample of patients with chronic low back pain, self-reported outcomes improved after the procedure and at follow-up evaluation. There was more improvement reported in the intervention group than the nonintervention group. This study supports the need for large-scale studies on MUA. It also revealed that self-reported outcome assessments are easily administered and a dependable method to study MUA.

Adult↗
PubMed2003

Bilateral occipital-parietal hemorrhagic infarctions following chiropractic cervical manipulation.

A 26-year-old woman presented with acute headache and hand-motion vision in both eyes. One day prior to presentation she went to her chiropractor for cervical manipulation. The patient had received 20 chiropractic manipulations over the previous two years. CT scan and MRI showed bilateral, symmetric occipital-parietal hemorrhagic infarctions. Angiography revealed severe focal stenosis in the distal vertebral arteries bilaterally at the superior C1 level possibly representing dissections. There was also a pseudoaneurysm of the left vertebral artery at the C1 level. Risk factors included chiropractic manipulation, recent fever, and therapies for polycystic ovarian disease. The patient showed slow, steady improvement in her vision. Twenty days following admission, vision was 20/20 OU. The improvement in her vision most likely reflects the reduction in swelling and absorption of blood at the site of the strokes.

Adult↗
PubMed2006

Thoraco lumbar junction syndrome: a case report.

This case report describes a 46-year-old female who experienced symptoms of low back pain with pain radiating into the right gluteal area. Initial intervention addressed mechanical dysfunction at the lumbosacral junction. Reduction in symptoms was observed following manual therapy procedures that addressed the lumbosacral junction; however, the right gluteal pain persisted with recurrence of back pain. Subsequent examination revealed non-neutral dysfunction at the thoracolumbar junction. Treatment was continued with manual therapy procedures that addressed facet restriction and soft tissue dysfunction in the thoracolumbar junction. A marked relief in symptoms was reported thereafter, with a decrease in right gluteal pain and improved functional ability. The anatomical and clinical relevance to this scenario is described. The thoracolumbar junction is described as a predominant contributor to the symptomatology. Its complementary role to the lumbosacral junction is enumerated.

Female↗
PubMed2005

Cranial manipulation can alter sleep latency and sympathetic nerve activity in humans: a pilot study.

OBJECTIVE: To determine if cranial manipulation is associated with altered sleep latency. Furthermore, we investigated the effects of cranial manipulation on muscle sympathetic nerve activity (MSNA) as a potential mechanism for altered sleep latency. DESIGN: Randomized block design with repeated measures. SETTING: The Integrative Physiology and Manipulative Medicine Departments, University of North Texas Health Science Center, Fort Worth, TX. SUBJECTS: Twenty (20) healthy volunteers (12 male, 8 female; age range, 22-35 years) participated in this investigation. INTERVENTIONS: Subjects were exposed to 3 randomly ordered treatments: compression of the fourth ventricle (CV4), CV4 sham (simple touch), and control (no treatment). OUTCOME MEASURES: Sleep latency was assessed during each of the treatments in 11 subjects, using the standard Multiple Sleep Latency Test protocol. Conversely, directly recorded efferent MSNA was measured during each of the treatments in the remaining 9 subjects, using standard microneurographic technique. RESULTS: Sleep latency during the CV4 trial was decreased when compared to both the CV4 sham or control trials (p < 0.05). MSNA during the CV4-induced temporary halt of the cranial rhythmic impulse (stillpoint) was decreased when compared to prestillpoint MSNA (p < 0.01). During the CV4 sham and control trials MSNA was not different between CV4 time-matched measurements (p > 0.05). Moreover, the change in MSNA prestillpoint to stillpoint during the CV4 trial was different compared to the CV4 sham and control trials (p < 0.05). However, this change in MSNA was similar between the CV4 sham and control trials (p > 0.80). CONCLUSIONS: The current study is the first to demonstrate that cranial manipulation, specifically the CV4 technique, can alter sleep latency and directly measured MSNA in healthy humans. These findings provide important insight into the possible physiologic effects of cranial manipulation. However, the mechanisms behind these changes remain unclear.

Adult↗
PubMed1998

Variations in posteroanterior stiffness in the thoracolumbar spine: preliminary observations and proposed mechanisms.

BACKGROUND AND PURPOSE: Evaluation of posteroanterior (PA) movement in the spine is commonly used in the clinic, but little is known about the mechanisms involved. The purposes of this study were to examine variations in PA stiffness along the thoracolumbar spine and to investigate possible factors that might determine the pattern of stiffness. SUBJECTS: Twenty-one pain-free volunteers (10 male, 11 female), aged 18 to 41 years (mean age=26.6, SD=7.5), participated. METHODS: Posteroanterior stiffness was measured at 5 locations (L4, L1, T10, T7, T4), together with various subject characteristics. RESULTS: Mean PA stiffness varied among locations, with the greatest stiffness at L4 (13.3 N/mm) and the lowest stiffness at L1 (10.4 N/mm). A relatively small, but important, proportion (22% or less) of the variance in stiffness data at some vertebral levels was accounted for by the variables describing subject characteristics. CONCLUSION AND DISCUSSION: Posteroanterior stiffness varies along the spine in a manner consistent with the nature of support for the spine. The observed pattern of variation of PA stiffness along the spine appears to be influenced by some factors other than those relating to the spine.

Adolescent↗
PubMed2005

The role of physiotherapy in the management of non-specific back pain and neck pain.

This paper provides an overview of best practice for the role of physiotherapy in managing back pain and neck pain, based mainly on evidence-based guidelines and systematic reviews. More up-to-date relevant primary research is also highlighted. A stepped approach is recommended in which the physiotherapist initially takes a history and carries out a physical examination to exclude any potentially serious pathology and identify any particular functional deficits. Initially, advice providing simple messages of explanation and reassurance will form the basis of a patient education package. Self-management is emphasized throughout. A return to normal activities is encouraged. For the patient who is not recovering after a few weeks, a short course of physiotherapy may be offered. This should be based on an active management approach, such as exercise therapy. Manual therapy should also be considered. Any passive treatment should only be used if required to relieve pain and assist in helping patients get moving. Barriers to recovery need to be explored. Those few patients who have persistent pain and disability that interferes with their daily lives and work need more intensive treatment or a different approach. A multidisciplinary approach may then be optimal, although it is not widely available. Liaison with the workplace and/or social services may be important. Getting all players on side is crucial, especially at this stage.

Back Pain↗
PubMed2002

Flexion and extension views are not cost-effective in a cervical spine clearance protocol for obtunded trauma patients.

BACKGROUND: Between 1994 and 1999, 837 flexion-extension cervical spine films (F/E) were ordered as part of a protocol to evaluate cervical stability in blunt trauma victims, particularly obtunded patients with otherwise normal films. After 5 years' experience with this protocol, a review of its efficiency and cost-effectiveness was performed. METHOD: The radiology reports and charts were reviewed for positive or suggestive F/E series. RESULTS: Nearly a third of all series were inadequate to rule out instability. Only four patients were identified who had decreased admission Glasgow Coma Scale score, normal plain films and/or CT, and positive or suggestive findings on F/E. One was felt to be a false positive, and the others had minor or borderline findings; all were treated with continuation of the cervical collar. Although one patient was lost to follow-up, none of the other three required subsequent surgery or developed deformity or neurologic injury. CONCLUSION: Flexion-extension studies were not a cost-effective part of the protocol, and they were dropped.

Cervical Vertebrae↗
PubMed1999

Functional outcome of low lumbar burst fractures. A multicenter review of operative and nonoperative treatment of L3-L5.

STUDY DESIGN: A retrospective review of 42 patients treated at three major medical centers for burst fractures of L3, L4, and L5. This is the largest low lumbar (L3-L5) burst fracture study in the literature to date. The study was designed to assess both radiographic and clinical outcomes in a cohort of patients treated during a 16-year period. OBJECTIVES: The objective of this study was to determine whether conservatively treated patients with low lumbar burst fractures had satisfactory outcomes compared with those in a surgically treated cohort of patients. The study included patients with and without neurologic deficits. SUMMARY OF BACKGROUND DATA: Burst fractures of the low lumbar spine (L3-L5) represent a small percentage of all spine fractures. The iliolumbar ligaments and location below the pelvic brim are two stabilizing factors that are unique to these fractures when compared with burst fractures at the thoracolumbar junction. METHODS: Forty-two (n = 42) patients with low lumbar burst fractures were identified from 1980 through 1996. Medical records, radiographs, and follow-up Dallas Pain Questionnaires were obtained. Loss of anterior vertebral height, kyphotic angulation, and amount of retropulsion were recorded at several phases of treatment. Mean follow-up time was 45.2 months (range, 5-132 months). Twenty patients were treated without surgery (18 were neurologically intact, and 2 had isolated nerve root injury), and 22 underwent surgery (14 had neurologic injury, 8 were intact). RESULTS: No patient showed neurologic deterioration, regardless of treatment. Fracture of the third lumbar segment showed the greatest tendency toward kyphotic collapse and loss of height in the nonoperative group, although this was not reflected in the final functional outcome of both groups. The ability to return to work and achieve a good-to-excellent long-term result was not significantly different among fracture levels or between surgical and nonsurgical treatments. CONCLUSIONS: The results of nonoperative treatment of low lumbar burst fractures were comparable with those of operative treatment. The rate of repeat surgery (41%) and absence of a clearly definable long-term functional or radiographic benefit in patients without neurologic compromise may make surgery less appealing.

Adolescent↗
PubMed2001

Comparison of three manual coccydynia treatments: a pilot study.

STUDY DESIGN: A prospective pilot study with independent assessment and a 2-year follow-up period was conducted. OBJECTIVES: To compare and assess the efficacy of three manual coccydynia treatments, and to identify factors predictive of a good outcome. SUMMARY OF BACKGROUND DATA: Various manual medicine treatments have been described in the literature. In an open study, the addition of manipulation to injection treatment produced a 25% increase in satisfactory results. Dynamic radiographs of the coccyx allow breakdown of coccydynia into four etiologic groups based on coccygeal mobility: luxation, hypermobility, immobility, and normal mobility. These groups may respond differently to manual treatments. METHODS: The patients were randomized into three groups, each of which received three to four sessions of a different treatment: levator anus massage, joint mobilization, or mild levator stretch. Assessment with a visual analog scale was performed by an independent observer at 7 days, 30 days, 6 months, and 2 years. RESULTS: The results of the manual treatments were satisfactory for 25.7% of the cases at 6 months, and for 24.3% of the cases at 2 years. The results varied with the cause of the coccydynia. The patients with an immobile coccyx had the poorest results, whereas those with a normally mobile coccyx fared the best. The patients with luxation or hypermobility had results somewhere between these two rates. Levator anus massage and stretch were more effective than joint mobilization, which worked only for patients with a normally mobile coccyx. Pain when patients stood up from sitting and excessive levator tone were associated with a good outcome. However, none of the results was significant because of the low success rate associated with manual treatment. CONCLUSIONS: There is a need for a placebo-controlled study to establish conclusively whether manual treatments are effective. This placebo must be an external treatment. A sample size of 190 patients would be required for 80% confidence in detecting a difference.

Adult↗