Cervical spinal cord injury without bony injury: a multicenter retrospective study of emergency and critical care centers in Japan.

BACKGROUND: To demonstrate the clinical characteristics of patients with cervical cord injury (CCI) without bony injury in Japan. METHODS: Retrospective review of 127 patients with CCI without bony injury treated between January 2003 and October 2005 at 11 institutions. RESULTS: Prevalence of CCI without bony injury was 32.2% among all CCIs and 0.81% among all blunt traumas. Mean age was 60.4 years (range, 19-90 years), with 104 patients (82%) > or = 46 years old (older group). The major mechanism of injury among younger patients (< 46 years) was traffic injuries (39%), whereas minor falls (44%) predominated in older patients. High-energy mechanisms of injury were significantly more common for younger patients (35% versus 15%, p = 0.041). Mean injury severity score, abbreviated injury score for the head and Glasgow coma scale on admission were 17.2 +/- 4.7, 0.6 +/- 0.9, and 14.2 +/- 2.1, respectively. Incomplete CCI occurred in 88.7%. On plain cervical spine radiography, spinal canal stenosis and spondylosis or ossification of the posterior longitudinal ligament were more frequent in older patients than in younger patients (43% vs. 13%, p = 0.008; 54% vs. 17%, p = 0.002, respectively). No abnormal findings were seen in 52% of younger patients. CONCLUSION: CCI without bony injury occurred more frequently in this study population than previously reported. Degenerative changes and spinal canal stenosis represent important risk factors for developing CCI without bony injury and the present results suggest that this injury may occur in younger adults during high-energy injuries in the absence of pre-existing cervical spine disease.

Cervical spondylotic myelopathy: proposal of a surveillance algorithm.

The review of the publications concerning cervical spondylotic myelopathy (CSM) suggests that it has not been achieved a clear consensus about the treatment of this pathology. In this paper an algorithm of surveillance, conceived as an assistant tool to decide the best indications of treatment is presented. The algorithm permits a clear separation of the symptomatic patients on the base of the presence or the absence of neurologic damage resulting at the evoked potentials examination. The negativity of the evoked potentials, that means neurologic integrity, excludes any type of surgical treatment. In case of proved neurologic damage, the algorithm permits a further differentiation in subgroups according to the degree of clinical disability. If evoked potentials are positive, a surgical decompression should be always performed in patients affected by a severe clinical disability. The group of patients affected by a mild degree of clinical disability but with positive evoked potentials represents the most challenging for the spinal surgeons. Actually, several studies support either surgical and non surgical treatment for these patients. Although the Authors think that a surgical decompression has to be always performed in case of proved neurologic damage, only further randomized studies based on accurate algorithms could elucidate the outcome of the CSM and could permit to choose the best treatment according to the degree of the disease.

Systematic review and meta-analysis of the efficacy of tuina for cervical spondylosis.

AIMS AND OBJECTIVES: This study performed a meta-analysis of seven parallel-group comparison studies evaluating the efficacy of tuina in treating cervical spondylosis. BACKGROUND: Tuina is a form of Chinese manipulative therapy. It has been used as a modality for the treatment of symptoms associated with such a musculoskeletal condition as cervical spondylosis. However, evidence regarding the efficacy of tuina for cervical spondylosis has yet to be determined. DESIGN: Systematic review. METHODS: Cochrane library, Pubmed, MEDLINE, EBM review, ProQuest Medical Bundle and SCOPUS databases were searched using the following medical subject headings or key words: tuina, tuinaology, manual medicine, massotherapy, cervical spondylopathy, cervical spondylosis and cervical vertebrae. Chinese research papers were searched through the Chinese electronic periodical services and Wangfane database. The publication date was limited from 1996-2007. Studies were selected if they were written in English or Chinese, used tuina as a stand-alone modality, used a parallel-group comparison design and explicated raw data regarding symptoms relief. Two independent reviewers reviewed the selected studies based on the evidence rating system of the US Preventive Services Task Force. Studies with an evidence rating of II-2 fair or above were included in this review. RESULTS: The direction of the effect size for the improvement of blood flow velocity of vertebral artery and basilar artery was not consistent across studies. Moreover, the pooled effect size was negligible. No evidence supported that tuina could improve headache and vertigo. A small effect of tuina on the viscosity of blood and plasma was found. CONCLUSION: Based on the results of this systematic review, a definitive conclusion regarding the effects of tuina on cervical spondylosis remains to be determined. RELEVANCE TO CLINICAL PRACTICE: The efficacy of tuina is not supported by parallel-group comparison studies.

[The evidence-based occupational health paradigm in managing back pain: identifying the problem and evaluation of the decision]. / Il paradigma dell'evidence based occupational health nella gestione della rachialgia in operatori sanitari: dalla formulazione del quesito alla valutazione della decisione.

BACKGROUND: Occupational health professionals must rely on the best available evidence in support of the appropriateness of diagnostic tests and preventive or clinical interventions. This study aims at comparing the decisions made in respect of health care personnel with the decisions made on the basis of the evidence and evaluating the effectiveness of these decisions. MATERIALS AND METHODS: Five female nurses with back problems exposed to health risk mostly associated with patient handling and movement were considered. The diagnostic results and the interventions following the decisions made in 2002 were evaluated and compared with the medical data during the years 2004-2005. To assess health changes occurring after the intervention, an indicator of impact was used. During 2006 the health problems were reviewed by means of the multi-step evidence-based occupational health paradigm: starting from identification of the problem and search for evidence (with a new and validated search string and the database Medline) followed by evaluation of performance. Professional performance was assessed by comparing the medical decisions made in 2002 with the decision supported by the evidence. RESULTS: All the medical decisions were in agreement with the decisions inferred from scientific evidence. Furthermore, all subjects showed an improvement in both perceived and objective health conditions after the intervention, together with increased acceptability of working conditions. CONCLUSION: Given that no gold standard exists and that guidelines for the management of back pain need to be assessed for their effectiveness, this study shows that the occupational health professional should be aware of the availability of up-to-date scientific evidence which can provide appropriate solutions to the commonly encountered problems. This perspective will be a challenge for professionals aware of the need to adopt practices related to the concept of quality in occupational health care.

[Cervicogenic headache]. / Szyjnopochodny ból glowy.

In 2004 cervicogenic headache was introduced into ICD-10 classification. The reasons of cervicogenic headache are changes within bones, soft tissue and nervous structures of cervical spine section. The pain may spread to the neck, occipital area of skull, area of jaw and eyeballs, and arms. There are many theories trying to explain spreading of the pain outside the area innervated by C1, C2 and C3 cervical roots. Their common denominator is communication between fibres running in those roots and neurons of trigeminal nerve. Many authors describe a possibility of such connection through the jelly-like nucleus of the trigeminal nerve located in the back funiculi of spinal cord. In this mechanism, the pain conducted via occipital nerves may affect activity of neurons of the trigeminal nerve and influence areas innervated by the trigeminal nerve. In general case history and physical examination are sufficient to make a diagnosis. Additional radiological and imaging examinations support this diagnosis. According to some authors, the necessary condition to make a diagnosis of cervicogenic headache is finding the changes of spondylosis nature of the cervical spine section in additional examinations. In doubtful cases, diagnostic blockade of greater occipital nerve, resulting in headache relief, supports finally a diagnosis. Any treatment includes pharmacotherapy, rehabilitation, psychotherapy and surgical methods. The purpose of the study is to view literature on cervicogenic headache which causes many diagnostic problems and hence makes it difficult to choose effective treatment.

Renal Artery Dissection in a Patient With Degenerative Scoliosis: A Rare Complication Caused by Lumbar Vertebra Osteophyte.

Isolated spontaneous renal artery dissection (RAD) without known trauma is rare, and its etiology has not been determined. However, notable risk factors including hypertension, strenuous exercise, connective tissue disorders, atherosclerosis, extracorporeal shock wave lithotripsy, and cocaine abuse have been reported. To the best of our knowledge, isolated RAD caused by lumbar vertebra osteophytes in patients with degenerative lumbar scoliosis has not been reported in the literature. In this article, we present a case of RAD caused by lumbar vertebra osteophyte in a patient with degenerative scoliosis and discuss the management of the disease.

Clinical equipoise and treatment decisions in cervical spondylotic myelopathy.

OBJECTIVE: The primary objective of this study is to evaluate clinician attitudes towards the treatment of cervical spondylotic myelopathy (CSM) in order to determine whether clinical equipoise exists for a segment of this patient population. The secondary objective is to examine the factors that influence treatment decisions. METHODS: Cross-sectional internet-based survey of neurologists, neurosurgeons and orthopedic surgeons. RESULTS: Between 40-60% of respondents recommended surgery for (1) patients with minimal or no symptoms, but incidentally discovered increased T2 signal within the cervical cord on MRI, (2) patients with mild symptoms and indentation of the cervical cord but without increased T2 signal and (3) those with at least moderately severe clinical findings accompanied by MRI showing effacement of the thecal sac but without indentation of the cord or increased T2 signal. The severity of the radiological abnormalities most strongly influence treatment decisions. CONCLUSIONS: We conclude that clinical equipoise does exist for certain groups of patients with CSM, suggesting that a randomized controlled trial could be performed in this population.

[Bone diseases with pain. Spondylosis].

Spondylosis is a common condition but not always symptomatic. Symptoms that manifest are grouped into axial pain, radiculopathy and myelopathy. An understanding of the pathophysiology of these conditions allows us to clinically determine whether the patients' symptoms are likely a result of spinal pathology and, in many cases, will also allow us to further localize a specific level within the spine. The most part patients with axial symptoms are best treated without surgery, whereas some patients with radiculopathy or myelopathy will continue to be disabled by their pain or dismobility and may be candidates for surgery. Surgical treatment should be considered in patients who continue to have symptoms in spite of appropriate treatment.

On the coincidence of cervical spondylosis and multiple sclerosis.

Multiple sclerosis (MS) and cervical spondylosis are relatively common diseases. It is therefore inevitable that the MS clinician will be confronted with patients with myelopathy in whom the two conditions coexist. When faced with an MS patient who has cord compression secondary to cervical spondylosis as well as cord demyelination, the issue of surgical decompression of the cord arises. Whether the trauma of cord compression aggravates the MS lesions is still a matter of debate and should not influence treatment decisions. There is little prospective evidence-based support for the notion of surgical cord decompression in cervical spondylosis without MS, and none at all for surgery in MS, with only small published retrospective series available. The clinician must therefore make a judgment-based treatment decision. Guidelines for the management of patients with coincidental cervical cord compression and MS are suggested.

Does nonoperative management play a role in the treatment of cervical spondylotic myelopathy?

BACKGROUND CONTEXT: Cervical spondylotic myelopathy has traditionally been managed through surgical decompression with or without reconstruction. Currently, a multicenter, blinded clinical trial that has supported such a therapeutic recommendation does not exist. There have been case-control studies that have and have not shown long-standing benefit to surgical decompression and reconstruction. PURPOSE: The purpose of this review is to examine the efficacy of nonoperative therapy for cervical spondylotic myelopathy. CONCLUSIONS: It appears that both static and dynamic factors play a role in the pathophysiology of cervical spondylotic myelopathy. Furthermore, once clinical cervical spondylotic myelopathy is evident, progression may occur despite the best of treatments, both surgical and nonsurgical.

Effect of cervical traction on cardiovascular and selected ECG variables of cervical spondylosis patients using various weights.

BACKGROUND: There is currently no consensus among the clinicians regarding the tractive force to be employed during cervical traction (CT) that will correlate precisely with the percentage body weight of the patient and reduce the side effects associated with CT therapy. OBJECTIVE: This study therefore aimed to investigate the response of cervical spondylosis (CS) patients to different CT weights and to establish the effect of CT on the cardiovascular system of patients with cervical spondylosis (CS). METHODS: Sixty out of 78 subjects participated in the study. They were randomly assigned into three experimental groups A, B and C. Their systolic and diastolic blood pressures (SBP and DBP) and heart rates (HR) were measured. Rate pressure product (RPP) was calculated using standard equation18 and ECG recorded using the KENZ, 201 machine. Subjects' cardiovascular and ECG responses were monitored in a supine resting position (baseline) and under three experimental conditions using the subjects' 7.5% kg total body weights (TBW), 10% kg TBW and 15% TBW at different time intervals (5, 10 and 15 minutes respectively). RESULTS: Compared with the baseline values, there was a drop in SBP, DBP and RPP for all subjects in the three groups. The SBP, DBP and RPP alteration were not significant for the 7.5% TBW CT, but significant (p <0.05) for the 10% and 15% TBW tractions. The HR and ECG variables revealed no significant difference in all the groups, these results signified that the cardiac muscles were not adversely affected by any of the traction weights during application. Twenty subjects had side-effects including 5 subjects that terminated the treatment due to pain during the CT application. CONCLUSIONS: Cardiovascular alterations do occur during the application of cervical traction weights resulting in untoward patient's reactions. Efforts should be made to monitor the cardiovascular variables during and immediately after CT especially in "high risk" patients, that is, elderly patients and patients with unstable cardiovascular systems.

Effects of different cervical traction weights on neck pain and mobility.

AIMS AND OBJECTIVES: This study investigated the effects of 3 different traction weights on neck pain and range of motion/mobility. MATERIALS AND METHODS: Ninety subjects, 42 men and 48 women, with neck pain due to cervical spondylosis participated in the study. They were assigned into three groups, each of which was subjected to a different cervical traction(CT) weight namely: group A = 7.5% total body weight(TBW), group B = 10%TBW, and group C =15%TBW CT respectively. Pain intensity and neck mobility, pre-treatment and post-treatment, were assessed using visual analogue scale(VAS) and universal goniometer respectively. RESULTS: There was no significant difference(p < 0.05) pre-treatment, but existed post-treatment (p < 0.05) between the groups for neck pain and mobility. Nineteen subjects had reactions due to the CT application: 3,5 and 11 in groups A,B and C respectively. The least reactions were recorded with the use of 7.5% TBW traction and the highest with the 15% TBW traction. The 10%TBW CT recorded the most significant pain relief and neck flexibility/mobility compared with the 7.5% TBW and 15% TBW CT therapy. CONCLUSION: This study established the 10% TBW CT as the ideal weight with minimal side effects and with highest therapeutic efficacy. Therefore clinicians could adopt this weight in managing neck disorders requiring traction.

Initial and long-term management of autoimmune neuropathies.

The inflammatory neuropathies (chronic inflammatory demyelinating polyradiculoneuropathy [CIDP], Guillain-Barré syndrome [GBS] and multifocal motor neuropathy [MMN]) affect only one to two individuals per 100 000 of the population, but result in major disability and impairment. Intravenous immunoglobulin (IVIg) can be used as an initial treatment for CIDP, GBS and MMN. While plasma exchange and corticosteroids can also be used initially, they are not as uniformly effective for each of these disorders as IVIg. Substituting corticosteroids, plasma exchange or immunosuppressants may be appropriate for patients not responding to initial IVIg therapy, and combination therapy may be needed in some patients. There are no data from controlled clinical trials of long-term management strategies for CIDP and MMN; however, empirical evidence suggests that a positive long-term response to IVIg can be achieved by increasing the initial dose or its frequency of administration. Corticosteroids and immunosuppressants may be appropriate in some patients with CIDP. Adverse events with IVIg are usually mild and not treatment limiting; however, patients do need to be monitored for uncommon, but serious, adverse events such as renal insufficiency, stroke and thromboembolic events. Nevertheless, the safety profile of IVIg is exceptional relative to the potential complications of other long-term treatments for CIDP and MMN, especially corticosteroids and immunosuppressants. Predictors of response have been reported for each of the neuropathies, and until controlled clinical trials provide evidence on which to base treatment strategies, effective management will require individualising therapy according to patient response.

Adjacent level degeneration after anterior cervical fusion: a clinical review.

Anterior cervical discectomy and corpectomy for the treatment of cervical spondylosis,cervical disc herniation, and ossification of the posterior longitudinal ligament enjoy favorable rates of fusion and successful clinical outcomes. Although the complications from these procedures have been well described, the pathogenesis and clinical development of adjacent segment degeneration (ASD) are not fully understood. The definition of symptomatic ASD is the development of radicular or myelopathic signs and symptoms referable to a motion segment adjacent to prior cervical arthrodesis. The incidence, pathogenesis, prevalence, and potential treatment strategies for symptomatic ASD are discussed in this article.

Degenerative disorders of the lumbar and cervical spine.

Degenerative disorders in the spine are normal, age-related phenomena and largely asymptomatic in most cases. Conservative management of lumbar and cervical spondylosis is the mainstay of treatment, and most patients with symptomatic degenerative changes respond appropriately with nonsurgical management. Surgical intervention can be considered an appropriate and viable option when conservative measures have failed. Treatment options should always be directed toward the specific nature and location of the patient's individual pathology. Although current standards in the surgical management of lumbar and cervical degenerative disorders include discectomy, neural decompression, and instrumented spinal arthrodesis, new approaches that address this often-challenging clinical entity are on the horizon.

Magnetic resonance imaging in diagnosis and follow-up of impending spondylolysis in children and adolescents: early treatment may prevent pars defects.

The lumbar spine was assessed by magnetic resonance imaging (MRI) in 14 children (mean age 12.4 years) with unspecific activity-related low back pain for more than 3 weeks presenting with normal plain radiographs. Impending spondylolysis was diagnosed when typical signal abnormalities were confined to the pars interarticularis without signs of thinning or fragmentation. After brace treatment for 3 months, follow-up MRI was performed 3 and 6 months after treatment. MRI signals returned to normal after 3 months in six patients and after 6 months in one patient. MRI showed promising results in detecting and monitoring the early onset of spondylolysis. Bracing and avoiding strenuous activities prevented the formation of pars defects in all our patients.

A case report of postulated 'Barré Liéou syndrome'.

The case history presented is of a 32 year old woman suffering with severe occipital and bilateral temporal pain together with autonomic disturbances affecting her vision, balance and breathing, symptoms which have been postulated as 'Barré Liéou syndrome'. She complained of pain referred to the left arm and associated circulatory and sensory disturbance in keeping with the diagnosis of complex regional pain syndrome type I. Traditional Chinese and Western trigger point acupuncture techniques were used in order to treat her pain and autonomic dysfunction. Acupuncture was successful in reducing, but not totally alleviating, her pain, and was particularly effective in reducing the majority of autonomic symptoms.

Forty-six cases of the nerve root-involved cervical spondylopathy treated by needling the "Sitian" points.

In order to investigate the analgesic effect of needling at "Sitian" points for the nerve root-involved cervical spondylopathy, 68 cases of the nerve root-involved cervical spondylopathy were randomly divided into a treatment group of 46 cases treated by needling at "Sitian" points, and a control group of 22 cases treated by needling at cervical Jiaji points. After 2 therapeutic courses, the therapeutic effects were evaluated by using the visual analogue scale (VAS) and the semeiographic format. The results showed that the markedly effective rate was 78.3% and 54.5%, respectively in the treatment group and the control group, and the difference between the two groups was of significance (P<0.05). It can be concluded that needling at "Sitian" points can bring about a better therapeutic effect on the improvement of clinical symptoms, physical signs and pain than that of the needling at the cervical Jiaji points.

[Effect of vertebral manipulation therapy on vertebro-basilar artery blood flow in cervical spondylosis of vertebral artery type].

OBJECTIVE: To observe the effect of vertebral manipulation (VM) therapy on vertebro-basilar artery (VBA) blood flow in patients with cervical spondylosis of vertebral artery type (CS-VAT) by transcranial Doppler (TCD) ultrasonic examination. METHODS: One hundred and fifty patients with CS-VAT were randomized into the VM group (n = 100) and the acupuncture group (n = 50), and treated for ten times as one therapeutic course. Changes of the contraction peak, the end-diastolic and average blood flow velocity of VBA before and after treatment in the two groups were observed and compared by TCD. RESULTS: Vp, Vd, Vm of LVA, RVA and BA in the two groups after treatment were all lowered, showing significant difference, excepting Vp of VBA in the acupuncture group, when compared with before treatment (P< 0.05 or P <0.01). Comparison between the two groups after treatment showed significant difference in Vp and Vm of LVA, Vp, Vd and Vm of RVA, Vp and Vm of VBA respectively (P<0.05, P <0.01). CONCLUSION: VM therapy in treating patients with CS-VAT shows therapeutic effect superior to VA therapy, which could significantly improve VBA blood flow.

Transcranial magnetic stimulation techniques in clinical investigation.

Transcranial magnetic stimulation (TMS) is a technique that can activate cortical motor areas and the corticospinal tract without causing the subject discomfort. Since TMS was introduced, numerous applications of the technique have been developed for the evaluation of neurologic diseases. Standard TMS applications (central motor conduction time, threshold and amplitude of motor evoked potentials) allow the evaluation of motor conduction in the CNS. Conduction studies provide specific information in neurologic conditions characterized by clinical and subclinical upper motor neuron involvement. In addition, they have proved useful in monitoring motor abnormalities and the recovery of motor function. TMS also gives information on the pathophysiology of the processes underlying the various clinical conditions. More complex TMS applications (paired-pulse stimulation, silent period, ipsilateral silent period, input-output curve, and evaluation of central fatigue) allow investigation into the mechanisms of diseases causing changes in the excitability of cortical motor areas. These techniques are also useful in monitoring the effects of neurotrophic drugs on cortical activity. TMS applications have an important place among the investigative tools to study patients with motor disorders.