Posts Tagged ‘cervical facets’

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A step forward for the surgical response to chronic Posterior Facet Syndrome – but do get some chiropractic in before you go this far!

Monday, July 19th, 2010

I found this article in PainMedicineNews. It sets out a finessing of the surgical response to chronic – and it must be chronic to be this bad, Posterior Facet Syndrome (PFS). Now, I’ve blogged about PFS before and so you’ll all know how important it is and if you are unsure have a look at what Dr Bennett has to say about PFS in this article.

Have a read and then see why we tell people to get some early care and so avoid this stuff as it just can’t be good for you!

“For Facet Joint Pain, Minimally Invasive Surgery A Good Fit
In pilot study, 30-minute surgery reduces pain, opioid use; multicenter trial to follow

Gabriel Miller

A minimally invasive approach for facet arthrodesis (artificial induction of joint ossification between two bones via surgery – my note) reduces pain as well as chronic opioid use in back pain patients, according to a new study. The procedure — originally developed and used by orthopaedic surgeons and neurosurgeons — also may be performed safely by interventional pain physicians, the study demonstrated.

Although arthrodesis of the facet joints is not a new procedure, experts say a minimally invasive approach — which can be performed by a number of specialties — is novel.

…Like an open surgical approach, the concept behind the minimally invasive arthrodesis is to fuse the facet joint by drilling a hole between the joint walls and tamping an allograft bone dowel into the joint, separating the joint surfaces, locking the facet joint into place and providing a minimal amount of stability. Facet joint disease most often results from degeneration of the cartilage within the facet joint; the joint then becomes unstable and shifts around loosely, causing painful bone-to-bone contact.“ The premise is if you can eliminate the motion that you have between these facet joints, then you can take away the pain,” said Dr. Guiot.

Daniel Bennett, MD, medical director of Integrative Treatment Centers in Denver, and the lead investigator of the pilot study presented at the AAPM meeting [said]: “Because the No. 1 cause of sustained low back pain is joint-related, this procedure is a new tool in the interventional pain specialists’ tool belt.”
The study included 28 prospectively enrolled patients with facet-mediated low back pain, (so, PFS in other words) that was confirmed by intraarticular facet injection. Patients also were required to have previous radiofrequency ablation (RFA) with a return of pain. “We wanted to start with a population that had experienced the current gold standard of care and [had] at least gone through all of the invasive treatments short of surgery,” Dr. Bennett said.

During the procedure, a minimally invasive (!), stab-wound incision is made and Steinman pins are placed between the facet walls. A drill guide is inserted using a spatula and the pins are removed; using the guide, a cortical reamer then bores a Morse taper-shaped canal of bleeding bone, into which the bone allograft is placed. (Minimally invasive, mind!)

The primary end points in the study were pain measured on a 100-point visual analog scale and function measured with the Oswestry Disability Index (ODI), each of which was measured at four, 12 and 52 weeks postoperatively. After complete follow-up, average pain scores decreased from 79 to 23 and functional disability, as measured by the ODI, improved from 33.46 to 8.32 (SD, 5.17).

Narcotic use also was measured before and after surgery, with morphine equivalents as high as 510 mg per day among patients. However, after 12 months, only four patients remained on opioids,

Dr. Bennett said:
“There was a big difference [in opioid use] and at the end of the day, when you look at that with the ODI data, there is a significant improvement in function,” he said.

“Pain management specialists inject facet joints all day long, so they are extremely accustomed to getting into that joint—in fact, much more accustomed than any surgeon would be,” said Dr. Guiot. “Once you are in the joint and you can access that space, that’s the toughest part of the procedure [and] the remaining portion is actually very simple.”

An additional key benefit, Dr. Guiot said, is that a minimally invasive (!) approach, which doesn’t damage or significantly alter surrounding tissue, doesn’t preclude any larger reconstruction procedures at a later date. “The most beneficial aspect is that this really doesn’t burn any bridges,” he said.

Dr. Bennett believes that the diagnostic approach used prior to minimally invasive (!) arthrodesis represents a shift toward treating pain at the source, rather than blunting nerves through ablation or opioids.

“One important thing to point out: This technique only treats the joint,” Dr. Bennett said. Arthodesis may prove more durable than RFA, but in order for it to work effectively physicians have to know precisely where the pain is originating.

“What I’m advocating based on the data is intraarticular facet injections that confirm the pain generator as the joints, not ligament or muscular structures,” he said. “Then you know what you should expect as an outcome when you fuse those painful joints.”

So stapling the joints together reduces the pain. Now this is laudable but no one should get to the point that they need their joints, which are designed to move, to be clamped together. Please get some care into those joints before you need ablating (!), opiods which I’m sure my mother warned me about or a minimally invasive (!) arthrodesis.

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Could Chiropractic prevent some cases of osteoarthritis – seems so.

Tuesday, January 5th, 2010

Rupert Clements, one of the chiros @ C1 writes about a powerful study showing a clear link between a lack of motion in the spinal joints and the development of osteoarthritis.

An interesting study was carried out by G.Cramer, J.Fournier, et al. in October last year titled:

Degenerative Changes Following Spinal Fixation in a Small Animal Model.

It was then published in the Journal of Manipulative and Physiological Therapeutics, Vol. 27 No. 3, Pgs. 141-154

The study evaluated changes in the small joints, the facet joints, of the lumbar spine after they were artificially fixed together and therefore prevented from moving.

The study used an established small animal (rat) model of spinal fixation (hypomobility) where 3 contiguous lumbar segments (L4, L5, L6) were fixed with a specially engineered vertebral fixation device. Spinal segments of control rats were compared with those of animals whose spines had been fixed for 1, 4, or 8 weeks. Subgroups of these fixation animals subsequently had the fixation device removed for 1, 2, 4, 8, or 12 weeks to evaluate the effects of attempting to re-establish normal forces to the vertebral segments following hypomobility. The joints that were fixated were examined microscopically to determine how the lack of motion affected the health of the joints. By using small animals such as mice or rats, the changes they go through in a study can be very closely observed in a way that, clearly, they can’t be in human studies.

The conclusion: These findings indicate that fixation (hypomobility) results in time-dependent degenerative changes of the Z joints (the small facet joints in the spine).

The study was a high quality study which produced some highly meaningful information.

So, what did they find? The joints that were immobilized began to break down and degenerate, while the joints that moved remained healthy. The type of breakdown that the researchers found in the fixated joints was the same as in osteoarthritis; which is the most common type of arthritis and while there are many types of arthritis, this is the type people are generally referring to when they say ‘arthritis’. They also found that the longer the joint did not move the more degenerative arthritic changes it showed. The point is that this reflects the same processes that occur in you and I and that is why it is so valuable.

So who do I pass this on to? Anyone who mentions suffering from, or wanting to avoid, arthritis. Or better yet, pass it on to the person you know who is already very health conscious, wants to stay active, and wants to learn how chiropractic care can help keep them moving and healthy!

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Posterior Facet Syndrome – what is it and can chiropractic help?

Friday, August 21st, 2009

Posterior Facet Syndrome – an injury of the joints in the back

I’ve had a hell of a day explaining to a very important lawyer why his back is hurting him. He has had a hell of a day refusing to hear what I have said and done, even though I’ve allowed him to stand upright for the first time in a few days (I suspect this is because he’s in the thrall of his denialist shrew of a wife).

However, the thrust of what I was banging on about is this:
Firstly, where are these Posterior Facet Joint things? The facet joints, or incredibly the zygapophyseal joints, are the relatively small joints on the outside of the bridge of bone that protects your spinal cord. They control the range of motion available at each level of the spine and you have them at every level. However, they do look different as you move up or down your spine, because ‘form follows function’ and they have to do different jobs in different parts of your spine- see?

Each joint, like most joints, is enclosed in a joint capsule which is a complex structure that provides feedback to the brain about the state of the joint, as well as a host of other tasks such as supplying synovial fluid to the joint space as well as some joint stability. Research has shown that in the low-back there can be a ‘meniscoid’ structure in the joint space, just like a mini version of the meniscus in the knee joint.
So that’s what the thing is like. Now what can go wrong?

Posterior Facet Syndrome (PFS). Contrary to what the physios may say this is a hugely prevalent problem and is, arguably, our bread and butter. It is a syndrome because the injury it involves far more than one structure and a whole raft of unpleasant things can go on.

In a severe, acute, PFS there may be some injury to the faces of the joint but rarely. There have also been several theories put forward about some nipping of the joint capsule or the meniscoid tissue between the two bones. However, there will certainly be some sprain/strain of the very sensitive structures of the capsule, the surrounding micro-ligaments and local muscles. Your body will rightly respond to this injury by stabilising the joint with whatever it can – in this case it will be the surrounding muscles and in the low-back these muscles are really powerful.

Your brain can stabilise your back very quickly and is why you will have seen people bending over and suddenly being unable to move or coming into work unable to move their heads. What your brain does is sacrifice these powerful muscles in favour of the PF joints and force the muscles to remain contracted for as long as required. Now, try holding a weight in your flexed arm for any length of time and you’ll see how painful this continued contraction can be. This is the same thing that is going on in your back BUT the contraction will be even stronger as it has to hold your body still and so far more painful. Also, your brain will not turn these stabilising muscles off until the problem is resolved and nor should you – so no early massage madness and NO MUSCLE RELAXANTS (aaahhhhh).

PFS will really sting. In a severe acute phase you may not be able walk and when I did mine after a rowing session I had to remain still until I was driven to stand by my bladder that was about to explode and even then I nearly passed out. The structures that hurt were the injured joint capsule; this will be the white hot sharp pain, and then the large paraspinal muscles that my body had wisely recruited in to span the joint like scaffolding which was a deeper burning pain.

As with trauma to any joint, such as spraining an ankle, there will be an inflammatory reaction with loads of swelling and pain around the joint, which may last for several days. This may also irritate the spinal nerves that pass out of the spine at this point and you may get a referred pain. Typically, this will be less defined and usually a burning pain. To check if your pain is a referred pain give the area a gently prod and if you can’t get a finger on a pain generating structure then, as a rule of thumb, it’ll be a referred pain (clear?). Please don’t call it sciatica unless you are still using terms like lumbago and ague as sciatica is a description of pain along the sciatic nerve distribution which goes far further than the hip and groin.

Typically, you’ll find back pain just to one side of the spine in the paraspinal muscles that are stabilising the joint. Side bending toward the affected side or backward bending will compress the facet joint faces together and make the pain worse – some physios find this concept a challenges as they tend to be muscle focused. The back will generally feel stiff in the morning as a post inflammatory response. Often the problem is made worse by prolonged sitting or standing in one position as the joints get compressed and start to sing.

What causes PFS?
A severe acute episode of PFS pain may be due to sudden, aberrant, movement, which traumatises the joint such as the classic lifting injury as a result of poor core stability. More commonly PFS is chronic with the underlying cause due to long term changes in the joint that are often again associated with poor core stability, wear and tear and poor posture.

What you can do?

Ice – it’s an inflammatory issue at heart so DON’T heat it up. If you listen to the stabilising muscles you will hear them shouting for heat as this is a muscle injury but the contraction is intentional and unless you have torn these in the initial injury (unlikely) you must ignore the cry. Get this wrong with an ankle joint and it can extend the time to recover by up to 5 times and I’d suggest that PFS is an ankle sprain/strain of the back joints and so the same thing will happen – so no hot baths, please.

It may be worth taking some non-steroidal anti-inflammatory (NSAIDs) with all the risks associated with these things.

“Get thee to a chiropractor” who will manipulate the joint with a controlled thrust to reduce the compression, restore correct movement and so reduce inflammation and pain.

DO NOT heat it up until much later. DO NOT wear a brace.

However, what I found on the web!
This: “In a more chronic type of Facet joint problem, the management is more difficult. The treatment outlined above will usually be attempted first, with the Chartered Physiotherapist giving symptomatic relief of the stiffness using heat packs and mobilisation techniques. However, where there is persistent pain originating from a Facet joint problem, this has to be addressed. An injection of long acting local anaesthetic and anti-inflammatory corticosteroid into the Facet joint may be effective in relieving symptoms and, if successful, it confirms the diagnosis. In order for this approach to work the injection is best done by a Consultant Radiologist under an image intensifier. This device allows the doctor to see exactly where the injection is going. This approach can give very good pain relief, but the effects may wear off after a while. It may be necessary to repeat the procedure at a later date.”
Good grief! all that radiation and then some powerful steroids when all it really needed was a dose of ice and some decent care. Try anything else first, please.

And then:
“In cases of Facet Syndrome that cause constant unremitting pain, a more lasting approach for pain relief is a procedure known as ‘Radiofrequency denervation’. Radiofrequency denervation is a technique where the nerves that supply the Facet joint are destroyed by ionizing radiation rather than surgery. This is effective for the relief of pain, but will not stop or reverse the underlying joint degeneration.”
Killing nerves! Can this really work?

The evidence from NICE and MEADE and others is that chiropractic and other manipulative therapies are the way forward. Give it a go and see what I mean.

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Can Chiropractic help with neck pain?

Wednesday, August 19th, 2009

We’ve had a recent rush of patients coming in with neck pain – something to do with added work stress, perhaps? I was irritated by how vague we are on neck pain and how difficult it was to describe in effective ‘lay’ (but not patronising) terms what the hell was going on. And this got me thinking….

How common is neck pain?
Well, you are certainly not alone – Hill and co-workers report that in the UK many as 31% of adults have had neck pain in the last month (the adult population of the UK has got to be over 50 million people so, as hey say in the US, “Go do the math”) and 48% of neck pain patients report persistent pain a year later.
- Hill J, Lewis M et al. (2004) Predicting Persistent Neck Pain. Spine 29:1648-1654

What’s going wrong?
Well, this is trickier. Liebenson, Skaggs et al. say that it is ‘difficult to pinpoint the specific pain-generating tissue’ of neck pain and even if you can the reasons why ‘are often elusive’. Now, in my experience the most common neck problem we see is ‘Posterior Facet Syndrome’, one of the mechanical neck pains, and it is caused by compression of the facet joints as a result of anterior head carriage commonly aggravated by peering into the computer for eight hours a day.

Though, try Googleing ‘Posterior Facet Syndrome’ and see what comes up as it is a hotly debated subject with some denialists saying it doesn’t exist though how can this be as I treat it daily and it responds very well.

In trying to describle what I am treating I say that PFS is similar to an ankle sprain but of the neck joints and that, like an ankle sprain, a whole raft of different tissues may be involved in the injury depending on how it was done. This seems pretty plausible to me and covers all the bases and, as long as we are treating these tissues, we should have some impact on the problem – yes?

There are some even stranger things happening out there in neck land. Up to 71% of patients who have chronic pain following whiplash have undetected vertebral end plate fractures at the spinal levels associated with the pain that were overlooked on standard medical imaging.
- Michael Freedman Dec 2001.
Not surprisingly, I suspect that this has some impact on the way things progress in a neck but, surprisingly, there may well be nothing that can be done about it and that even if the information was available it would not change the way the neck was managed anyway.

Neck pan can be split into these broad categories:

Grade 1 – neck pain with little or no interference with daily activity.
Grade 2 – limits daily activity.
Grade 3 – neck pain with accompanied radiculopathy (pinched nerve pain, weakness and/or numbness in the arm)
Grade 4 – neck pain with serious pathology – tumour, infection or systemic disease.

(Clearly, along with mechanical neck pain there are some real nasties out there; neck pain may be a symptom of meningitis and if any of the following symptoms occur, dial 999 or seek medical attention urgently:
• A rash develops that does not fade when you press it with a glass tumbler or a finger.
• You feel ill or are running a fever as well as feeling neck pain.
• It is to painful to bend the neck forward and put your chin on your chest.
• Light hurts.
• Your neck pain is accompanied by severe headache or continuous vomiting.
• Neck pain is accompanied by severe pain in the back.
And in some cases, neck pain can be a symptom of head injury or disc trouble in the neck, so. If any of the following symptoms occur, dial 999 or seek medical attention urgently:
• Neck pain is the result of a recent head injury and you are becoming drowsy, confused or are vomiting.
• Neck pain is accompanied by headache.
• If there is pain behind one eye.
• Vision, hearing, taste or balance are affected.
• Severe vomiting.
• The muscle power in your arms or legs is reduced.)
Treatment
Here’s the science bit:
Cleland et al. showed that manipulation of the thoracic spine produces immediate analgesic effects in patients with mechanical neck pain.
- Cleland JA, Childs JD et al. (2005) Immediate Effects of Thoracic Manipulation in Patients with Neck Pain: A Randomized Clinical Trail, Manipulative Therapy 10:127-135.
And Liebenson recommends manual therapy with some rehabilitation exercises. This has been supported by one of the strongest research trials in this field carried out by Bronfort, Evans et al. In this trial 191 patients were split into three treatment groups, like this:
• Spinal manipulation and low-tech exercise,
• Spinal manipulation and MedX exercise – receiving dynamic progressive resistance exercises on MedX machines,
• Spinal manipulation.
Outcomes were measured at 5 and 11 weeks and 3, 6 and 12 months after the trial. At the one year follow up the group that were receiving exercises and manipulation did significantly better than the group undergoing manipulation alone.

In a literature review published by Hurwitz, Aker et al. in Spine and Aker, Gross et al. in the British Medical Journal, so hardly slack journals I’d suggest, manipulation and mobilization were both more effective than muscle relaxants and usual medical care in providing pain relief for patients with sub-acute or chronic neck pain. In a study (2003) in Spine Giles and Muller compared acupuncture, joint manipulation and standard medication (NSAIDs). Patients in the acupuncture and medications groups had no significant improvement during the trial on any of the outcome measures and the manipulation group showed significant improvement on all measures with no patient made worse or experiencing side effects. Giles and Muller then followed up their patients a year later and reported that the manipulation group gained ‘significant broad-based beneficial…long-term outcomes’ (I like Giles and Muller).

In a great study by Haneline at Palmer College of Chiropractic, 79% of the patients improved to the point they had only minimal or minor restriction of movement and their satisfaction rates were an astounding 94% – and I suspect few trials can report the same, with 70% indicating they were very satisfied. When asked which provider helped the most 83% replied the chiropractor (this all sounds too much like a dodgy ‘election’ in North Korea for it to sit comfortably with me but….)

However, and there’s always one, here’s what the GP’s advise on http://www.patient.co.uk/:

Exercise your neck and keep active
Aim to keep your neck moving as normally as possible. At first the pain may be quite bad, and you may need to rest for a day or so. However, gently exercise the neck as soon as you are able. You should not let it ’stiffen up’. Gradually try to increase the range of the neck movements. Every few hours gently move the neck in each direction. Do this several times a day. As far as possible, continue with normal activities.
In the past, some people have worn a neck collar for long periods when a bout of neck pain developed. The problem with collars is that they prevent you from moving your neck properly. Studies have shown that you are more likely to make a quicker recovery if you do regular neck exercises, and keep your neck active rather than resting it for long periods in a collar. Also, if you keep the neck active during a bout of neck pain, it is thought to help prevent chronic (persistent) neck pain from developing.

(So good, reasonable advice so far but then…)

Medicines
Painkillers are often helpful. It is best to take painkillers regularly until the pain eases. This is better than taking them now and again just when the pain is very bad. If you take them regularly, it may prevent the pain from getting severe, and enable you to exercise and keep your neck active.
• Paracetamol at full strength is often sufficient. For an adult this is two 500 mg tablets, four times a day.
• Anti-inflammatory painkillers. Some people find that these work better than paracetamol. They include ibuprofen which you can buy at pharmacies or get on prescription. Other types such as diclofenac, naproxen, or tolfenamic need a prescription. Some people with asthma, high blood pressure, kidney failure, or heart failure may not be able to take anti-inflammatory painkillers.
• A stronger painkiller such as codeine is an option if anti-inflammatories do not suit or do not work well. Codeine is often taken in addition to paracetamol. Constipation is a common side-effect from codeine. To prevent constipation, have lots to drink and eat foods with plenty of fibre.
• A muscle relaxant such as diazepam is sometimes prescribed for a few days if your neck muscles become tense and make the pain worse.
(Awww, and they were doing so well. The problem in your neck has nothing to do with a lack of pain-killer in your blood so don’t do it. The evidence doesn’t support it so why advise it unless there is some other reason and I am not going to suggest that we are a drug reliant NHS, oh no. I will suggest that the muscle tightness has a purpose and is not a trick that your neck is doing just to irritate you, perhaps; just perhaps, your brain wants to immobilize the injured joints, just like an ankle sprain then, and is using the muscles surrounding the joint to do this. So why would you want to take a muscle relaxant to stop this happening, why would you want to over ride your clearly stupid brain and let your neck move freely during an acute phase?)
Other advice
Some other advice which is commonly given includes:
• A good posture may help. Brace your shoulders slightly backwards, and walk ‘like a model’. Try not to stoop when you sit at a desk. Sit upright.
• A firm supporting pillow seems to help some people when sleeping.
• Physiotherapy. It is not clear whether this makes much difference to the outcome of mechanical neck pain. Therapies such as traction, heat, cold, manipulation, etc, may be tried, but the evidence that these help is not strong. However, what is often helpful is the advice a physiotherapist can give on neck exercises to do at home. A common situation is for a doctor to advise on painkillers and gentle neck exercises. If symptoms do not begin to settle over a week or so, you may then be referred to a physiotherapist to help with pain relief and for advice on specific neck exercises.
So, manipulation gets one word. Yet the recent report from the Bone and Joint Decade 2000 – 2010 Task Force on Neck Pain and Its Associated Disorders (made up by a staggering 50 researchers in 9 countries comprising of 14 different clinical disciplines and looking at over 31,000 research criterion and over 1000 met relevant criteria.) recommended that neck manipulation, acupuncture and massage are better choices for managing most common neck pain. It also recommended exercises, education and neck mobilization but to be less effective than adjustment.

I know which one I’d chose.

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Frozen shoulder – who can help

Monday, July 13th, 2009

Frozen shoulder – what’s that all about?

We’ve seen a few of these lately at C1 Chiropractic Health Centre and we’ve come to see that a whole lot of madness is spouted on about them. Most irritatingly the term is wildly misused and so any painful shoulder with any loss of movement is labelled as a ‘frozen shoulder’. So, let’s start by calling it what it really is: adhesive capsulitis.

What is adhesive capsulitis?
‘Frozen shoulder’ is nearly a slang term – not as bad lumbago but getting close, and refers to loss of arm movement in the shoulder joint with inflammation of the connective tissue of the joint capsule surrounding the shoulder joint. These connective tissues protect the joint, they stabilize the joint and they control a large part of the range of motion of the joint. In an adhesive capsulitis they become inflamed, thickened, shortened and eventually bind together, hence the medical term – adhesive capsulitis which sort of says what it is on the tin.
It affects about two percent of the general adult population. It is most likely to occur in people between the ages of 40 and 60. At present I don’t think that there is any data to suggest that any gender, occupation, or arm domination is more predominant in those who suffer from it. However, diabetic individuals do have an increased risk of developing frozen shoulder. The key point here is the missing bit – the why does it occur and I think this is the strange and interesting part of the problem. We (and I don’t just mean us at the clinic) have no real idea what causes it.

What does it feel like?
Adhesive capsulitis often starts after some minor trauma, dislocation, prolonged immobilisation, heart attack (myocardial infarction) or neck problems (cervical radiculitis). It kicks off with a progressive limitation of shoulder motion which may or may not be painful. However, if you try to push the limited range of motion boundary you will feel pain. This stage is sometimes called the ‘freezing’ stage. The condition then progresses until all movement is reduced, or to the ‘frozen’ stage. Surprisingly, at this point it is common to have no pain. However, this all reversed during the recovery phase and it gets painful again but this will abate when movement is finally restored. This recovery period varies depending on how long the problem has been there and the severity of it.

What can we do to help?
Chiropractic is an effective treatment option for frozen shoulder because it focuses, not on the symptoms, but on the root of the problem. I have yet to meet a patient with AC who has not got some significant neck problems and this may well signpost the way to the elusive underlying cause. However, the most crucial way that chiropractic helps frozen shoulder is in prevention
If it has started then early diagnosis is vital because the condition can be reversed. AC needs more than just chiropractic and we use a mix of chiropractic and sports injury therapy at the clinic and this treatment is very effective.
One thing that seems to work really well with AC patients is having them lie on their back with bad arm in external rotation holding a weight with a hot pack on the shoulder for about 15 minutes. They all seem to get the range of motion back faster with this added to the treatment plan.

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