From: Sigmund Miller, DC Dean of Academic Affairs Texas Chiropractic College 281.998.6058 http://www.ChiroViewPresents.com Microsurgical Approach to Arm and Neck Pain May 2, 2000 - Spine / MedscapeWire For the 500,000 Americans suffering from arm and neck pain caused by a herniated disc or bone spur in the neck, an improved microsurgical technique developed by University of California, Los Angeles (UCLA), neurosurgeons may bring them the relief they seek. The new procedure avoids fusion surgery in the neck, reduces recovery time, and enables patients to return to their normal routine often within a week after surgery. The new surgical technique, called anterior cervical foraminotomy (ACF), was developed at UCLA to improve the treatment of cervical radiculopathy ã nerve problems in the arm and neck as a result of nerve compression in the neck due to herniated discs or bone spurs. Patients afflicted with this problem experience symptoms such as pain, numbness, limb immobility, a "pins and needles" sensation, a burning sensation, or a swollen feeling in the affected limb. The new procedure has an advantage over the current method of treatment ã a complete disc removal procedure ã because ACF preserves the disc within the vertebrae, thus retaining the normal mechanical function of the spinal column. The new technique is reported in the April issue of the journal Spine. In the study, UCLA neurosurgeons treated 21 patients who ranged in age from 27 to 58 years old over a 3-year period . Of the patients treated, 91% had improved or resolved radicular symptoms after follow-up visits ranging from 6 to 36 months. UCLA surgeons stress that ultra long-term follow-up outcomes are important in any study of this type. "Cervical radiculopathy is as common as low back problems," said J. Patrick Johnson, MD, lead author of the study and codirector of the UCLA Comprehensive Spine Center and associate professor of neurosurgery. "With this new procedure, we've essentially taken an operation that was devised in the '60s and revamped it with 21st century technology. It's now like taking a pebble out of your shoe to relieve the pain." In the standard cervical fusion method of treatment, surgeons remove the disc causing the arm or neck pain and replace it with bone from the patient's hip or treated bone from a cadaver obtained from a bone bank. Then the 2 vertebrae on either side are fused together with the inserted bone sandwiched in between. This surgery changes the mechanics of the patient's spine and puts more stress on areas next to the fused vertebrae. The UCLA neurosurgeons say that by removing only the herniated portion of the disc, they can preserve normal disc function and avoid bone fusion. They add that the recovery period for patients is half of the current discectomy procedures and patients can often return to full activity within 2 weeks of surgery. With the standard discectomy, a patient's total recovery time is usually between 4 to 8 weeks. "The outcomes appear to offer excellent results," said Johnson. "Patients maintain range of motion in the neck and definitely get the sought-after relief from their arm and neck pain. They also don't need to wear a neck collar since spinal stability is not affected by the surgery. Additionally, patients require less pain medication since there is very little incisional pain." Using delicate microsurgical instruments and techniques, surgeons can perform ACF quickly and easily, usually as an outpatient procedure, with the actual surgery lasting about 1 to 1.5 hours. The surgical approach exposes the lateral aspect of the spinal column through a small incision at the front of the neck in a naturally occurring crease. This exposes the affected nerve root, allows for removal of a herniated disc or bone spur, and decompresses the entire segment of the nerve. Ideal candidates for ACF are usually patients 30 to 60 years old with arm pain primarily related to nerve compression from a herniated disc or bone spur. #2 Management of ACL Injuries Variable in Canada Westport - May 2, 2000 (Reuters Health) There is "wide variation" in the approaches that orthopedic surgeons take to managing anterior cruciate ligament (ACL) injuries in Canada, according to the results of a new study. Dr. Annunziato Amendola, of the University of Western Ontario, London, Ontario, Canada, and a multicenter team surveyed 234 orthopedic surgeons in Canada regarding their approaches to the management of ACL injuries. The 72% of physicians who responded provided their diagnostic and treatment recommendations for a series of hypothetical scenarios. "The majority of respondents diagnose the ACL injury by means of clinical examination, wait until the acute inflammatory phase has settled before performing surgery, and prefer conservative treatment initially in less-active individuals," the investigators report in the April issue of the Clinical Journal of Sport Medicine. "On the other hand, several significant discrepancies in some basic diagnostic and treatment issues were identified." Specifically, 24% of orthopedic surgeons said that they routinely use arthroscopy in the diagnosis of ACL injuries, "despite a clear clinical presentation." And approximately one-half of physicians reported incorporating the ACL stump in reconstructions, even though there is little evidence to support this approach. There was substantial variability between surgeons in the treatment of young patients, between the ages of 8 and 14 years, the authors say. "The majority of respondents would not recommend ACL reconstruction in the skeletally immature patient, even if bracing had failed," Dr. Amendola and colleagues write. Yet "studies have shown that intraarticular ACL reconstruction does not adversely affect growth, and that results of nonsurgical treatment in this group of patients are unacceptable in terms of return to reinjury activity level and secondary meniscal tears." Physicians also varied in their approach to surgery in athletes with an acute ACL tear, with 59% using a bone-patellar tendon-bone autograft and 32% using a hamstring tendon autograft. In athletes with chronic ACL injury, 63% of surgeons recommended using a bone-patellar tendon-bone autograft and 27% recommended a hamstring tendon autograft. Clin J Sport Med 2000;10:85-88 #3 Is There a Role for Premanipulative Testing Before Cervical Manipulation? Background: Spinal manipulative therapy is used millions of times every year to relieve symptoms from biomechanic dysfunction of the cervical spine. Concern about cerebrovascular accidents after cervical manipulative therapy is common but rarely reported. Permanipulative tests of the vertebral artery are presumed to identify patients at risk but controversy exists about their usefulness. Objective: The aim of this study was to examine vertebral artery blood flow in patients with a positive premanipulative test for contraindication to spinal manipulative therapy and to investigate ifchiropractors [sic] would reconsider treating such patients if dynamic vascular Doppler examination was normal. Design and setting: A prospective study at a university hospital vascular laboratory. Methods: Chiropractors in private practice from 3 Danish counties referred patients with a positive premanipulative test for an examination of vertebral artery blood flow. Premanipulative testing was performed by an experienced chiropracton [sic] Flow velocities were measured in both vertebral arteries by color duplex sonography. In addition, chiropractors were asked if they would treat their patient despite a positive premanipulative test if the vascular ultrasound examination was normal. Results: A total of 20 consecutive patients with a positive premanipulative test were referred. Five were excluded because symptoms could not be reproduced during the vascular examination. In the remaining patients, no significant difference in peak flow velocity or time-averaged mean flow velocity with different head positions was found. Nineteen of 21 chiropractors would treat a patient with a positive premanipulative test if the vascular examination was normal. Eight of the patients with a positive manipulative test were treated without complications. Six are now symptom-free, and 2 have improved symptoms. The remaining 8 patients refused manipulation and continue to have the same symptoms. Conclusion: It appears that a positive premanipulative test is not an absolute contraindication to manipulation of the cervical spine. If the test is able to identify patients at risk for cerebrovascular accidents, we suggest patients with a reproducible positive test should be referred for a duplex examination of the vertebral artery flow. If duplex flow is normal, the patient should be eligible for cervical manipulation despite the positive premanipulative test. Licht PB, et al. Journal of Manipulative and Physiological Therapeutics. March/April 2000; Vol. 23, No. 3, pp. 175-179. #4 A Review of Psychological Risk Factors in Back and Neck Pain... Study Design. The literature on psychological factors in neck and back pain was systematically searched and reviewed. Objectives. To summarize current knowledge concerning the role of psychological variables in the etiology and development of neck and back pain. Summary of Background Data. Recent conceptions of spinal pain, especially chronic back pain, have highlighted the role of psychological factors. Numerous studies subsequently have examined the effects of various psychological factors in neck and back pain. There is a need to review this material to ascertain what conclusions may be drawn. Methods. Medical and psychological databases and cross-referencing were used to locate 913 potentially relevant articles. A table of 37 studies was constructed, consisting only of studies with prospective designs to ensure quality. Each study was reviewed for the population studied, the psychological predictor variables, and the outcome. Results. The available literature indicated a clear link between psychological variables and neck and back pain. The prospective studies indicated that psychological variables were related to the onset of pain, and to acute, subacute, and chronic pain. Stress, distress, or anxiety as well as mood and emotions, cognitive functioning, and pain behavior all were found to be significant factors. Personality factors produced mixed results. Although the level of evidence was low, abuse also was found to be a potentially significant factor. Conclusions. Psychological factors play a significant role not only in chronic pain, but also in the etiology of acute pain, particularly in the transition to chronic problems. Specific types of psychological variables emerge and may be important in distinct developmental time frames, also implying that assessment and intervention need to reflect these variables. Still, psychological factors account for only a portion of the variance, thereby highlighting the multidimensional view. Because the methodologic quality of the studies varied considerably, future research should focus on improving quality and addressing new questions such as the mechanisms, the developmental time factor, and the relevance that these risk factors have for intervention. Linton SJ. Spine. May 2000; Vol. 25, No. 9, pp. 1148-1156. #5 Neutral Wrist Splinting Improves Carpal Tunnel Syndrome... Westport - April 28,2000 (Reuters Health) Neutral wrist splinting improves the symptoms of carpal tunnel syndrome (CTS), researchers report in the April issue of the Archives of Physical Medicine and Rehabilitation. And physiologic improvement appears to be greater when the splints are worn full- time. Although previous studies have uniformly documented the symptomatic benefit of wrist splints for CTS, "this study represents the first randomized control trial to analyze different splint wear instructions," explain Dr. William C. Walker and colleagues from Virginia Commonwealth University, in Richmond. To quantify the efficacy of splint wearing, Dr. Walker group conducted a clinical trial of 17 CTS patients (24 hands), aged 44 to 81 years, who were randomly assigned to full-time or night-only wear instructions for a 6-week study period. Patients in both groups improved in sensory distal latency, symptom severity and functional deficits. In addition, the subjects "receiving full-time wear instructions showed superior distal latency improvement, both motor...and sensory...when compared with subjects receiving night-only wear instructions." Splinting also appeared to be as effective in patients with severe CTS as it was in those with mild-to-moderate CTS. Incomplete compliance with wearing instructions was frequently seen, Dr. Walker's group adds. For example, complete compliance with splint-wearing instructions was reported for only 46% of the affected hands. The researchers therefore recommend "patient education on the benefits of splinting and family support." These findings "are important clinically in that there is no standard recommendation for splint wear frequency and no prior research to guide recommendations," Dr. Walker said in an interview with Reuters Health. "We now have evidence that patients should be encouraged to wear the splint as much as possible, day and night." Arch Phys Med Rehabil 2000;81:424-429. #6 WASHINGTON (Reuters Health) In an effort to reduce the growing numbers of drug-resistant bacteria, officials at the Centers for Disease Control and Prevention (CDC) are urging physicians to stop prescribing antibiotics where the drugs are not necessary. Director of Antimicrobial Resistance for the CDC, Dr. Richard Besser, told an audience of physicians attending a medical conference that each year US physicians write $50 million worth of prescriptions that are ineffectual and unnecessary. A common reason for unnecessary prescriptions is patient demand for treatment. "We are facing a crisis because doctors are pressured to prescribe antibiotics for the common cold and inner ear infection, yet we know that it is not prudent to do so," Besser said. "We must collectively inform our patients about the reasons why overprescribing antibiotics will not help patients return to work sooner, and that in the long run, could make them more susceptible to drug-resistant diseases." Besser said that three fourths of all outpatients' antibiotics in the US have been prescribed for infections such as otitis media (ear infections), sinusitis, bronchitis, pharyngitis, or non-specific upper respiratory tract infection. Besser presented research showing that if unnecessary antibiotic use is curtailed, drug resistance will diminish. In Japan, for example, 62% of group A streptococcal isolates were resistant to erythromycin in 1974. However, use of the antibiotic was scaled back, and in 1988, less than 2% of group A streptococcal isolates were resistant to erythromycin. Senator Edward Kennedy, who spoke during the conference, said he and Senator Bill Frist will introduce legislation to Congress to address the "growing problems of antimicrobial resistance and its threat to public health." "One of the most urgent priorities to halt the spread of drug- resistant pathogens is to improve the capacity of state and local public health agencies to monitor and combat infectious disease," Kennedy said. "We must also educate medical professionals and the public alike to reduce unnecessary prescriptions, and halt the improper dissemination of antimicrobial drugs."