Back Clinic Chiropractic Spine Care Team. The spine is designed with three natural curves; the neck curvature or cervical spine, the upper back curvature or thoracic spine, and the lower back curvature or lumbar spine, all of which come together to form a slight shape when viewed from the side. The spine is an essential structure as it helps support the upright posture of humans, it provides the body with the flexibility to move and it plays the crucial role of protecting the spinal cord. Spinal health is important in order to ensure the body is functioning to its fullest capacity. Dr. Alex Jimenez strongly indicates across his collection of articles on spine care, how to properly support a healthy spine. For more information, please feel free to contact us at (915) 850-0900 or text to call Dr. Jimenez personally at (915) 540-8444.
Herniation of the nucleus pulposus, abbreviated as HNP, occurs when the nucleus pulposus, frequently described to have a gel-like substance, breaks through the anulus fibrosus, the tire-like structure of the intervertebral disc which acts as a spinal shock absorber.
A herniated disc occurs most frequently in the lumbar region of the backbone or spine, particularly at the L4-L5 and L5-S1 levels (L = Lumbar and S = Sacral). This is primarily because the lumbar spine generally carries the majority of the body’s weight. Since the elasticity and water content of the nucleus decreases with age through the natural process of degeneration, individuals between the ages of 30 and 50 often seem to be �more vulnerable to disc herniation.
The progression of a herniation of the nucleus pulposus, best known as a herniated disc, can vary and typically occurs gradually over time. There are four stages: (1) disc protrusion (2) prolapsed disk (3) disc extrusion (4) sequestered disc. Stages 1 and 2 are known as incomplete disc herniations, or as a disc bulge, where 3 and 4 are known as complete disc herniations, ruptured discs or herniated discs. Pain may be combined with some radiculopathy, which means deficit. The deficit might include sensory alterations, such as tingling sensations and/or numbness, or motor changes, such as weakness and/or �weight loss. Nerve compression resulting from added pressure, compression or impingement of the spinal nerves due to the substance from the herniated disc is often what causes these changes.
Progression of Herniated Disc
The extremities affected by herniated discs are dependent upon the vertebral level at which they occur in. Consider the following examples:
Cervical – Pain, discomfort and other symptoms in the throat, shoulders, and arms.
Thoracic – Symptoms radiate into the chest.
Lumbar – Symptoms extend into the buttocks, thighs, legs and feet. Sciatica is common.
Cauda Equina Syndrome is serious disorder requiring immediate surgical intervention which occurs from from a disc herniation. The symptoms include bilateral leg pain, reduction of perianal sensation (rectum), paralysis of the bladder, and weakness of the anal sphincter.
Analysis of Herniated Discs
The backbone is analyzed with the patient standing and laying down. Because of muscle spasm, a loss of normal spinal curvature may be noted. Radicular pain, described as inflammation of a spinal nerve, may increase if pressure is placed on the affected spinal segment.
A Lasegue test, also known as Straight-leg Raising Test, is often performed to determine the extent of the herniated disc and its manifested symptoms. To perform this test, the patient lies down, the knee is extended, and the hip is flexed. If pain is aggravated or produced, it is an indication the lower lumbosacral nerve roots may be inflamed.
Other neurological tests are performed to ascertain loss of sensation and/or engine function. Reflexes are noted as these changes may indicate the location of the herniation.
Radiographs can be helpful to determine the presence of a herniated disc, but Computed Axial Tomography (CAT) or Magnetic Resonance Imaging (MRI) provides more detail. The MRI is the best method allowing the physician to find the soft spinal tissues that are unseen in other imaging procedures.
Evidence of HNP
The findings in the examination and evaluations, such as the one below, are compared to earn a diagnosis. This includes ascertaining the precise location of the herniation so treatment options can be reviewed with the patient.
The scope of our information is limited to chiropractic and spinal injuries and conditions. To discuss options on the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .�
By Dr. Alex Jimenez
Additional Topics: Sciatica
Lower back pain is one of the most commonly reported symptoms among the general population. Sciatica, is well-known group of symptoms, including lower back pain, numbness and tingling sensations, which often describe the source of an individual’s lumbar spine issues. Sciatica can be due to a variety of injuries and/or conditions, such as spinal misalignment, or subluxation, disc herniation and even spinal degeneration.
A common cause of lower leg and back pain is a ruptured disc or herniated disc. Symptoms of a herniated disc may include muscle spasm or cramping sharp or dull pain, sciatica, and leg weakness or loss of leg work. Sneezing, coughing, or bending intensify the pain.
Rarely, bowel or bladder control is lost, and when this happens, seek medical attention at once.
Sciatica is a symptom often associated with a lumbar herniated disc. Stress on one or several nerves that contribute to the sciatic nerve can lead to pain, burning, tingling, and numbness that extends from the buttocks into the leg and into the foot. Normally one side (left or right) is affected.
Anatomy of Lumbar Spine Discs
First, a brief overview of spinal anatomy so that you can better understand the way the lumbar herniated disc may lead to lower back pain and leg pain.
In between each of the 5 lumbar vertebrae (bones) is a disc, a tough, fibrous shock-absorbing pad. Endplates line the endings of every vertebra and help hold discs in place. Every disc includes a tire-like outer ring (annulus fibrosus) that encases a gel-like material (nucleus pulposus).
Disc herniation occurs when the annulus fibrous breaks open or cracks, permitting the nucleus pulposus to escape. Though you may have heard it be called a ruptured disc or even a bulging disc, this is called a herniated nucleus pulposus or herniated disc.
When a disc herniates, it can press on the spinal cord or spinal nerves. All along your spine, nerves are branching off from the spinal cord and travelling to various parts of your body. The nerves pass through small passageways between the vertebrae and discs, so if a herniated disc presses into that passageway, it can compress (or “pinch”) the nerve. This can result in the pain associated with herniated discs. (In the case below, you can observe a close-up look at a herniated disc pressing on a spinal nerve.)
Lumbar Herniated Disc Risk Factors
Many factors can increase the risk for disc herniation, including:
Lifestyle choices like tobacco use, lack of regular exercise, and insufficient nourishment significantly contribute to inadequate disc health.
As the body ages, natural chemical modifications cause discs to slowly dry out, which can impact disc strength and resiliency. To put it differently, the aging process can make your discs less capable of absorbing the shock from the body’s movements, which is one of their most important jobs.
Poor posture combined with the habitual use of incorrect body mechanics stresses the lumbar spine and influences its usual ability to take the bulk of the body’s weight.
Combine these factors with the eeffects from daily wear and tear, injury, incorrect lifting, or twisting and it is simple to comprehend why a disc may herniate. For example, lifting something incorrectly may lead to disc pressure.
Disc Herniation Phases
A herniation may develop suddenly or slowly over weeks or months. The four phases to a herniated disc are:
1) Disc Degeneration: Chemical modifications related to aging causes discs to weaken, but with no herniation.
2) Prolapse: The form or position of the disc changes with a few small impingement into the spinal canal and/or spinal nerves. This stage is also referred to as a bulging disc or a disc that was protruding.
3) Extrusion: The gel-like nucleus pulposus breaks through the tire-like wall (annulus fibrosus) but remains within the disc.
4) Sequestration or Sequestered Disc: The nucleus pulposus fractures throughout the annulus fibrosus and can then go outside the intervertebral disc.
Lumbar Herniated Disc Diagnosis
Lately, not every herniated disc causes symptoms. Some people discover they have a ruptured disc or herniated disc after an x-ray for an unrelated reason.
Most of the time, the symptoms, notably the pain, prompt the patient to seek medical attention. The trip with the doctor includes a physical exam and neurological exam. He or she will examine your medical history, and inquire about what remedies you have tried for pain relief and what symptoms you’ve experienced.
An x-ray may be needed to rule out other causes of back pain like osteoarthritis (spondylosis) or spondylolisthesis. A CT or MRI scan verifies the extent and location of disc damage.These imaging tests can show the soft tissues (including the disc).
Sometimes a myelogram is essential. In that evaluation, you will receive an injection of a dye; the dye will appear on a CT scan, so allowing your physician to readily see problem areas.
The scope of our information is limited to chiropractic and spinal injuries and conditions. To discuss options on the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .�
By Dr. Alex Jimenez
Additional Topics: Sciatica
Lower back pain is one of the most commonly reported symptoms among the general population. Sciatica, is well-known group of symptoms, including lower back pain, numbness and tingling sensations, which often describe the source of an individual’s lumbar spine issues. Sciatica can be due to a variety of injuries and/or conditions, such as spinal misalignment, or subluxation, disc herniation and even spinal degeneration.
Clay-shoveler’s fracture is a breakage of the vertebrae in the spine as a consequence of stress in the neck or upper back. It is often described as a steady fracture during the process of a vertebra happening at C7 or C6, classically at some of the cervical or thoracic vertebrae.
Clay-shoveler’s fracture usually occurs in laborers who engage in tasks involving lifting weights with the arms stretched. Examples of these actions include physical activities like shoveling soil, rubble or snow up and over the head backwards, using a pickax or scythe, and pulling out roots.
Back in Australia in the 1930s, men digging deep ditches tossed clay 10 to 15 feet above their heads using long handled shovels. Rather than separating, the clay would stick to the spade; the employee would hear a pop followed by a sudden pain between the shoulder blades, making them unable to continue working.
Mechanism of Injury: Clay Shoveler’s Fracture
The mechanism of injury is thought to be secondary to reflex and muscle strain through the supraspinous ligaments with force transmission.
The spinous process is pulled on by the enormous force. The fracture is diagnosed by plain film examination. The shear power of the muscles (trapezius and rhomboid muscles) yanking on the spine at the bottom of the neck actually tears from the bone of the spine.
Symptoms of clay-shoveler’s fracture include burning, “knife- like” pain in the level of the fractured spine between the top shoulder blades. The pain may increase with repeated action that strains the muscles of the upper back. The broken spine and muscles that are nearby are exquisitely tender. Often these injuries found incidentally years later when the cervical spine is imaged for other explanations and only are unrecognised in the time.
Acutely, they tend to be associated with:
Motor vehicle accidents
sudden muscle contraction
Blows into the spine
Radiographic Features
The fracture is seen on lateral radiographs as an oblique through the spinous process, usually of C7. There’s usually substantial displacement. Other radiographic characteristics of the fracture include ghost signals on an AP view (i.e. double spinous process of C6 or C7 caused by displaced fractured spinous process).
Clay Shoveler’s Fracture
Atypical Clay Shoveler’s Fracture
While the extreme pain slowly subsides in days to weeks, the region may intermittently develop burning pain with certain activities that involve prolonged extending of their arms (such as computer function).
No therapy is required for most patients. Physical therapy, pain drugs, and massage can be of help. Surgical removal of the suggestion of the spine is performed for anyone who have pain.
The scope of our information is limited to chiropractic and spinal injuries and conditions. To discuss options on the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .�
By Dr. Alex Jimenez
Additional Topics: Automobile Accident Injuries
Whiplash, among other automobile accident injuries, are frequently reported by victims of an auto collision, regardless of the severity and grade of the accident. The sheer force of an impact can cause damage or injury to the cervical spine, as well as to the rest of the spine. Whiplash is generally the result of an abrupt, back-and-forth jolt of the head and neck in any direction. Fortunately, a variety of treatments are available to treat automobile accident injuries.
A good read to understanding alteration of motion segment integrity (AOMSI) is the article �Biomechanical Analysis of clinical instability in the cervical spine� White, et al., Clin Ortho Relat Res, 1975;(109):85-96.
AOMSI is a biomechanical analysis. It�s all about numbers that have clinical meaning and significance. Threshold values have been determined that quantify without a doubt the patient has serious injury. It is a test of structural integrity of the ligaments interconnecting the motion segments. In this case, structural integrity has to do with the material properties of ligament tissue. Those properties include strength and flexibility. When a material is both strong and flexible, it�s called a semi-rigid material. Strength is related to the composition of the material. Strength might be thought of as load carrying capacity before failure.
Mechanism of Injury: Ligaments
Ligament tissue has previously been bench tested to describe its physical characteristics of stress/strain. That is, given so much load (stress) how much elongation will occur (strain). During normal physiologic loads the ligament remains intact and recoils to its original length when the load is removed. If the load becomes too large the materials (ligaments) begin to yield. They go past their elastic limit. When this happens the (strained) ligament fibers will not return to their original shape. The ligament loses its restraining capacity to hold the joint in normal stabilization and hypermobility occurs.
The ligaments, if sufficiently strained or avulsed results in AOMSI. The following paragraphs illustrates that if AOMSI is found there must be gross destruction or yielding of multiple ligaments. We need to build a BIG motion segment with Velcro ligaments. When you tear them off, they make a really nice ripping noise. That drives home the point.
In the White et al work, they found that the motion segment stayed intact i.e., less than 11 degrees� rotation (angualr mtion) and less than 3.5 mm translation, until they transected over 50% of the ligaments from an anterior or posterior approach. And when they transected from either approach the loss of stability was not linear but suddenly catastrophic. And they meant that suddenly the two vertebra totally separated in rotation or translation.
Suddenly Separated: pulled apart, head off of body, all neural components compromised, paralysis. Keeping that in mind, what are the injuries of someone just under the threshold? Severe to very severe. They stand the possibility of a serious event with much less force.
Prevalence of Ligament Injury: AOMSI
If AOMSI is detected, think about more than 50% of ligaments transected. That will start to explain the seriousness of the finding. In a patient/child that demonstrates hypermobility everywhere, then you take a statistical average of all segments, and look at the aberrant statistical finding if it exists. There are clues to injury everywhere when you understand what the numbers mean in reference to stability and function.
To diagnose ligament laxity, it is imperative that imaging be performed and a basic flexion-extension x-ray is all that is required. In today�s medical economy, advanced imaging of MRI or CT Scan, although accurate becomes an unnecessary expenditure and an x-ray renders very accurate demonstrative images to conclude a definitive diagnosis. In determining if there is an impairment, it is necessary to follow the AMA Guides to the Evaluation of Permanent Impairment as the 4th, 5th and 6th editions all render an impairment for AOMSI as sequella to ligament laxity, which is damage to the ligament from trauma.
This document is intended to serve as a simple explanation as to the severity of ligament damage and how to demonstrably diagnose the injury. It is also critical to remember that ligament do �wound repair.� In normal physiology, ligaments grow during puberty from cells within the ligaments called fibroblasts. They produce both collagen (white) and elastin (yellow) tissue, which gives the ligaments both tensile and elastic strength. Upon puberty the cells stop producing tissue and remains dormant. Upon injury, the fibroblast reactivates, but can only produce collage leaving the joint wound repaired in an aberrant juxtaposition (place) with poor movement abilities due to the lack of the requisite elastin. In turn, according to Hauser et. Al (2013) this leads to permanent loss of function of the ligament and arthritis of the joint. This is not a speculative statement; it is based upon Wolff�s that dates back to the late 1800�s and has been a guiding principle in healthcare for more than a century.
The scope of our information is limited to chiropractic and spinal injuries and conditions. To discuss options on the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .�
References:
White, et al., Clin Ortho Relat Res, 1975;(109):85-96
Hauser, Dolan,Phillips, Newlin, Moore Woldin, B.A.(2013) Ligament injury and healing: A review of current clinical diagnostics and therapeutics.The Open Rehabilitation Journal, 6,1-20.
Additional Topics: Weakened Ligaments After Whiplash
Whiplash is a commonly reported injury after an individual has been involved in an automobile accident. During an auto accident, the sheer force of the impact often causes the head and neck of the victim to jerk abruptly, back-and-forth, causing damage to the complex structures surrounding the cervical spine. Chiropractic care is a safe and effective, alternative treatment option utilized to help decrease the symptoms of whiplash.
Thomas M Kosloff1*�, David Elton1�, Jiang Tao2� and Wade M Bannister2�
CHIROPRACTIC & MANUAL THERAPIES
Abstract
Background: There is controversy surrounding the risk of manipulation, which is often used by chiropractors, with respect to its association with vertebrobasilar artery system (VBA) stroke. The objective of this study was to compare the associations between chiropractic care and VBA stroke with recent primary care physician (PCP) care and VBA stroke.
Methods: The study design was a case�control study of commercially insured and Medicare Advantage (MA) health plan members in the U.S. population between January 1, 2011 and December 31, 2013. Administrative data were used to identify exposures to chiropractic and PCP care. Separate analyses using conditional logistic regression were conducted for the commercially insured and the MA populations. The analysis of the commercial population was further stratified by age (<45 years; ?45 years). Odds ratios were calculated to measure associations for different hazard periods. A secondary descriptive analysis was conducted to determine the relevance of using chiropractic visits as a proxy for exposure to manipulative treatment.
Results: There were a total of 1,829 VBA stroke cases (1,159 � commercial; 670 � MA). The findings showed no significant association between chiropractic visits and VBA stroke for either population or for samples stratified by age. In both commercial and MA populations, there was a significant association between PCP visits and VBA stroke incidence regardless of length of hazard period. The results were similar for age-stratified samples. The findings of the secondary analysis showed that chiropractic visits did not report the inclusion of manipulation in almost one third of stroke cases in the commercial population and in only 1 of 2 cases of the MA cohort.
Conclusions: We found no significant association between exposure to chiropractic care and the risk of VBA stroke. We conclude that manipulation is an unlikely cause of VBA stroke. The positive association between PCP visits and VBA stroke is most likely due to patient decisions to seek care for the symptoms (headache and neck pain) of arterial dissection. We further conclude that using chiropractic visits as a measure of exposure to manipulation may result in unreliable estimates of the strength of association with the occurrence of VBA stroke.
Keywords: Chiropractic, Primary care, Cervical manipulation, Vertebrobasilar stroke, Adverse events
Background
The burden of neck pain and headache or migraine among adults in the United States is significant. Survey data indicate 13% of adults reported neck pain in the past 3 months [1]. In any given year, neck pain affects 30% to 50% of adults in the general population [2]. Prevalence rates were reportedly greater in more eco- nomically advantaged countries, such as the USA, with a higher incidence of neck pain noted in office and com- puter workers [3]. Similar to neck pain, the prevalence of headache is substantial. During any 3-month time- frame, severe headaches or migraines reportedly affect one in eight adults [1].
Neck pain is a very common reason for seeking health care services. �In 2004, 16.4 million patient visits or 1.5% of all health care visits to hospitals and physician offices, were for neck pain� [4]. Eighty percent (80%) of visits occurred as outpatient care in a physician�s office [4]. The utilization of health care resources for the treatment of headache is also significant. �In 2006, adults made nearly 11 million physician visits with a headache diagno- sis, over 1 million outpatient hospital visits, 3.3 million emergency department visits, and 445 thousand inpatient hospitalizations� [1].
In the United States, chiropractic care is frequently utilized by individuals with neck and/or headache com- plaints. A national survey of chiropractors in 2003 re- ported that neck conditions and headache/facial pain accounted respectively for 18.7% and 12% of the patient chief complaints [5]. Chiropractors routinely employ spinal manipulative treatment (SMT) in the management of patients presenting with neck and/or headache [6], either alone or combined with other treatment approaches [7-10].
While evidence syntheses suggest the benefits of SMT for neck pain [7-9,11-13] and various types of headaches [10,12,14-16], the potential for rare but serious adverse events (AE) following cervical SMT is a concern for researchers [17,18], practitioners [19,20], professional organizations [21-23], policymakers [24,25] and the public [26,27]. In particular, the occurrence of stroke affecting the vertebrobasilar artery system (VBA stroke) has been associated with cervical manipulation. A recent publication [28] assessing the safety of chiropractic care reported, �…the frequency of serious adverse events varied between 5 strokes/ 100,000 manipulations to 1.46 serious adverse events/ 10,000,000 manipulations and 2.68 deaths/10,000,000 manipulations�. These estimates were, however, derived from retrospective anecdotal reports and liability claims data, and do not permit confident conclusions about the actual frequency of neurological complications following spinal manipulation.
Several systematic reviews investigating the association between stroke and chiropractic cervical manipulation�have reported the data are insufficient to produce definitive conclusions about its safety [28-31]. Two case�control studies [32,33] used visits to a chiropractor as a proxy for SMT in their analyses of standardized health system databases for the population of Ontario (Canada). The more recent of these studies [32] also included a case-crossover methodology, which reduced the risk of bias from confounding variables. Both case�control studies reported an increased risk of VBA stroke in association with chiropractic visits for the population under age 45 years old. Cassidy, et al. [32] found, how- ever, the association was similar to visits to a primary care physician (PCP). Consequently, the results of this study suggested the association between chiropractic care and stroke was non-causal. In contrast to these studies, which found a significant association between chiropractic visits and VBA stroke in younger patients (<45 yrs.), the analysis of a population-based case-series suggested that VBA stroke patients who consulted a chiropractor the year before their stroke were older (mean age 57.6 yrs.) than previously documented [34].
The work by Cassidy, et al. [32] has been qualitatively appraised as one of the most robustly designed investigations of the association between chiropractic manipulative treatment and VBA stroke [31]. To the best of our knowledge, this work has not been reproduced in the U.S. population. Thus, the main purpose of this study is to replicate the case�control epidemiological design published by Cassidy, et al. [32] to investigate the association between chiropractic care and VBA stroke; and compare it to the association between recent PCP care and VBA stroke in samples of the U.S. commercial and Medicare Advantage (MA) populations. A secondary aim of this study is to assess the utility of employing chiropractic visits as a proxy measure for exposure to spinal manipulation.
Methods
Study design and population
We developed a case�control study based on the experience of commercially insured and MA health plan members between January 1, 2011 and December 31, 2013. General criteria for membership in a commercial or MA health plan included either residing or working in a region where health care coverage was offered by the in- surer. Individuals must have Medicare Part A and Part B to join a MA plan. The data set included health plan members located in 49 of 50 states. North Dakota was the only State not represented.
Both case and control data were extracted from the same source population, which encompassed national health plan data for 35,726,224 unique commercial and 3,188,825 unique MA members. Since members might be enrolled for more than one year, the average�annual commercial membership was 14.7 million members and the average annual MA membership was 1.4 million members over the three year study period, which is comparable to ~5% of the total US population based on the data available from US Census Bureau [35]. Administrative claims data were used to identify cases, as well as patient characteristics and health service utilization.
The stroke cases included all patients admitted to an acute care hospital with vertebrobasilar (VBA) occlusion and stenosis strokes as defined by ICD-9 codes of 433.0, 433.01, 433.20, and 433.21 during the study period. Pa- tients with more than one admission for a VBA stroke were excluded from the study. For each stroke case, four age and gender matched controls were randomly se- lected from sampled qualified members. Both cases and controls were randomly sorted prior to the matching using a greedy matching algorithm [36].
Exposures
The index date was defined as the date of admission for the VBA stroke. Any encounters with a chiropractor or a primary care physician (PCP) prior to the index date were considered as exposures. To evaluate the impact of chiropractic and PCP treatment, the designated hazard period in this study was zero to 30 days prior to the index date. For the PCP analysis, the index date was excluded from the hazard period since patients might consult PCPs after having a stroke. The standard health plan coverage included a limit of 20 chiropractic visits. In rare circumstances a small employer may have selected a 12-visit limit. An internal analysis (data not shown) revealed that 5% of the combined (commercial and MA) populations reached their chiropractic visit limits. Instances of an employer not covering chiropractic care were estimated to be so rare that it would have had no measurable impact on the analysis. There were no limits on the number of reimbursed PCP visits per year.
Analyses
Two sets of similar analyses were performed, one for the commercially insured population and one for the MA population. In each set of analyses, conditional logistic regression models were used to examine the association between the exposures and VBA strokes. To measure the association, we estimated the odds ratio of having the VBA stroke and the effect of total number of chiropractic visits and PCP visits within the hazard period. The analyses were applied to different hazard periods, including one day, three days, seven days, 14 days and 30 days for both chiropractic and PCP visits. The results of the chiropractic and PCP visit analyses were then compared to find evidence of excess risk of having stroke for patients with chiropractic visits during the
hazard period. Previous research has indicated that most patients who experience a vertebral artery dissection are under the age of 45. Therefore, in order to investigate the impact of exposure on the population at different ages, separate analyses were performed on patients stratified by age (under 45 years and 45 years and up) for the study of the commercial population. The number of visits within the hazard period was entered as a con- tinuous variable in the logistic model. The chi square test was used to analyze the proportion of co-morbidities in cases as compared to controls.
A secondary analysis was performed to evaluate the relevance of using chiropractic visits as a proxy for spinal manipulation. The commercial and MA databases were queried to identify the proportions of cases of VBA stroke and matched controls for which at least one chiropractic spinal manipulative treatment procedural code (CPT 98940 � 98942) was or was not recorded. The analysis also calculated the use of another manual therapy code (CPT 97140), which may be employed by chiropractors as an alternative means of reporting spinal manipulation.
Ethics
The New England Institutional Review Board (NEIRB) determined that this study was exempt from ethics review.
Results
The commercial study sample included 1,159 VBA stroke cases over the three year period and 4,633 age and gender matched controls. The average age of the patients was 65.1 years and 64.8% of the patients were male (Table 1). The prevalence rate of VBA stroke in the commercial population was 0.0032%.
There were a total of 670 stroke cases and 2,680 matched controls included in the MA study. The aver- age patient age was 76.1 years and 58.6% of the patients were male (Table 2). For the MA population, the prevalence rate of VBA stroke was 0.021%.
Claims during a one year period prior to the index date were extracted to identify comorbid disorders. Both the commercial and MA cases had a high percentage of comorbidities, with 71.5% of cases in the commercial study and 88.5% of the cases in the MA study reporting at least one of the comorbid conditions (Table 3). Six comorbid conditions of particular interest were identified, including hypertensive disease (ICD-9 401�404), ischemic�heart disease (ICD-9 410�414), disease of pulmonary circulation (ICD-9 415�417), other forms of heart disease (ICD-9 420�429), pure hypercholesterolemia (ICD-9 272.0) and diseases of other endocrine glands (ICD-9 249�250). There were statistically significant differences (p = <0.05) between groups for most comorbidities. Greater proportions of comorbid disorders (p = <0.0001) were reported in the commercial and MA cases for hyper- tensive disease, heart disease and endocrine disorders (Table 3). The commercial cases also showed a larger proportion of diseases of pulmonary circulation, which was statistically significant (p = 0.0008). There were no significance differences in pure hypercholesterolemia for either the commercial or MA populations. Overall, cases in both the commercial and MA populations were more likely (p = <0.0001) to have at least one co- morbid condition.
Among the commercially insured, 1.6% of stroke cases had visited chiropractors within 30 days of being admit- ted to the hospital, as compared to 1.3% of controls visit- ing chiropractors within 30 days prior to their index date. Of the stroke cases, 18.9% had visited a PCP within 30 days prior to their index date, while only 6.8% of controls had visited a PCP (Table 4). The proportion of exposures for chiropractic visits was lower in the MA sample within the 30-day hazard period (cases = 0.3%; controls = 0.9%). However, the proportion of exposures for PCP visits was higher, with 21.3% of cases having PCP visits as compared to12.9% for controls (Table 5).
The results from the analyses of both the commercial population and the MA population were similar (Tables 6, 7 and 8). There was no association between chiropractic visits and VBA stroke found for the�overall sample, or for samples stratified by age. No estimated odds ratio was significant at the 95% confidence level. MA data were insufficient to calculate statistical measures of association for hazard periods less than 0�14 days for chiropractic visits. When stratified by age, the data were too sparse to calculate measures of association for hazard periods less than 0�30 days in the commercial population. The data were too few to analyze associative risk by headache and/or neck pain diagnoses (data not shown).
These results showed there is an association existing between PCP visits and VBA stroke incidence regardless of age or length of hazard period. A strong association was found for those visits close to the index date (OR 11.56; 95% CI 6.32-21.21) for all patients with a PCP visit within 0�1 day hazard period in the commercial sample. There was an increased risk of VBA stroke associated with each PCP visit within 30-days prior to the index date for MA patients (OR 1.51; 95% CI 1.32-1.73) and commercial patients (OR 2.01; 95% CI 1.77-2.29).
The findings of the secondary analysis showed � that of 1159 stroke cases from commercial population � there were a total of 19 stroke cases associated with chiropractic visits for which 13 (68%) had claims documentation indicating chiropractic SMT was performed. For the control group of the commercial cohort, 62 of 4633 controls had claims of any kind of chiropractic visits and 47 of 4633 controls had claims of SMT. In the commercial control group, 47 of 62 DC visits (76%) included SMT in the claims data. Only 1 of 2 stroke cases in the MA population included SMT in the claims data. For the MA cohort, 21 of 24 control chiropractic visits (88%) included SMT in the claims data (Table 9).
None of the stroke cases in either population included CPT 97140 as a substitute for the more conventionally re- ported chiropractic manipulative treatment procedural codes (98940 � 98942). For the control groups, there were three instances where CPT 97140 was reported without CPT 98940 � 98942 in the commercial population. The CPT code 97140 was not reported in MA control cohort.
Discussion
The primary aim of the present study was to investigate the association between chiropractic manipulative treatment and VBA stroke in a sample of the U.S. population. This study was modeled after a case�control design previously conducted for a Canadian population [32]. Administrative data for enrollees in a large national health care insurer were analyzed to explore the occurrence of VBA stroke across different time periods of exposure to chiropractic care in comparison with PCP care.
Unlike Cassidy et al. [32] and most other case�control studies [33,37,38], our results showed there was no significant association between VBA stroke and chiropractic visits. This was the case for both the commercial and MA populations. In contrast to two earlier case�control studies [32,33], this lack of association was found to be irrespective of age. Although, our results (Table 8) did lend credence to previous reports that VBA stroke occurs more frequently in patients under the age of 45 years. Additionally, the results from the present study did not identify a relevant temporal impact. There was no significant association, when the data were sufficient to calculate estimates, between chiropractic visits and stroke regardless of the hazard period (timing of most recent visit to a chiropractor and the occurrence of stroke).
There are several possible reasons for the variation in results with previous similar case�control studies. The younger (<45 yrs.) commercial cohort that received chiropractic care in our study had noticeably fewer cases. The 0�30 days hazard period included only 2 VBA stroke cases. There were no stroke cases for other hazard periods in this population. In contrast, earlier studies reported sufficient cases to calculate risk estimates for most hazard periods [32,33].
Another factor that potentially influenced the difference in results concerns the accuracy of hospital claims data in the U.S. vs. Ontario, Canada. The source population in the Province of Ontario was identified, in part, from the Discharge Abstract Database (DAD). The DAD includes hospital discharge and emergency visit diagnoses that have undergone a standardized assessment by a medical records coder [39]. To the best of our know- ledge, similar quality management practices were not routinely applied to hospital claims data used in sourcing the population for our study.
An additional reason for the disparity in results may be due to differences in the proportions of chiropractic visits where SMT was reportedly performed. Our study showed that SMT was not reported by chiropractors in more than 30% of commercial cases. It is plausible that a number of the cases in earlier studies also did not�include SMT as an intervention. Differences between studies in the proportion of cases reporting SMT may have affected the calculation of risk estimates.
Also, there were an insufficient number of cases having cervical and/or headache diagnoses in our study. Therefore, our sample population may have included proportionally less cases where cervical manipulation was performed.
Our results were consistent with previous findings [32,33] in showing a significant association between PCP visits and VBA stroke. The odds ratios for any PCP visit increase dramatically from 1�30 days to 1�1 day (Tables 6 and 7). This finding is consistent with the hypothesis that patients are more likely to see a PCP for symptoms related to vertebral artery dissection closer to the index date of their actual stroke. Since it is unlikely that the services provided by PCPs cause VBA strokes, the association�between recent PCP visits and VBA stroke is more likely attributable to the background risk related to the natural history of the condition [32].
A secondary goal of our study was to assess the utility of employing chiropractic visits as a surrogate for SMT. Our findings indicate there is a high risk of bias associated with using this approach, which likely overestimated the strength of association. Less than 70% of stroke cases (commercial and MA) associated with chiropractic care included SMT. A somewhat higher proportion of chiropractic visits included SMT for the control groups (commercial = 76%; MA = 88%).
There are plausible reasons that support these findings. Internal analyses of claims data (not shown) consistently demonstrate that one visit is the most common number associated with a chiropractic episode of care. The single visit may consist of an evaluation without treatment such as SMT. Further; SMT may have been viewed as contraindicated due to signs and symptoms of vertebral artery dissection (VAD) and/or stroke. This might explain the greater proportion of SMT provided to control groups in both the commercial and MA populations.
Overall, our results increase confidence in the findings of a previous study [32], which concluded there was no excess risk of VBA stroke associated chiropractic care compared to primary care. Further, our results indicate there is no significant risk of VBA stroke associated with chiropractic care. Additionally, our findings highlight the potential flaws in using a surrogate variable (chiropractic visits) to estimate the risk of VBA stroke in association with a specific intervention (manipulation).
Our study had a number of strengths and limitations. Both case and control data were extracted from the same source population, which encompassed national health plan data for approximately 36 million�commercial and 3 million MA members. A total of 1,829 cases were identified, making this the largest case� control study to investigate the association between chiropractic manipulation and VBA stroke. Due to the nationwide setting and large sample size, our study likely reduced the risk of bias related to geographic factors. However, there was a risk of selection bias � owing to the data set being from a single health insurer � including income status, workforce participation, and links to health care providers and hospitals.
Our study closely followed a methodological approach that had previously been described [32], thus allowing for more confident comparisons.
The current investigation analyzed data for a number of comorbid conditions that have been identified as potentially modifiable risk factors for a first ischemic stroke [40]. The differences between groups were statistically significant for most comorbidities. Information was not obtainable about behavioral comorbid factors e.g., smoking and body mass. With the exception of hypertensive disease, there are reasons to question the clinical significance of these conditions in the occurrence of ischemic stroke due to vertebral artery dissection. A large multinational case-referent study investigated the association between vascular risk factors (history of vascular disease, hypertension, smoking, hypercholesterolemia, diabetes mellitus, and obesity/overweight) for ischemic stroke and the occurrence of cervical artery dissection [41]. Only hypertension had a positive association (odds ratio 1.67; 95% confidence interval, 1.32 to 2.1; P <0.0001) with cervical artery dissection.
While the effect of other unmeasured confounders cannot be discounted, there is reason to suspect the absence of these data was not deleterious to the results. Cassidy, et al. found no significant differences in the results their case-crossover design, which affords better control of unknown confounding variables, and the findings of their case�control study [32].
Our results highlight just how unusual VBA stroke is in the MA cohort (prevalence = 0.021%) and � even more so � for the commercial population (prevalence = 0.0032%). As a result, some limitations of this study re- lated to the rarity of reporting VBA stroke events. Despite the larger number of cases, data were insufficient to calculate estimates and confidence intervals for seven measures of exposure (4 commercial and 3 MA) for chiropractic visits. Additionally, we were not able to compute estimates specifically for headache and neck pain diagnoses due to small numbers. Confidence intervals associated with estimates tended to be wide making the results imprecise [42].
There were limitations related to the use of administrative claims data. �Disadvantages of using secondary data for research purposes include: variations in coding from hospital to hospital or from department to department, errors in coding and incomplete coding, for example in the presence of comorbidities. Random errors in coding and registration of discharge diagnoses may dilute and attenuate estimates of statistical association� [43]. The recordings of unvalidated hospital discharge diagnostic codes for stroke have been shown to be less precise when compared to chart review [44,45] and validated patient registries�[43,46]. Cassidy, et al. [32] conducted a sensitivity analysis to determine the effect of diagnostic misclassification bias. Their conclusions did not change when the effects of misclassification were assumed to be similarly distributed between chiropractic and PCP cases.
A particular limitation in using administrative claims data is the paucity of contextual information surround- ing the clinical encounters between chiropractors/PCPs and their patients. Historical elements describing the occurrence/absence of recent trauma or activities reported in case studies [47-51] as potential risk factors for VBA stroke were not available in claims data. Confidence was low concerning the ability of claims data to provide accurate and complete reporting of other health disorders, which have been described in case�control designs as being associated with the occurrence of VBA stroke e.g., migraine [52] or recent infection [53]. Symptoms and physical examination findings that would have permitted further stratification of cases were not reported in the claims data.
The reporting of clinical procedures using current pro- cedural terminology (CPT) codes presented additional shortcomings concerning the accuracy and interpretation of administrative data. One inherent constraint was the lack of anatomic specificity associated with the use of standardized procedural codes in claims data. Chiropractic manipulative treatment codes (CPT 98940 � 98942) have been formatted to describe the number of spinal regions receiving manipulation. They do not identify the particular spinal regions manipulated.
Also, treatment information describing the type(s) of manipulation was not available. When SMT was re- ported, claims data could not discriminate among the range of techniques including thrust or rotational manipulation, various non-thrust interventions e.g., mechanical instruments, soft tissue mobilizations, muscle energy techniques, manual cervical traction, etc. Many of these techniques do not incorporate the same bio- mechanical stressors associated with the type of manipulation (high velocity low amplitude) that has been investigated as a putative risk factor for VBA stroke [54-56]. It seems plausible that the utility of future VBA stroke research would benefit from explicit descriptions of the particular type of manipulation performed.
Moreover, patient responses to care � including any adverse events suggestive of vertebral artery dissection or stroke-like symptoms � were not obtainable in the data set used for the current study.
In the absence of performing comprehensive clinical chart audits, it is not possible to know from claims data what actually transpired in the clinical encounter. Further, chart notes may themselves be incomplete or otherwise fail to precisely describe the nature of interventions [57]. Therefore, manipulation codes represent surrogate
measures, albeit more direct surrogate measures, than simply using the exposure to chiropractic visits.
Our study was also limited to replication of the case� control design described by Cassidy, et al. [32]. For pragmatic reasons, we did not attempt to conduct a case-crossover design. While the addition of a case- crossover design would have provided better control of confounding variables, Cassidy, et al. [32] showed the results were similar for both the case control and case crossover studies.
The findings of this case�control study and previous retrospective research underscore the need to rethink how to better conduct future investigations. Researchers should seek to avoid the use of surrogate measures or use the least indirect measures available. Instead, the focus should be on capturing data about the types of services and not the type of health care provider.
In alignment with this approach, it is also important for investigators to access contextual data (e.g., from electronic health records), which can be enabled by qualitative data analysis computer programs [58]. The acquisition of the elements of clinical encounters � including history, diagnosis, intervention, and adverse events � can provide the infrastructure for more action- able research. Because of the rarity of VBA stroke, large data sets (e.g., registries) containing these elements will be necessary to achieve adequate statistical power for making confident conclusions.
Until research efforts produce more definitive results, health care policy and clinical practice judgments are best informed by the evidence about the effectiveness of manipulation, plausible treatment options (including non-thrust manual techniques) and individual patient values [20].
Conclusions
Our findings should be viewed in the context of the body of knowledge concerning the risk of VBA stroke. In contrast to several other case�control studies, we found no significant association between exposure to chiropractic care and the risk of VBA stroke. Our secondary analysis clearly showed that manipulation may or may not have been reported at every chiropractic visit. Therefore, the use of chiropractic visits as a proxy for manipulation may not be reliable. Our results add weight to the view that chiropractic care is an unlikely cause of VBA strokes. However, the current study does not exclude cervical manipulation as a possible cause or contributory factor in the occurrence of VBA stroke.
Authors’ Contributions
DE conceived of the study, and participated in its design and coordination. JT participated in the design of the study, performed the statistical analysis and helped to draft the manuscript. TMK participated in the design and coordination of the study, and wrote the initial draft and revisions of the manuscript. WMB participated in the coordination of the study and the statistical analysis, and helped to draft the manuscript. All authors contributed to the interpretation of the data. All authors read and approved the final manuscript.
Author Details
1Optum Health � Clinical Programs at United Health Group, 11000 Optum Circle, Eden Prairie MN 55344, USA. 2Optum Health � Clinical Analytics at United Health Group, 11000 Optum Circle, Eden Prairie MN 55344, USA.
Received: 14 October 2014 Accepted: 28 April 2015
Published Online: 16 June 2015
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This paper explores the relationship between traumatic ligament laxity of the spine and the resultant instability that may occur. Within, there is a discussion of the various spinal ligamentous structures that may be affected by both macro and micro traumatic events, as well as the neurologic and musculoskeletal effects of instability. There is detailed discussion of the diagnosis, quantification, and documentation as well.
Soft tissue cervical and lumbar sprain/strains are the most common injury in motor vehicle collisions, with 28% to 53% of collision victims sustaining this type of injury (Galasko et al., 1993; Quinlan et al., 2000). The annual societal costs of these injuries in the United States are estimated to be between 4.5 and 8 billion dollars (Kleinberger et al., 2000; Zuby et al., 2010). Soft tissue injuries of the spinal column very often become chronic, with the development of long-term symptoms, which can inevitably adversely affect the victim�s quality of life. Research has indicated that 24% of motor vehicle collision victims have symptoms 1 year after an accident and 18% after 2 years (Quinlan et al., 2004). Additionally, it has been found that between 38% and 52% of motor vehicle collision cases involved rear-impact scenarios
It is well known that the major cause of chronic pain due to these injuries is directly related to the laxity of spinal ligamentous structures (Ivancic, et al., 2008). One must fully understand the structure and function of ligaments in order to realize the effects of traumatic ligament laxity. Ligaments are fibrous bands or sheets of connective tissue which link two or more bones, cartilages, or structures together. We know that one or more ligaments provide stability to a joint during rest as well as movement. Excessive movements such as hyper-extension or hyper-flexion, which occur during a traumatic event such as a motor vehicle collision, may be restricted by ligaments, unless these forces are beyond the tensile-strength of these structures; this will be discussed later in this paper.
Ligament Laxity Spine Injury Background
Three of the more important ligaments in the spine are the ligamentum flavum, the anterior longitudinal ligament, and the posterior longitudinal ligament (Gray�s Anatomy, 40th Edition). The ligamentum flavum forms a cover over the dura mater, which is a layer of tissue that protects the spinal cord. This ligament connects under the facet joints to create a small curtain, so to speak, over the posterior openings between vertebrae (Gray�s Anatomy, 40th edition). The anterior longitudinal ligament attaches to the front (anterior) of each vertebra and runs vertical or longitudinal (Gray�s Anatomy, 40th edition). The posterior longitudinal ligament also runs vertically or longitudinally behind (posterior) the spine and inside the spinal canal (Gray�s Anatomy, 40th Edition). Additional ligaments include facet capsular ligaments, interspinous ligaments, supraspinous ligaments, and intertransverse ligaments. The aforementioned ligaments limit flexion and extension, with the exception of the ligament, which limits lateral flexion. The ligamentum nuchae, which is a fibrous membrane, limits flexion of the cervical spine (Gray�s Anatomy, 40th Edition). The four ligaments of the sacroiliac joints:
(iliolumbar, sacroiliac, sacrospinus, sacrotuberous), provide stability and some motion. The upper cervical spine has its own ligamentous structures or systems; occipitoatlantal ligament complex, occipitoaxial ligament complex, atlantoaxial ligament complex, and the cruciate ligament complex (Gray�s Anatomy, 40th Edition). The upper cervical ligament system is especially important in stabilizing the upper cervical spine from the skull to C2 (axis) (Stanley Hoppenfeld, 1976). It is important to note, that although the cervical vertebrae are the smallest, the neck has the greatest range of motion.
Causes of Ligament Laxity Injuries in the Spine
Ligament laxity may happen as a result of a �macro trauma�, such as a motor vehicle collision, or may develop overtime as a result of repetitive use injuries, or work-related injuries. The cause of this laxity develops through similar mechanisms, which leads to excessive motion of the facet joints, and will cause various degrees of physical impairment. When ligament laxity develops over time, it is defined as �creep� and refers to the elongation of a ligament under a constant or repetitive stress (Frank CB, 2004). Low-level ligament injuries, or those where the ligaments are simply elongated, represent the vast majority of cases and can potentially incapacitate a patient due to disabling pain, vertigo, tinnitus, etc.. Unfortunately, these types of strains may progress to sub-failure tears of ligament fibers, which will lead to instability at the level of facet joints (Chen HB et al., 2009). Traumatic or repetitive causes of ligament laxity will ultimately produce abnormal motion and function between vertebrae under normal physiological loads, inducing irritation to nerves, possible structural deformation, and/or incapacitating pain.
Patients�, who have suffered a motor vehicle collision or perhaps a work-related injury, very often have chronic pain syndromes due to ligament laxity. The ligaments surrounding the facet joints of the spinal column, known as capsular ligaments, are highly innervated mechanoreceptive and nociceptive free nerve endings. Therefore, the facet joint is thought of as the primary source of chronic spinal pain (Boswell MV et al., 2007; Barnsley L et al., 1995). When the mechanoreceptors and nociceptors are injured or even simply irritated the overall joint function of the facet joints are altered (McLain RF, 1993).
One must realize that instability is not similar to hyper-mobility. Instability, in the clinical context, implies a pathological condition with associated symptomatology, whereas joint hypermobility alone, does not. Ligament laxity which produces instability refers to a loss of �motion stiffness�, so to speak, in a particular spinal segment when a force is applied to this segment, which produces a greater displacement than would be observed in a normal motion segment. When instability is present, pain and muscular spasm can be experienced within the patient�s range of motion and not just at the joint�s end-point. In Chiropractic, we understand that there is a �guarding mechanism�, which is triggered after an injury, which is the muscle spasm. These muscle spasms can cause intense pain and are the body�s response to instability, since the spinal supporting structures, the ligamentous structures, act as sensory organs, which initiate a ligament-muscular reflex. This reflex is a �protective reflex� or �guarding mechanism�, produced by the mechanoreceptors of the joint capsule and these nerve impulses are ultimately transmitted to the muscles. Activation of surrounding musculature, or guarding, will help to maintain or preserve joint stability, either directly by muscles crossing the joint or indirectly by muscles that do not cross the joint, but limit joint motion (Hauser RA et al., 2013). This reflex is fundamental to the understanding of traumatic injuries.
This reflex is designed to prevent further injury. However, the continued feedback and reinforcement of pain and muscle spasm, will delay the healing process. The �perpetual loop� may continue for a long period of time, making further injury more likely due to muscle contraction. Disrupting this cycle of pain and inflammation is key to resolution.
When traumatic ligament laxity produces joint instability, with neurologic compromise, it is understood that the joint has sustained considerable damage to its stabilizing structures, which could include the vertebrae themselves. However, research indicates that joints that are hypermobile demonstrate increased segmental mobility, but are still able to maintain their stability and function normally under physiological loads (Bergmann TF et al., 1993).
Clinical Diagnosis
Clinicians classify instability into 3 categories, mild, moderate, and severe. Severe instability is associated with a catastrophic injury, such as a motor vehicle collision. Mild or moderate clinical instability is usually without neurologic injury and is most commonly due to cumulative micro-trauma, such as those associated with repetitive use injuries; prolonged sitting, standing, flexed postures, etc..
In a motor vehicle collision, up to 10 times more force is absorbed in the capsular ligaments versus the intervertebral disc (Ivancic PC et al., 2007). This is true, because unlike the disc, the facet joint has a much smaller area in which to disperse this force. Ultimately, as previously discussed, the capsular ligaments become elongated, resulting in abnormal motion in the affected spinal segments (Ivancic PC et al., 2007; Tominaga Y et al., 2006). This sequence has been clearly documented with both in vitro and in vivo studies of segmental motion characteristics after torsional loads and resultant disc degeneration (Stokes IA et al., 1987; Veres SP et al., 2010). Injury to the facet joints and capsular ligaments has been further confirmed during simulated whiplash traumas (Winkelstein BA et al., 2000).
Maximum ligament strains occur during shear forces, such as when a force is applied while the head is rotated (axial rotation). While capsular ligament injury in the upper cervical spine region can occur from compressive forces alone, exertion from a combination of shear, compression and bending forces is more likely and usually involves much lower loads to causes injury (Siegmund GP et al., 2001). If the head is turned during whiplash trauma, the peak strain on the cervical facet joints and capsular ligaments can increase by 34% (Siegmund GP et al., 2008). One research study reported that during an automobile rear-impact simulation, the magnitude of the joint capsule strain was 47% to 196% higher in instances when the head was rotated 60 degrees during impact compared with those when the head was forward facing (Storvik SG et al., 2011). Head rotation to 60 degrees is similar to an individual turning his/her head to one side while checking for on-coming traffic and suddenly experiences a rear-end collision. The impact was greatest in the ipsilateral facet joints, such that head rotation to the left caused higher ligament strain at the left facet joint capsule.
Other research has illustrated that motor vehicle collision trauma has been shown to reduce ligament strength (i.e., failure force and average energy absorption capacity) compared with controls or computational models (Ivancic PC et al., 2007; Tominaga Y et al., 2006). We know that this is particularly true in the case of capsular ligaments, since this type of trauma causes capsular ligament laxity. Interestingly, one research study conclusively demonstrated that whiplash injury to the capsular ligaments resulted in an 85% to 275% increase in ligament elongation (laxity), compared to that of controls (Ivancic PC et al., 2007).
The study also reported evidence that tension of the capsular ligaments due to trauma, requisite for producing pain from the facet joint. Whiplash injuries cause compression injuries to the posterior facet cartilage. This injury also results in trauma to the synovial folds, bleeding, inflammation, and of course pain. Simply stated, this stretching injury to the facet capsular ligaments will result in joint laxity and instability.
Traumatic ligament laxity resulting in instability is a diagnosis based primarily on a patient�s history (symptoms) and physical examination. Subjective findings are the patient�s complaints in their own words, or their perception of pain, sensory changes, motor changes, or range of motion alterations. After the patient presents their subjective complaints to the clinician, these subjective findings, must be correlated and confirmed through a proper and thorough physical examination, including the utilization of imaging diagnostics that explain a particular symptom, pattern, or area of complaint objectively. Without some sort of concrete evidence that explains a patient�s condition, we merely have symptoms with no forensic evidence. Documentation is key, as well as quantifying the patient�s injuries objectively.
In order to adequately quantify the presence of instability due to ligament laxity, the clinician could utilize functional computerized tomography, functional magnetic resonance imaging scans, as well as digital motion x-ray (Radcliff K et al., 2012; Hino H et al., 1999). Studies using functional CT for diagnosing ligamentous injuries have demonstrated the ability of this technique to shoe excess movement during axial rotation of the cervical spine (Dvorak J et al., 1988; Antinnes J et al., 1994).
This is important to realize when patients have the signs and symptoms of instability, but have normal MRI findings in the neutral position. Functional imaging technology, as opposed to static standard films, is necessary for the adequate radiologic depiction of instability because they provide dynamic imaging during movement and are extremely helpful for evaluating the presence and degree of instability.
Although functional imaging maybe superior plain-film radiography is still a powerful diagnostic tool for the evaluation of instability due to ligament laxity. When a patient presents status-post motor vehicle collision, it is common practice to perform a �Davis Series� of the cervical spine. This x-ray series consists of 7 views: anterior-posterior open mouth, anterior-posterior, lateral, oblique views, and flexion-extension views. The lumbar spine is treated in similar fashion. X-ray views will include: anterior-posterior, lateral, oblique views, and flexion-extension views. The flexion-extension views are key in the diagnosis of instability. It is well known, that the dominant motion of the cervical and lumbar spine, where most pathological changes occur, is flexion-extension. Translation of one vertebral segment in relation to the one above and/or below will be most evident on these views. Translation is the total anterior-posterior movement of vertebral segments. After the appropriate views are taken, the images may be evaluated utilizing CRMA or Computed Radiographic Mensuration Analysis. These measurements are taken to determine the presence of ligament laxity. In the cervical spine, a 3.5mm or greater translation of one vertebra on another is an abnormal and ratable finding, indicative of instability (AMA Guides to the Evaluation of Permanent Impairment, 6th Edition).
Alteration of Motion Segment Integrity (AOMSI) is extremely crucial as it relates to ligament laxity. The AMA Guides to the Evaluation of Permanent Impairment 6th Edition, recognize linear stress views of radiographs, as the best form of diagnosing George�s Line (Yochum & Rowe�s Essentials of Radiology, page 149), which states that if there is a break in George�s Line on a radiograph, this could be a radiographic sign of instability due to ligament laxity.
Discussion
Our discussion of ligament laxity and instability continues with the �Criteria for Rating Impairment Due to Cervical and Lumbar Disorders�, as described in the AMA Guides to the Evaluation of Permanent Impairment, 6th Edition. According to the guidelines, a DRE (Diagnosed Related Estimate) Cervical Category IV is considered to be a 25% to 28% impairment of the whole person. Category IV is described as, �alteration of motion segment integrity or bilateral or multilevel radiculopathy; alteration of motion segment integrity is defined from flexion and extension radiographs, as at least 3.5mm of translation of one vertebra on another, or angular motion of more than 11 degrees greater than at each adjacent level; alternatively, the individual may have loss of motion of a motion segment due to a developmental fusion or successful or unsuccessful attempt at surgical arthrodesis; radiculopathy as defined in Cervical Category III need not be present if there is alteration of motion segment integrity; or fractures: (1) more than 50% compression of one vertebral body without residual neural compromise. One can compare a 25% to 28% cervical impairment of the whole person to the 22% to 23% whole person impairment due to an amputation at the level of the thumb at or near the carpometacarpal joint or the distal third of the first metacarpal.
Additionally, according to the guidelines, a DRE (Diagnosed Related Estimate) Lumbar Category IV is considered to be a 20% to 23% impairment of the whole person. Category IV is described as, �loss of motion segment integrity defined from flexion and extension radiographs as at least 4.5mm of translation of one vertebra on another or angular motion greater than 15 degrees at L1-2, L2-3, and L3-4, greater than 20 degrees at L4-5, and greater than 25 degrees at L5-S1; may have complete or near complete loss of motion of a motion segment due to developmental fusion, or successful or unsuccessful attempt at surgical arthrodesis or fractures: (1) greater than 50% compression of one vertebral body without residual neurologic compromise. One can compare a 20% to 23% Lumbar Impairment of the whole person to the 20% whole person impairment due to an amputation of the first metatarsal bone.
Conclusions
After careful interpretation of the AMA Guides to the Evaluation of Permanent Impairment, 6th Edition, regarding whole person impairment due to ligament laxity/instability of the cervical and lumbar spine, one can certainly see the severity and degree of disability that occurs. Once ligament laxity is correctly diagnosed, it will objectively quantify a patient�s spinal injury regardless of symptoms, disc lesions, range of motion, reflexes, etc. When we quantify the presence of ligament laxity, we also provide a crucial element with which to demonstrate instabilities in a specific region. Overall, clarification and quantification of traumatic ligament laxity will help the patient legally, objectively, and most importantly, clinically.
The scope of our information is limited to chiropractic and spinal injuries and conditions. To discuss options on the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .�
References
AMA Guides to the Evaluation of Permanent Impairment, 6th Edition
Antinnes J, Dvorak J, Hayek J, Panjabi MM, Grob D. The value of functional computed tomography in the evaluation of soft-tissue injury in the upper cervical spine. Eur Spine J. 1994; 98-101. [PubMed]
Barnsley L, Lord SM, Wallis BJ, Bogduk N. The prevalence of cervical zygapophaseal joint pain after whiplash. Spine (Phila Pa 1976). 1995;20: 20-5. [PubMed]
Bergmann TF, Peterson DH. Chiropractic technique principles and procedures, 3rd ed. New York Mobby Inc. 1993
Boswell MV, Colson JD, Sehgal N, Dunbar EE, Epter R. A systematic review of therapeutic facet joint interventions in chronic spinal pain. Pain Physician. 2007;10(1): 229-53. [PubMed]
Chen HB, Yang KH, Wang ZG. Biomechanics of whiplash injury. Chin J Traumatol.2009;12(5): 305-14. [PubMed]
Dvorak J, Penning L, Hayek J, Panjabi MM, Grob D, Zehnder R. Functional diagnostics of the cervical spine using computer tomography. Neuroradiology. 1988;30: 132-7. [PubMed]
Examination of the Spine and Extremities, Stanley Hoppenfeld, 1976
Frank CB. Ligament structure, physiology, and function. J Musculoskelet Neuronal Interact. 2004;4(2): 199-201. [PubMed]
Galasko, C.S., P.M. Murray, M. Pitcher, H. Chanter, S. Mansfield, M. Madden, et. al Neck sprains after road traffic accidents: a modern epidemic. Injury 24(3): 155-157, 1993
American Medical Association. (2009). Guides to the evaluation of permanent impairment,
6th edition. Chicago, Il:AMA
Antinnes, J., Dvorak, J., Hayek, J., Panjabi, M.M., & grob, D. (1994). The value of functional
Computed tomography in the evaluation of soft tissue injury in the upper cervical
spine. European Spine Journal, 98-101.
Barnsley, L., Lord, S.M., Wallis, B.J., & Bogduk, N. (1995). The prevalence of cervical zygaphaseal
facet capsule and its role in whiplash injury: A biomechanical investigation. Spine,
25(10), 1238-1246.
Additional Topics: Preventing Spinal Degeneration
Spinal degeneration can occur naturally over time as a result of age and the constant wear-and-tear of the vertebrae and other complex structures of the spine, generally developing in people over the ages of 40. On occasion, spinal degeneration can also occur due to spinal damage or injury, which may result in further complications if left untreated. Chiropractic care can help strengthen the structures of the spine, helping to prevent spinal degeneration.
Abstract objective: �To examine the diagnosis and care of a patient suffering from chronic low back pain with associated right leg pain and numbness. ���Diagnostic studies include standing plain film radiographs, lumbar MRI without contrast, chiropractic analysis, range of motion, orthopedic and neurological examination. ���Treatments include both manual and instrument assisted chiropractic adjustments, ice, heat, cold laser, Pettibon wobble chair and repetitive neck traction exercises and non-surgical spinal decompression. ��The patient’s� outcome was very good with significant reduction in pain frequency, pain intensity and abatement of numbness in foot.
Introduction: �A 58 year old, 6�0�, 270 pound male was seen for a chief complaint of lower back pain with radiation into the right leg with right foot numbness. �The pain had started 9 months prior with an insidious onset. ��The patient had first injured his back in high school lifting weights with several episodes of pain over the ensuing years. ��The patient had been treating with Advil and had tried physical therapy, acupuncture, chiropractic and ice with no relief of pain and numbness. ��Walking and standing tend to worsen the problem and lying down did provide some relief. ���A number of activities of daily living were affected at a severe level including standing, walking, bending over, climbing stairs, looking over shoulder, caring for family, grocery shopping, household chores, lifting objects staying asleep and exercising. ��The patient remarked that he �Feels like 100 years old.� �Social history includes three to four beers per week, three diet cokes per day.
The patient�s health history included high blood pressure, several significant shoulder injuries, knee injuries, apnea, hearing loss, weight gain, anxiety and low libido. ���Family history includes Alzheimer�s disease, heart disease, colon cancer and obesity.
Clinical Findings
Posture analysis revealed a high left shoulder and hip with 2 inches of anterior head projection. Bilateral weight scales revealed a +24 pound differential on the left. ��Weight bearing dysfunction and imbalance suggest that neurological compromise, ligamentous instability and or spinal distortion may be present. �Range of motion in the lumbar spine revealed a 10 degree decrease in both flexion and extension. There was a 5 degree decrease in both right and left lateral bending with sharp pain with right lateral bending.
Cervical range of motion revealed a 30 degree decrease in extension, a 42 and 40 degree decrease in right and left rotation respectively and a 25 degree decrease in both right and left lateral flexion. ��Stability analysis to assess and identify the presence of dynamic instability of the cervical and lumbar spine showed positive in the cervical and lumbar spine and negative for sacroiliac dysfunction. ��Palpatory findings include spinal restrictions at occiput, C5, T5, T10, L4,5 and the sacrum. ��Muscle palpation findings include +2 spasm in the psoas, traps, and all gluteus muscles.
Cervical radiographs reveal significant degenerative changes throughout the cervical spine. This represents phase II of spinal degeneration according the Kirkaldy-Wills degeneration classification. ���Cervical curve is 8 degrees which represents an 83% loss from normal. ��Flexion and extension stress x-rays reveal decreased flexion at occiput through C4 and decreased extension at C2, C4-C7.
Lumbar radiographs reveal significant degenerative changes throughout representing phase II of spinal degeneration according to the Kirkaldy-Willis spinal degeneration classification. ���There is a 9 degree lumbar lordosis which represents a 74% loss from normal. ��There is a 2 mm short right leg and a grade II spondylolisthesis at the L5-S1 level.
Lumbar MRI without contrast was ordered immediately with a 4 mm slice thickness and 1 mm gap in between slices on a Hitachi Oasis 1.2 Telsa machine for optimal visualization of pathology due to the clinical presentation of right L5 nerve root compression.
Lumbar MRI Imaging Results
Significant degenerative changes throughout the lumbar spine including multi-level degenerative disc changes at all levels.
Transverse Annular Fissures at L1-2 (17.3 mm), L2-3 (29.5 mm), L4-5 (14.3 mm) and L5-S1 (30.8 mm) and broad based disc bulging at all levels except L5-S1. ���The fissures at L2-3 and L5-S1 both have radial components extends through to the vertebral endplate.
Facet osteoarthritic changes and facet effusions at all levels.
Grade II spondylitic spondylolisthesis is confirmed at L5-S1 with severe narrowing of the right neural foramen compressing the right exiting L5 nerve root.
Degenerative retrolisthesis at L1-2.
Modic Type II changes at L2 inferior endplate, L3 superior endplate, L4 inferior endplate and L5 inferior endplate.2
There is a 18.9 mm wide Schmorl�s node at the superior endplate of L3.
There is a 5.7 mm wide focal protrusion type disc herniation at L4-5 which impinges on the thecal sac.
T2 sagittal Lumbar Spine MRI:� Note the Modic Type II changes and the L2-3 Schmorls node.
T1 Sagittal Annular fissures at multiple levels and spondylolisthesis at L5S1
T2 Axial L4-5:� Focal Disc Protrusion Type Herniation
Definition �Bulging Disc: A disc in which the contour of the outer annulus extends, or appears to extend, in the horizontal (axial) plane beyond the edges of the disc space, over greater than 50% (180 degrees) of the circumference of the disc and usually less than 3mm beyond the edges of the vertebral body apophyses.3
Definition: Herniation is defined as a localized or focal displacement of disc material beyond the limits of the intervertebral disc space.3
Protrusion Type Herniation: is present if the greatest distance between the edges of the disc material presenting outside the disc space is less than the distance between the edges of the base of that disc material extending outside the disc space.3
Definition: Extrusion Type Herniation: �is present when, in at least one plane, any one distance between the edges of the disc material beyond the disc space is greater than the distance between the edges of the base of the disc material beyond the disc space or when no continuity exists between the disc material beyond the disc space and that within the disc space. 3
Definition: �Annular Fissures: �separations between the annular fibers of separations of the annual fibers from their attachments to the vertebral bone. 4
Definition � Radiculopathy: Sometimes referred to as a pinched nerve, it refers to compression of the nerve root – the part of a nerve between vertebrae. This compression causes pain to be perceived in areas to which the nerve leads.
The patient underwent multimodal treatment regime consisting of 4 months of active chiropractic adjustments, non-surgical spinal decompression with pretreatment spinal warm-up exercises on the Pettibon wobble chair and neck traction and heat. Post spinal decompression with ice and cold laser. ��The patient reported long periods of symptom free activities of daily living with occasional short flare-ups of pain. ��Exacerbations are usually of short duration and much lower frequency. �The only activity of daily living noted as affected severely at the end of care is exercising.
Post care lumbar radiographs revealed a 26 degree lumbar curve a 15 degree (38%) increase
Post care cervical x-rays revealed a 10 mm decrease in anterior head projection and a 2 degree improvement in the cervical lordosis.
Range of Motion
pre
post
increase
Lumbar
flexion
60
60
0
extension
40
40
0
r. lateral flexion
20
25
5
l. lateral flexion
20
25
5
cervical
pre
Post
increase
flexion
50
50
0
extension
30
40
10
r. lateral flexion
20
35
15
l. lateral flexion
20
20
0
r. rotation
38
70
42
l. rotation
40
80
40
Discussion of Results
It is appropriate to immediately order MRI imaging with radicular pain and numbness. ��Previous health providers who did not order advanced imaging with these long term radicular symptoms are at risk of missing important clinical findings that could adversely affect the patient�s health. ��The increasing managed care induced trend to forego taking plain film radiographs is also a risk factor for patients with these problems.
This case is a typical presentation of long standing spinal injuries that over many years have gone through periods of high and low symptoms but continue to get worse functionally and eventually result in a breakdown of spinal tissues leading to neurological compromise and injury.
Chiropractic treatment resulted in a very favorable outcome aided by an accurate diagnosis. �This is also the case where the different treatment modalities all contributed to the success of the protocol. ��The different modalities all focus on different areas of pathology contributing to the patients� disabled condition.
Modality
Therapeutic Goals
Chiropractic adjustment
Manual and instrument assisted forces introduced to the osseous structures that focuses on improving motor segment mobility
Cold laser
Increases speed of tissue repair and decreases inflammation.4
Pettibon
wobble chair
Loading and unloading cycles applied to injured soft tissues and
Pettibon
neck traction
speeds up & improves remodeling of injured tissue as well as rehydrates dehydrated vertebral discs.5
Non-surgical
spinal decompression
Computer assisted, slow and controlled stretching of spine, creating vacuum effect on spinal disc, bringing it back into its proper place in the spine.6,7
Ice
Decrease inflammation through vasoconstriction
Heat
Warm up tissues for mechanical therapy through increasing blood flow.
Posture Correction Hat
Weighted hat that activates righting reflex resetting head posture.8
A major factor in the success of the care plan in this case was an integrative approach to the spine. �John Bland, M.D. in the text Disorders of the Cervical Spine writes
�We tend to divide the examination of the spine into regions: cervical, thoracic and the lumbar spine clinical studies.� This is a mistake.� The three units are closely interrelated structurally and functionally- a whole person with a whole spine.� The cervical spine may be symptomatic because of a thoracic or lumbar spine abnormality, and vice versa!� Sometimes treating a lumbar spine will relieve a cervical spine syndrome, or proper management of cervical spine will relieve low backache.�9
When addressing the spine as an integrative system, and not regionally it has a very strong benefit to the total care results. ��The focus on the restoration of the cervical spine function as well as lumbar spine function is a hallmark of a holistic spine approach that has been a tradition in the chiropractic profession.
The scope of our information is limited to chiropractic and spinal injuries and conditions. To discuss options on the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .�
References:
Kirkaldy-Willis, W.H, Wedge JH, Young-Hing K.J.R. Pathology and pathogenesis of lumbar spondylosis and stenosis. �Spine 1978; 3: 319-328
David F. Fardon, MD, Alan L. Williams, MD, Edward J. Dohring, MD. Lumbar disc nomenclature: version 2.0 Recommendations of the combined task forces of the North American Spine Society, the American Society of Spine Radiology and the American Society of Neuroradiology. The Spine Journal 14 (2014) 2525�2545
Shealy CM, Decompression, Reduction and Stabilization of the Lumbar Spine: A cost effective treatment for lumbosacral pain.�� Pain management 1955, pg 263-265
Shealy, CM, New Concepts of Back Pain Management, Decompression, Reduction and Stabilization.�� Pain Management, a Practical guide for Clinicians.� Boca Raton, St. Lucie Press: 1993 pg 239-251
Bland, John MD, Disorders of the Cervical Spine WB Saunders Company, 1987 pg 84
Additional Topics: Preventing Spinal Degeneration
Spinal degeneration can occur naturally over time as a result of age and the constant wear-and-tear of the vertebrae and other complex structures of the spine, generally developing in people over the ages of 40. On occasion, spinal degeneration can also occur due to spinal damage or injury, which may result in further complications if left untreated. Chiropractic care can help strengthen the structures of the spine, helping to prevent spinal degeneration.
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Among the commercially insured, 1.6% of stroke cases had visited chiropractors within 30 days of being admit- ted to the hospital, as compared to 1.3% of controls visit- ing chiropractors within 30 days prior to their index date. Of the stroke cases, 18.9% had visited a PCP within 30 days prior to their index date, while only 6.8% of controls had visited a PCP (Table 4). The proportion of exposures for chiropractic visits was lower in the MA sample within the 30-day hazard period (cases = 0.3%; controls = 0.9%). However, the proportion of exposures for PCP visits was higher, with 21.3% of cases having PCP visits as compared to12.9% for controls (Table 5).
The results from the analyses of both the commercial population and the MA population were similar (Tables 6, 7 and 8). There was no association between chiropractic visits and VBA stroke found for the�
