One spinal manipulation session reduces local pain sensitivity but does not affect postural stability in individuals with chronic low back pain: a randomised, placebo-controlled trial.

BACKGROUND: Clinical practice guidelines recommend spinal manipulation for patients with low back pain. However, the effects of spinal manipulation have contradictory findings compared to placebo intervention. Therefore, this study investigated the immediate effects of lumbar spinal manipulation on pressure pain threshold (PPT) and postural stability in people with chronic low back pain (cLBP). Second, we investigated the immediate effect of lumbar spinal manipulation on pain intensity and the interference of the participant beliefs about which treatment was received in the PPT, postural stability, and pain intensity. METHODS: A two-arm, randomised, placebo-controlled, double-blind trial was performed. Eighty participants with nonspecific cLPB and a minimum score of 3 on the Numeric Pain Rating Scale received one session of lumbar spinal manipulation (n = 40) or simulated lumbar spinal manipulation (n = 40). Primary outcomes were local and remote PPTs and postural stability. Secondary outcomes were pain intensity and participant's perceived treatment allocation. Between-group mean differences and their 95% confidence intervals (CIs) estimated the treatment effect. One-way analysis of covariance (ANCOVA) was performed to assess whether beliefs about which treatment was received influenced the outcomes. RESULTS: Participants had a mean (SD) age of 34.9 (10.5) years, and 50 (62.5%) were women. Right L5 [between-group mean difference = 0.55 (95%CI 0.19 to 0.90)], left L5 [between-group mean difference = 0.45 (95%CI 0.13 to 0.76)], right L1 [between-group mean difference = 0.41 (95%CI 0.05 to 0.78)], left L1 [between-group mean difference = 0.57 (95%CI 0.15 to 0.99)], left DT [between-group mean difference = 0.35 (95%CI 0.04 to 0.65)], and right LE [between-group mean difference = 0.34 (95%CI 0.08 to 0.60)] showed superior treatment effect in the spinal manipulation group than sham. Neither intervention altered postural stability. Self-reported pain intensity showed clinically significant decreases in both groups after the intervention. A higher proportion of participants in the spinal manipulation group achieved more than two points of pain relief (spinal manipulation = 90%; sham = 60%). The participants' perceived treatment allocation did not affect the outcomes. CONCLUSION: One spinal manipulation session reduces lumbar pain sensitivity but does not affect postural stability compared to a sham session in individuals with cLPB. Self-reported pain intensity lowered in both groups and a higher proportion of participants in the spinal manipulation group reached clinically significant pain relief. The participant's belief in receiving the manipulation did not appear to have influenced the outcomes since the adjusted model revealed similar findings.

Additional effect of pain neuroscience education to spinal manipulative therapy on pain and disability for patients with chronic low back pain: a randomized controlled trial.

BACKGROUND: Spinal manipulative therapy (SMT) demonstrates small effects on pain intensity in low back pain. Combining SMT with a psychosocial intervention like pain neuroscience education (PNE) could promote additional effect. OBJECTIVES: To evaluate the additional effect of PNE when combined to SMT on pain intensity and low back pain-related disability in patients with chronic low back pain (CLBP). METHOD: One hundred and four patients with CLBP of both sexes aged between 18 and 55 years were treated with PNE + SMT compared to SMT alone. The primary outcome measures were pain intensity and disability post-treatment (4 weeks). Secondary outcomes were fear-avoidance beliefs, global perceived effect of improvement, and pain self-efficacy. Results were obtained immediately post-treatment and at three follow-ups (30-days, 90-days, and 180-days). RESULTS: No significant between-group difference was observed for pain intensity and disability post-treatment. In contrast, our results showed a significantly longer additional effect for the group treated with SMT + PNE for the following outcomes: pain intensity (change baseline to 90 day follow-up = -0.90 [95% CI= -1.76, -0.4] and change baseline to 180 day follow-up = -1.19 [95% CI= -2.06, -0.32]) and low back pain-related disability, global perceived effect of improvement and pain self-efficacy (180th day follow-up). CONCLUSION: The results of this trial suggest the addition of PNE to SMT did not bring any additional effect on pain intensity and disability in the short term, but SMT + PNE can result in longer-lasting effects in patients with CLBP and that such an effect could be related to a possible mediator effect of pain self-efficacy.

Investigating the hypoalgesic effects of spinal manipulative therapy using hidden pain conditioning and positive expectation in patients with chronic low back pain: protocol for a randomised controlled trial.

INTRODUCTION: Placebo effects are responses capable of modulating pain and influencing treatment response. Two mechanisms are commonly related to placebo effects: expectations and conditioning. However, the research in this field is focused on laboratory studies with healthy participants. This study aims to identify whether a conditioning procedure with positive induced expectations about spinal manipulative therapy (SMT) will result in greater hypoalgesic effects in adults with chronic low back pain (CLBP) in a clinical trial design. METHODS AND ANALYSIS: This trial will enrol 264 patients with non-specific CLBP, aged 18-60 years. Patients will undergo a calibration test to determine the thermal pain threshold for the hidden pain conditioning procedure. Afterward, they will be randomised to one of the three groups: hidden pain conditioning with positive induced expectations-group one (G1); positive expectations-group two (G2) and neutral expectations-group three (G3). Patients will receive instructions to manipulate the expectations. The pretreatment heat pain test will be performed before the SMT and after the intervention patients will undergo again the heat pain intensity test. However, only patients in G1 will receive hidden pain conditioning to reinforce the association between SMT and pain intensity reduction. All patients will undergo five sessions of SMT. The outcomes will be assessed immediately after the last session and at the 6 weeks and 3-month follow-ups. All statistical analyses will be conducted following intention-to-treat principles, and the treatment effects will be determined with linear mixed models. ETHICS AND DISSEMINATION: The Federal University of São Carlos approved this research (Process n° 52359521.1.0000.5504). All participants will give written informed consent. Dissemination of the results will include publications in peer-reviewed journals and presentations at conferences. If positive expectations and classical conditioning improve outcomes, it may support the administration of such intervention. TRIAL REGISTRATION NUMBER: NCT05202704.

Finite element analysis of a new intervertebral disc prosthesis developed for the canine cervical spine / Elementos finitos de uma nova prótese de disco intervertebral desenvolvida para a coluna cervical canina

Cervical spondylomyelopathy (CSM) is a disease that affects mostly large- and giant-breed dogs. It is characterized by abnormalities of the cervical spine that may cause damage to the spinal cord and nerve roots. Cervical disc arthroplasty has been proposed as a treatment option in veterinary medicine. The current study evaluated the main stresses in a novel canine vertebral disc prosthesis and vertebral bodies using finite element analysis. Two experimental groups were created based on the material used for the prosthesis: stainless steel group (SSG) and titanium alloy group (TAG). Vertebral and prosthetic average equivalents von-Mises stress (VMS) and minimum principal stress (MiPS) were assessed while compressive, tensile, and lateral bending shear loads were applied. The stainless steel group had greater VMS distribution on all the evaluated parameters while the titanium alloy group had greater MiPS. Stresses were more concentrated on the lateral and ventral surfaces of the vertebral bodies than on their endplates. The average prosthetic stresses were more concentrated on the bone/implant contact surface than on the prosthesis/screw interface. Maximum stresses were concentrated in the screws' cranial surface. The novel prosthesis allows even distribution along the vertebral body. Comparing prosthesis materials, titanium alloy was marginally superior regarding average stresses in all directions and should be less likely to suffer subsidence.

Espondilomielopatia cervical (EMC) é uma doença que geralmente afeta cães de raças grandes e gigantes. Ela é caracterizada por anormalidades da coluna cervical que podem causar danos à medula espinhal ou às raízes nervosas. Artroplastia cervical com prótese de disco tem sido proposta como opção de tratamento na medicina veterinária. O presente estudo teve como objetivo avaliar os principais estresses em uma nova prótese de disco intervertebral canina e corpos vertebrais por meio da análise de elementos finitos. Foram compostos dois grupos experimentais que representaram o material constituinte da nova prótese: grupos aço inoxidável (SSG) e o liga de titânio (TAG). Tensões equivalente de von-Mises (VMS) e tensão principal mínima (MiPS) média foram avaliadas sob forças de compressão, tração e torção para vértebras e prótese. O grupo SSG teve maior distribuição de VMS para todos parâmetros avaliados, enquanto o grupo TAG teve maior MiPS. Estresses estiveram mais concentrados nas superfícies lateral e ventral dos corpos vertebrais do que nas placas terminais. Os estresses médios da prótese foram mais concentrados na superfície de contato osso/implante do que na interface prótese/parafuso. Estresses máximos foram concentrados na superfície cranial do parafuso. A nova prótese permitiu distribuição uniforme do estresse ao longo do corpo vertebral. Comparando os materiais da prótese, a liga de titânio foi marginalmente superior quanto aos estresses médios em todas as direções, sendo menos provável que sofra afundamento da prótese.

Analysis of the decompressive treatment of the vertebral canal through the trans-spinal approach / Análise do tratamento descompressivo do canal vertebral pela via transespinhosa / Análisis del tratamiento descompresivo del canal vertebral mediante el enfoque transespinal

ABSTRACT Objective: The spinous process separation technique is a less invasive surgical technique for treating lumbar canal stenosis. The objective is to evaluate this technique's results in treating lumbar canal stenosis. Method: Thirty patients with lumbar spinal canal stenosis underwent surgical treatment using the spinous process separation technique and were evaluated in the 3-year postoperative period using the Denis Pain and Work Scale and by the SF-36 questionnaire and radiographic evaluation of the operated segment. Results: In the evaluation of the Denis pain scale, 21 (70%) patients had no pain (P1), and nine (30%) patients reported minimal low back pain, not needing medication (P2). Denis' work schedule showed that nine (30%) patients had restrictions on returning to their previous work activity (W2), and 21 (70%) patients were classified as W1. The SF-36 questionnaire showed results of 81.25 for physical aspects (PA), 81.9 for functional capacity (FC), 81.3 for emotional aspects (EA), 64.3 for vitality (V), 65.9 for mental health (MH), 81.98 for social aspects (SA), 75.6 for pain (P) and 68.1 for general health status (GHS). In addition, there were no radiographic signs of instability of the operated vertebral segment in the radiographic evaluation. Conclusion: The decompression of the lumbar spinal canal using the spinous process separation technique showed good results in the evaluated patients three years after the operation. Level of Evidence II, Retrospective Comparative Study.

Resumo: Objetivo: A técnica de separação do processo espinhoso é uma técnica cirúrgica menos invasiva para o tratamento da estenose do canal lombar. O objetivo é avaliar os resultados dessa técnica no tratamento da estenose do canal lombar. Método: Trinta pacientes portadores de estenose do canal vertebral lombar foram submetidos ao tratamento cirúrgico por meio da técnica da separação do processo espinhoso, tendo sido avaliados no período de três anos de pós-operatório, por meio da escala de dor e de trabalho de Denis, pelo questionário SF-36 e avaliação radiográfica do segmento operado. Resultados: Na avaliação da escala de dor de Denis, 21 (70%) pacientes não apresentavam dor (P1) e nove (30%) pacientes relataram dor mínima lombar, não necessitando medicação (P2). A escala de trabalho de Denis evidenciou que nove (30%) pacientes apresentavam restrições ao retorno à atividade prévia de trabalho (W2) e 21 (70%) pacientes foram classificados como W1. O questionário SF-36 apresentou resultados 81,25 para aspectos físicos (AF), 81,9 para capacidade funcional (CF), 81,3 para aspectos emocionais (AE), 64,3 para vitalidade(V), 65,9 para saúde mental (SM), 81,98 para aspectos sociais (AS), 75,6 para dor (D) e 68,1 para estado geral de saúde (EGS). Não foram observados sinais radiográficos de instabilidade do segmento vertebral operado na avaliação radiográfica. Conclusão: A descompressão do canal vertebral lombar por meio da técnica de separação do processo espinhoso apresentou bons resultados na avaliação num período de três anos de pós-operatório dos pacientes avaliados. Nível de Evidência II, Estudo Retrospectivo Comparativo.

Resumen: Objetivo: La técnica de separación de la apófisis espinosa es una técnica quirúrgica menos invasiva para el tratamiento de la estenosis del canal lumbar. El objetivo es evaluar los resultados de esta técnica en el tratamiento de la estenosis del canal lumbar. Método: Treinta pacientes con estenosis del conducto raquídeo lumbar fueron intervenidos quirúrgicamente mediante la técnica de separación de la apófisis espinosa, y fueron evaluados en el postoperatorio de tres años mediante la Escala de Dolor y Trabajo de Denis, mediante el cuestionario SF-36 y evaluación radiográfica del segmento operado. Resultados: En la evaluación de la escala de dolor de Denis, 21 (70%) pacientes no presentaron dolor (P1) y nueve (30%) pacientes refirieron dolor lumbar mínimo, sin necesidad de medicación (P2). La escala de trabajo de Denis mostró que nueve (30%) pacientes tenían restricciones para regresar a su actividad laboral anterior (W2) y 21 (70%) pacientes fueron clasificados como W1. El cuestionario SF-36 arrojó resultados 81,25 para aspectos físicos (AF), 81,9 para capacidad funcional (CF), 81,3 para aspectos emocionales (AE), 64,3 para vitalidad (V), 65,9 para salud mental (SM), 81,98 para aspectos sociales (AS), 75,6 para dolor (D) y 68,1 para estado general de salud (EGS). No hubo signos radiográficos de inestabilidad del segmento vertebral intervenido en la evaluación radiográfica. Conclusión: La descompresión del canal espinal lumbar mediante la técnica de separación de apófisis espinosa mostró buenos resultados en la evaluación de un período de 3 años después de la operación de los pacientes evaluados.

Absence of Neuroplastic Changes in the Bilateral H-Reflex Amplitude following Spinal Manipulation with Activator IV.

Background and Objectives: Chiropractic spinal manipulation is an alternative medical procedure for treating various spinal dysfunctions. Great interest exists in investigating its neuroplastic effects on the central nervous system. Previous studies have found contradictory results in relation to the neuroplastic changes in the H-reflex amplitude as a response to manual spinal manipulation. The discrepancies could be partly due to differences in the unilateral nature of these recordings and/or the variable force exerted in manual techniques applied by distinct chiropractors. Concerning the latter point, the variability in the performance of manual interventions may bias the determination of the significance of changes in H-reflex responses derived from spinal manipulation. To investigate such responses, a chiropractic device can be used to provide more precise and reproducible results. The current contribution aimed to examine whether spinal manipulation with an Activator IV instrument generates neuroplastic effects on the bilateral H-reflex amplitude in dancers and non-dancers. Materials and Methods: A radiograph verified spinal dysfunction in both groups of participants. Since there were significant differences between groups in the mean Hmax values of the H-reflex amplitude before spinal intervention, an assessment was made of the possible dependence of the effects of spinal manipulation with Activator IV on the basal conditions. Results: Ten sessions of spinal manipulation with Activator IV did not cause statistically significant changes in the bilateral H-reflex amplitude (measured as the Hmax/Mmax ratio) in either group. Furthermore, no significant difference was detected in the effects of spinal manipulation between groups, despite their distinct basal H-reflex amplitude. Conclusions: Regarding the therapeutic benefits of a chiropractic adjustment, herein carried out with Activator IV, the present findings suggest that the mechanism of action is not on the monosynaptic H-reflex pathway. Further research is needed to understand the mechanisms involved.

Immediate effects of spinal manipulation on painful sensitivity and postural stability in patients with chronic nonspecific low back pain: study protocol for a controlled randomised clinical trial.

BACKGROUND: Low back pain is one of the main public health concerns. Chronic low back pain (cLBP) reduces functional capacity and affects postural stability. Although health professionals widely use spinal manipulation, its immediate effect on painful sensitivity and postural stability is lacking. This study aims to verify the immediate effects of lumbar spinal manipulation on the pressure pain threshold and postural stability in individuals with cLBP. METHODS: A two-arm, placebo-controlled clinical trial with parallel groups and examiner-blinded will be conducted with 80 participants with cLBP from an outpatient physical therapy department, randomly allocated at a 1:1 distribution. The experimental group will receive a lumbar spinal manipulation technique, and the placebo group will receive a simulated lumbar spinal manipulation. Both groups will receive one session of treatment and will be evaluated before and immediately after the intervention. The primary outcomes will be the pressure pain threshold and postural stability. Pain intensity and patient's expectation will be assessed as a secondary outcome. The pressure pain threshold will be assessed using a pressure algometer in 6 different anatomical regions. The evaluation of postural stability will be performed in a baropodometry exam by displacing the centre of pressure. The pain intensity will be measured using the Numeric Pain Rating Scale. A Likert scale will be used for the patient's expectation about the treatment. A two-way analysis of variance will compare the effect of the interventions between groups. DISCUSSION: This study will provide insights regarding the immediate effects of spinal manipulation in patients with cLBP against a simulated spinal manipulation using objective outcomes and considering patients' expectations regarding the treatment. TRIAL REGISTRATION: Brazilian Registry of Clinical Trials RBR-3ksq2c . Registered on 13 July 2020.

Impact of the covid-19 pandemic on the surgical treatment of spine pathologies in sus / Impacto da pandemia da covid-19 no tratamento cirúrgico de patologias de coluna no sus / Impacto de la pandemia de covid-19 en el tratamiento quirúrgico de patologías de la columnavertebral enel sus

ABSTRACT Objective: To evaluate the impact of the COVID-19 pandemic on spine surgeries performed by SUS. To identify changes in surgical volume, as well as which procedures and regions of Brazil were most affected. To correlate such changes with literature data. Methods: A retrospective, descriptive study was conductedwith an analysis of the databases available to the public on the performance of spinal surgical procedures by SUS during the period from 2017 to 2021. The databases were created from variables of interest available in the SIH (Hospital Information System) of the SUS Information Technology Department website (DATASUS; http://datasus.saude.gov.br). The procedures were grouped according to type of surgery, topography, and access route for the construction of tables and statistical analysis. Results: In the years of the pandemic, a greater drop in surgical volume was observed, with a total of 13,276 procedures in 2020 and 12,158 in 2021, equivalent to -28.51% and -34.53%, respectively, of the average of the previous period. Conclusions: Given the paramount importance of attention to the fight against the pandemic, maintaining the level of assistance for spinal pathologies proved to be a great challenge, especially in relation to elective surgical pathologies that, when delayed too much, can seriously impact the quality of life and outcomes of future treatments. Level of Evidence: IV; Retrospective, descriptive.

RESUMO Objetivo: Avaliar o impacto da pandemia de COVID-19 na realização de cirurgias de coluna no SUS. Identificar mudanças do volume de cirurgias, bem como quais procedimentos e regiões do Brasil foram mais afetados. Correlacionar tais mudanças com dados da literatura. Métodos: Realizou-se um estudo retrospectivo, descritivo, com análise de banco de dados disponíveis para o público sobre a realização de procedimentos cirúrgicos de coluna pelo SUS no período de 2017 a 2021. Os bancos de dados foram criados a partir das variáveis de interesse disponíveis no SIH (Sistema de Informações Hospitalares) do site do Departamento de Informática do SUS (DATASUS; http://datasus.saude.gov.br). Os procedimentos foram agrupados de acordo com tipo de cirurgia, topografia e via de acesso para construção das tabelas e análise estatística. Resultados: Nos anos da pandemia observou-se uma queda maior no volume cirúrgico com um total de 13.276 procedimentos em 2020 e 12.158 em 2021, equivalentes a -28,51% e -34,53% com relação à média do período anterior, respectivamente. Conclusões: Diante da importância primordial da atenção ao combate da pandemia, a manutenção da assistência às patologias de coluna revela-se um grande desafio, principalmente com relação a patologias cirúrgicas eletivas que, quando postergadas em demasia, podem impactar de maneira grave a qualidade de vida e resultados de tratamentos futuros. Nível de EvidênciaIV; Estudo RetrospectivoDescritivo.

RESUMEN Objetivo: Evaluar el impacto de la pandemia de COVID-19 en larealización de cirugías de columna en el SUS. Identificar cambios en el volumen de cirugías, así como qué procedimientos y regiones de Brasil se vieron más afectados. Correlacionar dichos cambios con datos de la literatura. Métodos: Se realizó un estudio retrospectivo, descriptivo, con análisis de bases de datos disponibles públicamente sobre la realización de procedimientos quirúrgicos de columna vertebral por el SUS en el período comprendido entre 2017 y 2021. Las bases de datos fueron creadas a partir de las variables de interés disponibles en el SIH (Sistema de Información Hospitalaria) del sitio web del Departamento de Informática del SUS (DATASUS; http://datasus.saude.gov.br). Los procedimientos fueron agrupados según tipo de cirugía, topografía y vía de acceso para la elaboración de tablas y análisis estadístico. Resultados: En los años de pandemia se observó un mayor descenso en el volumen quirúrgico, con un total de 13.276 procedimientos en 2020 y 12.158 en 2021, equivalentes a -28,51% y -34,53% respecto a la media del periodo anterior, respectivamente. Conclusiones: Dada la trascendental importancia de la atención en el combate a la pandemia, mantener la asistencia a las patologías de la columna resulta un gran desafío, especialmente en lo que respecta a las patologías quirúrgicas electivas que, cuando se demoran demasiado, pueden repercutir gravemente en la calidad de vida y en los resultados de futuros tratamientos. Nivel de evidencia: IV; Estudio Retrospectivo Descriptivo.

Impact of obesity on the clinical outcomes of spinal surgery by transpsoas lateral fusion / Impacto da obesidade sobre os desfechos clínicos da cirurgia da coluna por artrodese lateral via transpsoas / Impacto de la obesidad en los resultados clínicos de la cirugía de columna mediante fusión lateral transpsoas

ABSTRACT Introduction: Obesity is a global phenomenon that affects the quality of life of the population. In addition to being a factor that can lead to cases of degeneration in the spine, it can also influence the clinical outcomes of spine surgeries. However, with the development of minimally invasive techniques, the impact of obesity has become uncertain. Methods: A single-center, non-randomized, comparative, observational study, here clinical and surgical outcomes and postoperative complications were analyzed between obese and non-obese patients undergoing LLIF surgery. Results: There was no difference between surgical times and blood loss between the groups; the number of postoperative complications was similar. Both groups showed significant improvement in clinical parameters, but there was no difference between the amount of improvement between the obese and non-obese groups. Conclusion: The present study demonstrated that LLIF is a safe and effective technique regardless of the patient's degree of obesity. Level of Evidence III; Retrospective study.

RESUMO Introdução: A obesidade é um fenômeno global que possui diversos sobre a qualidade de vida da população. Além de ser um fator que pode levar a casos de degeneração na coluna, como também pode influenciar nos desfechos clínicos das cirurgias de coluna. No entanto, com o desenvolvimento de técnicas minimamente invasivas o impacto da obesidade se tornou incerto. Métodos: Estudo de centro único, não-randomizado, comparativo, observacional, onde foram analisados os desfechos clínicos, cirúrgicos e complicações pós-operatórias entre pacientes obesos e não-obesos submetidos a cirurgia de LLIF. Resultados: Não houve diferença entre os tempos cirúrgicos e perda sanguínea entre os grupos, ademais o número de complicações pós-operatórias foi similar entre os grupos. Ambos os grupos apresentaram melhora significativa dos parâmetros clínicos, porém não houve diferença entre a quantidade de melhora entre os grupos obeso e não-obeso. Conclusão: O presente estudo demonstrou que o LLIF é uma técnica segura e eficaz independentemente do grau de obesidade do paciente. Nível de evidência III; Estudo retrospectivo.

RESUMEN Introducción: La obesidad es un fenómeno mundial que afecta la calidad de vida de la población. Además de ser un factor que puede conducir a casos de degeneración en la columna, también puede influir en los resultados clínicos de las cirugías de columna. Sin embargo, con el desarrollo de técnicas mínimamente invasivas, el impacto de la obesidad se ha vuelto incierto. Métodos: Estudio observacional, comparativo, no aleatorizado, unicéntrico, donde se analizaron los resultados clínicos, quirúrgicos y las complicaciones postoperatorias entre pacientes obesos y no obesos sometidos a cirugía LLIF. Resultados: No hubo diferencia entre los tiempos quirúrgicos y la pérdida de sangre entre los grupos, además, el número de complicaciones postoperatorias fue similar entre los grupos. Ambos grupos mostraron una mejora significativa en los parámetros clínicos, pero no hubo diferencia entre la cantidad de mejora entre los grupos obesos y no obesos. Conclusión: El presente estudio demostró que la LLIF es una técnica segura y eficaz independientemente del grado de obesidad del paciente. Nivel de Evidencia III; Estudio retrospectivo.

Minimally invasive laminar lift and posterior cervical laminoplasty via the intermuscular approach: a canine model study

Purpose: This study aimed to develop a minimally invasive surgical procedure for laminar lift and posterior cervical laminoplasty via the intermuscular approach using a canine model. Methods: Six Alaskan dogs were used for developing the surgical approach. The bilateral laminae of C3-7 were cut with an ultrasonic osteotome and fixed with bilateral plates to maintain the lamina lifting and reshape a wider spinal canal. The important structures, such as ligaments, supraspinous ligaments, interspinous ligaments, and ligamentum flavum were preserved. The therapeutic effect was evaluated by preoperative and postoperative imaging results and neck mobility. Results: The surgical procedures were all successfully performed in the 6 animals. All the dogs survived well within 1 year of postoperative follow-up. The postoperative neck mobility was as good as the preoperative one. Computed tomography results showed that the anteroposterior diameter of the spinal canal was successfully enlarged and maintained well. Conclusions: The minimally invasive surgical procedure for laminar lift and posterior cervical laminoplasty via the intermuscular approach was feasible in a canine model, which might be applied in clinical practice.

Hypoalgesic effects of specific vs non-specific cervical manipulation in healthy subjects: a randomized crossover trial.

BACKGROUND: Joint manipulation is generally used to reduce musculoskeletal pain; however, evidence has emerged challenging the effects associated with the specificity of the manipulated vertebral segment. The aim of this study was to verify immediate hypoalgesic effects between specific and non-specific cervical manipulations in healthy subjects. METHOD: Twenty-one healthy subjects (18-30 years old; 11 males, 10 females) were selected to receive specific cervical manipulation at the C6-7 segment (SCM) and non-specific cervical manipulation (NSCM) in aleatory order. A 48h interval between manipulations was considered. Pressure pain threshold (PPT) was measured pre- and post-manipulation with a digital algometer on the dominant forearm. RESULTS: The SCM produced a significant increase in the PPT (P < 0.001) however no difference was observed in the PPT after the NCSM (P = 0.476). The difference between the two manipulation techniques was 37.26 kPa (95% CI: 14.69 to 59.83, p = 0.002) in favor of the SCM group CONCLUSION: Specific cervical manipulation at the C6-7 segment appears to increase PPT on the forearm compared to non-specific cervical manipulation in healthy subjects.

Traumatic Atlantoaxial Rotatory Subluxation in Adult: Case Report

Traumatic atlantoaxial rotatory subluxation (AARS) is generally found in pediatric patients, rarely found in adults, being a life-threatening condition especially when early diagnosis is not possible, which can lead to severe late neurological deficits.We describe a 38-year-old patient, victim of physical aggression caused by strangulation attempt who developed AARS, an uncommontraumatic cause. During the hospital care, the early diagnosis allowed us to institute a conservative treatment, which made the case uncommon, since most of the time surgical treatment is imperative. With the patient awake and under analgesia, a closed reduction was performed that promoted immediate pain relief, followed by a prescription of wearing a Philadelphia-type collar for 8 weeks. During the follow-up, cervical spine radiographies demonstrated no subluxation after removing the cervical collar. The patient was asymptomatic after 6months of treatment. This case supports the importance of nonoperative management of AARS in selected cases.

Hypoalgesic Effects of Transcutaneous Electrical Nerve Stimulation Combined With Joint Manipulation: A Randomized Clinical Trial.

OBJECTIVE: The objective of this study was to compare the hypoalgesic effects of isolated or combined use of transcutaneous electrical nerve stimulation (TENS) and cervical joint manipulation (JM) in asymptomatic participants. METHODS: One hundred and forty-four healthy participants aged 18 to 30 years old were randomly assigned to 1 of 4 groups (n = 36 per group): active TENS + active JM, active TENS + placebo JM, placebo TENS + active JM, and placebo TENS + placebo JM. Active or placebo TENS was applied to the dominant forearm. JM was applied to the C6-7 segments. The pressure pain threshold was measured pre- and postintervention and after 20 minutes on the forearm and tibialis anterior of the dominant side. RESULTS: Segmental hypoalgesia was greater in the group active TENS + active JM compared with active TENS + placebo JM (P = .002), placebo TENS + active JM (P < .0001), and placebo TENS + placebo JM (P < .0001). For the extrasegmental hypoalgesia, active TENS + active JM had greater hypoalgesic effect compared with active TENS + placebo JM (P = .033), placebo TENS + active JM (P = .002), and placebo TENS + placebo JM (P < .0001). CONCLUSION: TENS and JM produced hypoalgesia when used alone and, when the treatments were combined, a higher segmental and extrasegmental hypoalgesic effect was obtained in asymptomatic participants.

Efeito da mobilização neural no tratamento da dor em indivíduos com cervicobraquialgia: uma revisão sistemática / Effect of neural mobilization on the treatment of pain in individuals with cervicobrachialgia: a systematic review

: A cervicobraquialgia (CB) é caracterizada por uma dor com origem em diferentes níveis estruturais da coluna cervical baixa (C3- C7), com irradiação bilateral ou unilateral para o membro superior. Considerando as causas e consequências advindas da CB, novas modalidades de tratamento têm sido propostas na tentativa de promover intervenções efetivas. Entre os procedimentos fisioterapêuticos encontram-se as técnicas de terapia manual como liberação miofascial, quiropraxia, mobilização articular, estabilização segmentar e a mobilização neural (MN) que procura restabelecer a função do tecido neural, sua condução elétrica, elasticidade, movimento e fluxo axoplasmático. Sendo assim, o objetivo do estudo foi avaliar sistematicamente as evidências sobre o efeito da MN no tratamento da dor em indivíduos com CB. A busca bibliográfica foi realizada no período entre Novembro de 2018 a Junho de 2019, sem limite de ano de publicação, nas bases de dados: PEDro, PubMed, Biblioteca Virtual em Saúde (Lilacs, Scielo e Medline) e Cochrane Library. A análise foi restrita aos ensaios clínicos randomizados. Para a análise etodológica dos artigos aptos a inclusão, foi utilizada a escala PEDro. Foi encontrado um total de 38 artigos. Após remoção de duplicatas, 14 artigos foram elegidos por resumo, 8 artigos foram recuperados para leitura completa e analisados quanto a sua adequação, dos quais 3 foram excluídos por não cumprirem os critérios de elegibilidade, ao fim 5 artigos foram incluídos na revisão. Houve redução significativa da dor, em pacientes tratados com MN. Considerando os resultados obtidos nesta revisão, foi possível concluir que a MN demonstra ser eficaz na redução da dor presente na CB. Embora os estudos mostrem que os resultados da MN como tratamento da CB são significativamente inferiores ao efeito do Ibuprofeno, deve-se ter em consideração as consequências a longo prazo para a saúde sobre a utilização de anti- inflamatórios orais.(AU)

Cervicobrachialgia (CB) is characterized by pain originating from different structural levels of the lower cervical spine (C3-C7), w ith bilateral or unilateral irradiation to the upper limb. Considering the causes and consequences of CB, new treatment modalities have been proposed in an attempt to promote effective interventions. Among the physical therapy procedures are manual therapy techniques such as myofascial release, chiropractic, joint mobilization, segmental stabilization and neural mobilization (NM) that seeks to restore the function of neural tissue, its electrical conduction, elasticity, movement and ax oplasmic flow . Thus, the objective of the study w as to evaluate systematically evaluate the evidence on the effect of NM on pain management in individuals w ith CB. The bibliographic search w as performed from November 2018 to June 2019, w ithout limit of year of publication, in the databases: PEDro, PubMed, Virtual Health Library (Lilacs, Scielo and Medline) and Cochrane Library. The analysis w as restricted to randomized controlled trials. For the methodological analysis of the articles eligible for inc lusion, the PEDro scale w as used. A total of 38 articles w ere found. After removal of duplicates, 14 articles w ere elected by abstract, 8 articles w ere retrieved for full reading and analyzed for suitability, of w hich 3 w ere excluded for not meeting eligibility c riteria, at the end 5 articles w ere included in the review . There was a significant pain reduction in patients treated w ith NM. Considering the results obtained in this review , it w as concluded that NM demonstrates to be effective in reducing pain present in CB. Although studies show that the results of NM as a treatment for CB are significantly low er than the effect of ibuprofen, consideration should be given to the long-term health consequences about the utilization of oral anti-inflammatory drugs.(AU)

One Session of Spinal Manipulation Improves the Cardiac Autonomic Control in Patients with Musculoskeletal Pain: A Randomized Placebo-Controlled Trial.

STUDY DESIGN: Three-arm, parallel, randomized, placebo-controlled, assessor-blinded trial. OBJECTIVE: To compare the immediate effect of manual therapy at the upper thoracic spine on the cardiovascular autonomic control of patients with musculoskeletal pain. SUMMARY OF BACKGROUND DATA: Musculoskeletal pain increases the risk of cardiovascular events. Thus, manual therapy applied to the upper thoracic region is likely efficient to improve the cardiac autonomic control. METHODS: The study included 59 patients with musculoskeletal pain enrolled at an outpatient clinic. Participants were randomly assigned to spinal manipulation (n = 19), myofascial manipulation (n = 20), or placebo (n = 20) administered to the upper thoracic region. Resting heart rate variability provided indexes of the cardiac autonomic control, and the blood pressure response to the cold pressor test as a proxy of the sympathetic responsiveness to a stressor stimulus. RESULTS: Groups were similar for baseline variables except for blood pressure. Two-way repeated-measures one-way analysis of covariance (ANCOVA) revealed that only spinal manipulation induced immediate increase of the square root of the mean squared differences of successive RR intervals (RMSSD), absolute (ms2), and normalized units (n.u.) of the high-frequency power (HF) as compared with pre-intervention evaluation, indicating an improvement in the parasympathetic activity to the heart. Normalized units of low-frequency power (LF) and the LF/HF ratio reduced after the spinal manipulation solely, suggesting a reduction of the sympathetic activity to the heart. There were no significant differences in the blood pressure responsiveness among the three treatments. There were no adverse events. CONCLUSION: In patients with musculoskeletal pain, spinal manipulation on the upper thoracic spine led to an immediate improvement in the resting cardiac autonomic control without an effect on the blood pressure responsiveness to a sympathoexcitatory stimulus. Myofascial manipulation or placebo did not change cardiovascular autonomic control.Level of Evidence: 2.

Directed vertebral manipulation is not better than generic vertebral manipulation in patients with chronic low back pain: a randomised trial.

QUESTION: In people with chronic low back pain, what is the average effect of directing manipulation at the most painful lumbar level compared with generic manipulation of the spine? DESIGN: Randomised controlled trial with concealed allocation, a blinded assessor and intention-to-treat analysis. PARTICIPANTS: 148 people with non-specific chronic low back pain with a minimum level of pain intensity of 3 points (measured from 0 to 10 on the Pain Numerical Rating Scale). INTERVENTIONS: All participants received 10 spinal manipulation sessions over a 4-week period. The experimental group received treatment to the most painful segment of the lower back. The control group received treatment to the thoracic spine. OUTCOME MEASURES: The primary outcome was pain intensity, measured at the end of the intervention (Week 4). Secondary outcomes were: pain intensity at Weeks 12 and 26; pressure pain threshold at Week 4; and global perceived change since onset and disability, both measured at Weeks 4, 12 and 26. RESULTS: Each group was randomly allocated 74 participants. Data were collected at all time points for 71 participants (96%) in the experimental group and 72 (97%) in the control group. There were no clinically important between-group differences for pain intensity, disability or global perceived effect at any time point. The estimate of the effect of directing manipulation at the most painful lumbar level, as compared with generic manipulation, on pain intensity was too small to be considered clinically important: MD 0 (95% CI -0.9 to 0.9) at Week 4 and -0.1 (95% CI -1.0 to 0.8) at Week 26. CONCLUSION: No clinically important differences were observed between directed manipulation and generic manipulation in people with chronic low back pain. TRIAL REGISTRATION: NCT02883634.

Immediate effects of a lumbar spine manipulation on pain sensitivity and postural control in individuals with nonspecific low back pain: a randomized controlled trial.

BACKGROUND: According to the American Physical Therapy Association, there is strong evidence to show that vertebral mobilization and manipulation procedures can be used to improve spinal and hip mobility and reduce pain and incapacity in low back pain patients that fit the clinical prediction rule. OBJECTIVES: To evaluate the immediate effects of high-velocity low-amplitude (HVLA) manipulation on pain and postural control parameters in individuals with nonspecific low back pain. METHODS: This study used a participant-blinded and assessor-blinded randomized controlled clinical trial involving a single session, in which 24 participants were randomly distributed into control (simulated manipulation) and intervention (HVLA lumbar manipulation) groups. The primary (pain: subjective pain intensity and pressure pain threshold) and secondary outcomes (postural control: ellipse area, center of pressure [COP] excursion, COP RMS velocity, and differences between the COP and center of projected gravity) were evaluated before and after the session using a numerical pain scale, algometer, and a force platform. For all outcomes, multiple mixed 2 (group) × 2 (time) ANOVAs were performed. RESULTS: For the subjective pain intensity, only time was significant as a main effect, where pre-intervention presented a greater value then post-intervention (F [1.44] = 4.377; p = 0.042; r = 0.30). For the pressure pain threshold no significant effect was found. For the postural control parameters, as a main effect, only the ellipse area was significantly greater in the control group (F [1.44] = 6.760; p = 0.013; effect size = 0.36). CONCLUSIONS: There was a reduction in subjective pain intensity, evaluated using a numerical scale, in both the intervention and control groups immediately after the intervention, suggesting that the spinal manipulation had a similar effect to the placebo procedure. No effect of HVLA lumbar manipulation was identified for postural control variables in either the intervention or control groups. TRIAL REGISTRATION: The study was registered at ClinicalTrials.gov under the number NCT02312778, registered at 14 September 2014.

Effectiveness of spinal manipulation and myofascial release compared with spinal manipulation alone on health-related outcomes in individuals with non-specific low back pain: randomized controlled trial.

OBJECTIVE: To investigate the effectiveness of spinal manipulation combined with myofascial release compared with spinal manipulation alone, in individuals with chronic non-specific low back pain (CNLBP). DESIGN: Randomized controlled trial with three months follow-up. SETTING: Rehabilitation clinic. PARTICIPANTS: Seventy-two individuals (between 18 and 50 years of age; CNLBP ≥12 consecutive weeks) were enrolled and randomly allocated to one of two groups: (1) Spinal manipulation and myofascial release - SMMRG; n=36) or (2) Spinal manipulation alone (SMG; n=36). INTERVENTIONS: Combined spinal manipulation (characterized by high velocity/low amplitude thrusts) of the sacroiliac and lumbar spine and myofascial release of lumbar and sacroiliac muscles vs manipulation of the sacroiliac and lumbar spine alone, twice a week, for three weeks. MAIN OUTCOME MEASURES: Assessments were performed at baseline, three weeks post intervention and three months follow-up. Primary outcomes were pain intensity and disability. Secondary outcomes were quality of life, pressure pain-threshold and dynamic balance. RESULTS: No significant differences were found between SMMRG vs SMG in pain intensity and disability post intervention and at follow-up. We found an overall significant difference between-groups for CNLBP disability (SMG-SMMRG: mean difference of 5.0; 95% confidence interval of difference 9.9; -0.1), though this effect was not clinically important and was not sustained at follow-up. CONCLUSIONS: We demonstrated that spinal manipulation combined with myofascial release was not more effective compared to spinal manipulation alone for patients with CNLBP. CLINICAL TRIAL REGISTRATION NUMBER: NCT03113292.

Four-rod Technique Stabilization after Pedicle Subtraction Osteotomy (PSO) for the Treatment of Thoracolumbar Hyperkyphosis Secondary to Pott Disease: A Two-Year Follow-Up Case Report

Pedicle subtraction osteotomy (PSO) is a powerful tool for themanagement of sagittal misalignment. However, this procedure has a high rate of implant failure, particularly rod breakages. The four-rod technique diminishes this complication in the lumbar spine. The aim of the present study is to provide a case report regarding PSO and fourrod technique stabilization in the treatment of short-angle hyperkyphosis in the thoracolumbar (TL) junction. The authors describe the case of a patient with TL hyperkyphosis secondary to spinal tuberculosis treated with L1 PSO and fixation with a four-rod technique. There were no major surgical complications. The self-reported quality of life questionnaires (the Short-Form Health Survey 36 [SF-36] and the Oswestry disability index) and radiological parameters were assessed preoperatively, as well as 6, 12 and 24 months after surgery, and they showed considerable and sustained improvements in pain control and quality of life. No hardware failure was observed at the two-year follow-up.