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Manipulation or Microdiskectomy for Sciatica? A Randomized Clinical Study
Gordon McMorland, DC, Esther Suter, PhD, Steve Casha, MD, PhD, FRCSC, et al.
Objective: The purpose of this study was to compare the clinical efficacy of spinal manipulation against microdiskectomy in patients with sciatica secondary to lumbar disk herniation (LDH).
Methods: One hundred twenty patients presenting through elective referral by primary care physicians to neurosurgical spine surgeons were consecutively screened for symptoms of unilateral lumbar radiculopathy secondary to LDH at L3-4, L4-5, or L5-S1. Forty consecutive consenting patients who met inclusion criteria (patients must have failed at least three months of nonoperative management including treatment with analgesics, lifestyle modification, physiotherapy, massage therapy, and/or acupuncture) were randomized to either surgical microdiskectomy or standardized chiropractic spinal manipulation. Crossover to the alternate treatment was allowed after three months.
Results: Significant improvement in both treatment groups compared to baseline scores over time was observed in all outcome measures. After one year, follow-up intent-to-treat analysis did not reveal a difference in outcome based on the original treatment received. However, three patients crossed over from surgery to spinal manipulation and failed to gain further improvement. Eight patients crossed from spinal manipulation to surgery and improved to the same degree as their primary surgical counterparts.
Conclusions: Sixty percent of patients with sciatica who had failed other medical management benefited from spinal manipulation to the same degree as if they underwent surgical intervention. Of 40% left unsatisfied, subsequent surgical intervention confers excellent outcome. Patients with symptomatic LDH failing medical management should consider spinal manipulation followed by surgery if warranted.
Functional Anatomy of Human Scalene Musculature: Cervical Spine Rotation
Anthony Olinger, PhD, Phillip Homier, BS
Objectives: Actions of the scalene muscles include flexion and lateral flexion of the cervical spine and elevation of the first and second ribs. The cervical rotational qualities of the scalene muscles remain unclear. Textbooks and recent studies report contradictory findings with respect to the cervical rotational properties of the scalene muscles. The present study was designed to take a mechanical approach to determining whether the scalene muscles produce rotation of the cervical spine.
Methods: The scalene muscles were isolated, removed, and replaced by a durable suture material. The suture material was attached at the origin and then passed through a hole on the corresponding rib near the central point of the insertion. The suture material was pulled down through the corresponding costal insertion hole to simulate contraction of each muscle.
Results: The simulated anterior, middle, and posterior scalene muscles, working independently and jointly, produced ipsilateral rotation of the cervical spine. The upper cervical spine rotated in the ipsilateral direction in response to the simulated muscle contraction. Findings were similar for the lower cervical spine with the exception of two specimens, which rotated contralaterally in response to the simulation.
Conclusion: Experimental models of the scalene muscles are capable of producing ipsilateral rotation of the cervical spine. The findings of this study support the accepted main actions of the scalene muscles. The clinical applications for understanding the cervical rotational properties of the scalene muscles include the diagnosis, management, and treatment of cervical pain conditions as well as thoracic outlet syndrome.
Neck Pain: Validity of Weekly Recall Ratings of Average Pain Intensity
Jennifer Bolton, PhD, B. Kim Humphreys, DC, PhD, Hubertus van Hedel, PT, PhD
Objective: Ratings of usual pain over a period of one week are commonly used to rate a patient's usual level of pain intensity. This study investigated the validity of weekly recall pain ratings and biasing effects of pain levels on these ratings.
Methods: Seventy-eight patients presenting to a chiropractic outpatient clinic with nonspecific neck pain completed a seven-day diary rating their pain four times each day on an 11-point numerical rating scale. From these 28 ratings, the patients' "actual average" pain was computed. On day 8, patients were asked to rate their current pain, as well as recall their pain "on average," at its "worst," and at its "least" over the previous week.
Results: Recall of average pain over the previous week was shown to be a valid measure using ratings of actual pain as the criterion standard (Pearson r = 0.95). The error between actual and recall readings was random and consistent across all levels of actual pain. Patients were also able to accurately recall their pain at its worst (r = 0.93) and at its least (r = 0.92) over the preceding week. In regression analyses, there were no appreciable biasing effects on the recall of average pain of either current pain at the time of recall, or of pain at its worst or at its least during the recall period.
Conclusion: These results suggest that recall ratings of pain intensity may be valid for use in clinical research and practice on patients with nonspecific neck pain.
Lumbar Disk Protrusion Rates of Symptomatic Patients Using MRI
John Gilbert, MD, J. Chad Martin, DC, Greg Wheeler, MD, et al.
Objective: The purpose of this study was to determine the rate of disk protrusions detected via magnetic resonance imaging (MRI) in patients symptomatic for spine pain, radiculopathy, or other spine-related pain.
Methods: A retrospective review of 1983 MRI scans was performed over a two-year period on 1486 patients, each of whom was symptomatic for spine pain, radiculopathy, or other noncancer, spine-related pain. Of these patients, 761 were scanned in the recumbent position using low-field (0.3 T, Airis II, Hitachi, Twinsburg, Ohio) MRI, and 725 were scanned in an upright, sitting position using mid-field (0.6 T) open Upright MRI (Fonar, Melville, NY). In total, 986 serial scans were performed on patients in the recumbent position and 997 serial scans on patients in the weight-bearing position.
Results: One or more disk protrusions were identified in 73.3% of scans performed in the sitting position and in 50.1% of scans performed in the recumbent position. Most disk protrusions occurred at L5-S1 (52.3% and 29.8%), L4-L5 (42.6% and 26.7%), and L3-L4 (26.7% and 13.1%) in upright and recumbent positions, respectively.
Conclusions: The disk protrusion rate in this group of patients ranged between 50.1% (recumbent) and 73.3% (weight-bearing). These rates are higher than rates reported in the medical literature for asymptomatic patients, a finding that supports the decision to further evaluate patients with persistent spine-related pain.
Ultrasonography of the Upper Cervical Muscles: A Review of the Literature
Khodabakhsh Javanshir, PhD, et al.
Objective: This article presents a review of the literature concerning size measurement of cervical muscles using real-time ultrasound imaging (RUSI) in patients with neck pain and in healthy populations.
Methods: A literature search from 1996 to December 2009 making use of Science Direct and PubMed databases was conducted. Medical Subject Headings and other terms were as follows: ultrasonography, cervical, muscle, neck, size, pain, validity, reliability, neck pain, and healthy subjects. We included studies using RUSI for assessing cervical paraspinal muscles both in healthy subjects and in patients with neck pain. We assessed muscles investigated and the reliability and validity of the method used.
Results: The literature search yielded 16 studies. Twelve (75%) studies assessed the posterior muscles, whereas in the remaining four (25%), the anterior muscles were studied. Three studies quantified the size of the muscles during contraction; three assessed the relationship between cross-sectional area, linear dimensions, and anthropometric variables; one evaluated the training-induced changes in muscle size; one assessed the differences in muscle shape and cross-sectional area of cervical multifidus between patients with chronic neck pain and controls; eight studies looked at the reliability of using RUSI in patients with neck pain or healthy subjects; and three studies evaluated the validity of RUSI compared with magnetic resonance imaging.
Conclusions: This literature review has shown that there are not sufficient studies for assessing neck muscles with RUSI. It seems that using constant landmarks, knowledge of anatomy and function of target muscle, and a proper definition of muscle borders can help to take a clear image. Standardized position of the subject, correct placement of the transducer, and using multiple RUSI for statistical analyses may improve results.
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