-
Pain Physician May 2024Cervical manipulations are widely used by physiotherapists, chiropractors, osteopaths, and medical doctors for musculoskeletal dysfunctions like neck pain and... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Cervical manipulations are widely used by physiotherapists, chiropractors, osteopaths, and medical doctors for musculoskeletal dysfunctions like neck pain and cervicogenic headache. The use of cervical manipulation remains controversial, since it is often considered to pose a risk for not only benign adverse events (AEs), such as aggravation of pain or muscle soreness, but also severe AEs such as strokes in the vertebrobasilar or carotid artery following dissections. Studies finding an association between cervical manipulation and serious AEs such as artery dissections are mainly case control studies or case reports. These study designs are not appropriate for investigating incidences and therefore do not imply causal relationships. Randomized controlled trials (RCTs) are considered the gold standard study designs for assessing the unconfounded effects of benefits and harms, such as AEs, associated with therapies.
OBJECTIVE
Due to the unclear risk level of AEs associated with high-velocity, low-amplitude (HVLA) cervical manipulation, the aim of this study was to extract available information from RCTs and thereby synthesize the comparative risk of AEs following cervical manipulation to that of various control interventions.
STUDY DESIGN
Systematic review and meta-analysis.
METHODS
A systematic literature search was conducted in the PubMed and Cochrane databases. This search included RCTs in which cervical HVLA manipulations were applied and AEs were reported. Two independent reviewers performed the study selection, the methodological quality assessment, and the GRADE approach. Incidence rate ratios (IRR) were calculated. The study quality was assessed by using the risk of bias 2 (RoB-2) tool, and the certainty of evidence was determined by using the GRADE approach.
RESULTS
Fourteen articles were included in the systematic review and meta-analysis. The pooled IRR indicates no statistically significant differences between the manipulation and control groups. All the reported AEs were classified as mild, and none of the AEs reported were serious or moderate.
LIMITATIONS
The search strategy was limited to literature in English or German. Furthermore, selection bias may have occurred, since only PubMed and Cochrane were used as databases, and searching was done by hand. RCTs had to be excluded if the results did not indicate the group in which the AEs occurred. A mandatory criterion for inclusion in the meta-analysis was a quantitative reproduction of the frequencies of AEs that could be attributed to specific interventions.
CONCLUSION
In summary, HVLA manipulation does not impose an increased risk of mild or moderate AEs compared to various control interventions. However, these results must be interpreted with caution, since RCTs are not appropriate for detecting the rare serious AEs. In addition, future RCTs should follow a standardized protocol for reporting AEs in clinical trials.
Topics: Humans; Cervical Vertebrae; Manipulation, Spinal; Neck Pain; Randomized Controlled Trials as Topic
PubMed: 38805524
DOI: No ID Found -
BMJ Neurology Open 2024Bronchial artery embolization (BAE) is the established first-line treatment for patients presenting with massive haemoptysis, a life-threatening condition that can occur...
BACKGROUND
Bronchial artery embolization (BAE) is the established first-line treatment for patients presenting with massive haemoptysis, a life-threatening condition that can occur because of numerous underlying diseases. BAE is a relatively safe procedure with control of haemorrhage achieved in 77%-90% of cases and rare occurrence of complications. Spinal cord infarction is one such rare complication, which can have severe implications in terms of morbidity.
CASE PRESENTATIONS
We present a case of a 70-year-old man who developed paraplegia with loss of pain and temperature sensation as well as sphincteric involvement following BAE for hemoptysis. MRI of the spine was suggestive of an ischaemic event involving anterolateral spinal cord segment T4-T6, so a diagnosis of anterior spinal artery syndrome post BAE was made. The patient was given corticosteroids, dual antiplatelet medications, pregabalin, supportive management and regular physiotherapy. Follow-up of the patient at 3 and 6 months failed to show any significant improvement in neurological function, although the patient did not report problem of significant hemoptysis afterward.
CONCLUSION
Spinal cord infarct is a rare and disabling complication of BAE despite it being a safe procedure with good long-term outcomes. Detailed knowledge about the anatomy of bronchial arteries and spinal arteries with detailed preprocedure investigations may lower the risk of this disabling complication.
PubMed: 38800071
DOI: 10.1136/bmjno-2024-000684 -
Plastic and Reconstructive Surgery.... May 2024Acute cervical osteomyelitis due to an epidural abscess and pyogenic spondylodiscitis in an immunosuppressed patient with progressive myelopathy is a challenge for the...
Acute cervical osteomyelitis due to an epidural abscess and pyogenic spondylodiscitis in an immunosuppressed patient with progressive myelopathy is a challenge for the reconstructive surgeon. This report presents our novel approach to treat such a condition in a 56-year-old patient in whom antibiotic treatment and decompression of the medulla by laminectomy of C4-C6 failed. Under general anesthesia, debridement of all infected tissue, including anterior corpectomy of C4-C6, was performed. Simultaneously, a free vascularized fibula graft (FVFG) was harvested, adapted to the bone defect, and anastomosed to the superior thyroid artery and external jugular vein. The graft was stabilized with an anterior plate. A scheduled posterior stabilization was performed 1 week later. was cultured from bone samples and was treated with antibiotics. The postoperative course was uncomplicated besides a dorsal midline defect 6 weeks postoperatively that was closed with a sensate midline-based perforator flap. Five years on, the patient is infection free, and regular control computed tomography and magnetic resonance imaging scan images show progressive fusion and hypertrophy of the fibula to C3/C7 vertebrae. An FVFG combined with posterior stabilization could be a promising primary salvage procedure in cases with progressive myelopathy caused by acute cervical osteomyelitis due to spinal infection. The FVFG contributes to blood circulation, delivery of antibiotics, and an immunological response to the infected wound bed and can stimulate rapid fusion and hypertrophy over time.
PubMed: 38798940
DOI: 10.1097/GOX.0000000000005837 -
Global Spine Journal May 2024Randomized Control Trial.
STUDY DESIGN
Randomized Control Trial.
OBJECTIVE
DCM refers to compression of spinal cord either due to static/dynamic causes or commonly, a result of combination of both. Number of variables exist, which determine prognosis post-surgery. Role of intra-operative blood pressure has not been analyzed in depth in current literature. Elevating MAP post SCI is widely practiced and forms a recommendation of AANS/CNS Joint Committee Guidelines. This led us to investigate role played by elevated MAP during surgery for DCM, in order to optimize outcomes.
METHODS
This prospective randomized comparative pilot study was conducted at a tertiary care spine centre. 84 patients were randomly divided in two groups. Group 1 had intra-operative MAP in normal range. Group 2, had intra-operative BP 20 mmHg higher than preoperative average MAP with a variation of + 5 mmHg. Outcomes were recorded at 3 months, 6 months and 1 year by mJOA, VAS and ASIA scale.
RESULTS
Neurological improvement was documented in 19/30 (63.3%) patients of hypertensive group compared to 16/30 (53.3%) patients of normotensive group. Improvements in mJOA scores were better for hypertensive group during the 1-year follow-up. Improvement in VAS scores were comparable between two groups, but at 1-year follow-up the VAS score of hypertensive groups was significantly lower.
CONCLUSION
MAP should be individualized according to preoperative average blood pressure assessment of patient. Keeping intraoperative MAP at higher level (preoperative MAP + 20 mmHg) during surgery for DCM can result in better outcomes.
PubMed: 38798232
DOI: 10.1177/21925682241256350 -
NeuroImage May 2024Perivascular cerebrospinal fluid (pCSF) flow is a key component of the glymphatic system. Arterial pulsation has been proposed as the main driving force of pCSF influx...
Perivascular cerebrospinal fluid (pCSF) flow is a key component of the glymphatic system. Arterial pulsation has been proposed as the main driving force of pCSF influx along the superficial and penetrating arteries; however, evidence of this mechanism in humans is limited. We proposed an experimental framework of dynamic diffusion tensor imaging with low b-values and ultra-long echo time (dynDTI) to capture pCSF flow properties during the cardiac cycle in human brains. Healthy adult volunteers (aged 17-28 years; seven men, one woman) underwent dynDTI using a clinical 3T scanner (MAGNETOM Prisma, Siemens Healthcare, Erlangen, Germany) with simultaneously recorded cardiac output. The results showed that diffusion tensors reconstructed from pCSF were mainly oriented in the direction of the neighboring arterial flow. When switching from vasoconstriction to vasodilation, the axial and radial diffusivities of the pCSF increased by 5.7% and 4.94%, respectively, suggesting that arterial pulsation alters the pCSF flow both parallel and perpendicular to the arterial wall. DynDTI signal intensity at b=0 s/mm (i.e., T2-weighted, [S(b=0 s/mm)]) decreased in systole, but this change was ∼7.5% of a cardiac cycle slower than the changes in apparent diffusivity, suggesting that changes in S(b=0 s/mm) and apparent diffusivity arise from distinct physiological processes and potential biomarkers associated with perivascular space volume and pCSF flow, respectively. Additionally, the mean diffusivities of white matter showed cardiac-cycle dependencies similar to pCSF, although a delay relative to the peak time of S(b=0 s/mm) was present, suggesting that dynDTI could potentially reveal the dynamics of magnetic resonance imaging-invisible pCSF surrounding small arteries and arterioles in white matter; this delay may result from pulse wave propagation along penetrating arteries. In conclusion, the vasodilation-induced increases in axial and radial diffusivities of pCSF and mean diffusivities of white matter are consistent with the notion that arterial pulsation can accelerate pCSF flow in human brain. Furthermore, the proposed dynDTI technique can capture various pCSF dynamics in artery pulsation.
PubMed: 38795798
DOI: 10.1016/j.neuroimage.2024.120653 -
Journal of Clinical Medicine May 2024The impact of the tourniquet on cardiac efficiency remains unknown. This study aimed to assess the impact of the tourniquet on cardiac cycle efficiency (CCE) and to...
The impact of the tourniquet on cardiac efficiency remains unknown. This study aimed to assess the impact of the tourniquet on cardiac cycle efficiency (CCE) and to interpret how general anesthesia (GA) or combined spinal epidural anesthesia (CSEA) affects this during surgery using cardiac energy parameters. This prospective observational study included 43 patients undergoing elective unilateral total knee arthroplasty (TKA) with a tourniquet divided into GA ( = 22) and CSEA ( = 21) groups. Cardiac energy parameters were measured before anesthesia (T1), pre-tourniquet inflation (T2), during inflation (T3-T8), and post-deflation (T9). The estimated power of the study was 0.99 based on the differences and standard deviations in CCE at T2-T3 for all patients (effect size: 0.88, alpha error: 0.05). CCE decreased significantly more at T3 in the GA group than in the CSEA group, whereas dP/dt and Ea increased more ( < 0.05, < 0.001, and < 0.01, respectively). At T9, CCE increased significantly in the GA group, whereas dP/dt and Ea decreased ( < 0.05, < 0.001, and < 0.001, respectively). The tourniquet reduces cardiac efficiency through compensatory responses, and CSEA may mitigate this effect.
PubMed: 38792287
DOI: 10.3390/jcm13102745 -
Plastic and Reconstructive Surgery.... May 2024A 13-year-old girl with a painful left neck mass was referred to our institution due to suspicions of malignancy. The patient reported pain that accompanied her frequent...
A 13-year-old girl with a painful left neck mass was referred to our institution due to suspicions of malignancy. The patient reported pain that accompanied her frequent neck spasms. Computed tomography revealed a large, soft-tissue mass in the left neck, deep to the sternocleidomastoid. The lesion anteriorly displaced the internal carotid artery and both displaced and crushed the internal left jugular vein. Uniquely, a three-dimensional virtual reality model combining magnetic resonance imaging and computed tomography data was used to determine the lesion's resectability and visualize which structures would be encountered or require protection while ensuring total resection. During operation, we confirmed that the mass also laterally displaced the brachial plexus, cranial nerves X and XI, and spinal nerves C3-C5 (including the phrenic) of the cervical plexus. Postsurgical pathological analysis confirmed a diagnosis of desmoid tumor, also known as aggressive fibromatosis, whereas DNA sequencing revealed a mutation, a somatic genetic marker found in approximately 90% of desmoid tumor cases. When possible, the most widely used method for the treatment of desmoid tumors has been gross resection. Chemotherapy, radiotherapy, and local excision are also used in the treatment of fibromatoses when complete resection is judged infeasible. In this case, a complete surgical resection with tumor-free surgical margins was performed. A standard cervical approach with a modified posterolateral incision site was implemented to avoid a conspicuous anterior neck scar. No flap, nerve repair, or reconstruction was warranted. At 1 year of postsurgical follow-up, the patient showed minimal scarring and no signs of recurrence.
PubMed: 38784831
DOI: 10.1097/GOX.0000000000005763 -
Journal of Physiological Investigation Jan 2024Spinal cord injury is associated with spinal vascular disruptions that result in spinal ischemia and tissue hypoxia. This study evaluated the therapeutic efficacy of...
Spinal cord injury is associated with spinal vascular disruptions that result in spinal ischemia and tissue hypoxia. This study evaluated the therapeutic efficacy of normobaric hyperoxia on spinal cord oxygenation and circulatory function at the acute stage of cervical spinal cord injury. Adult male Sprague Dawley rats underwent dorsal cervical laminectomy or cervical spinal cord contusion. At 1-2 days after spinal surgery, spinal cord oxygenation was monitored in anesthetized and spontaneously breathing rats through optical recording of oxygen sensor foils placed on the cervical spinal cord and pulse oximetry. The arterial blood pressure, heart rate, blood gases, and peripheral oxyhemoglobin saturation were also measured under hyperoxic (50% O2) and normoxic (21% O2) conditions. The results showed that contused animals had significantly lower spinal cord oxygenation levels than uninjured animals during normoxia. Peripheral oxyhemoglobin saturation, arterial oxygen partial pressure, and mean arterial blood pressure are significantly reduced following cervical spinal cord contusion. Notably, spinal oxygenation of contused rats could be improved to a level comparable to uninjured animals under hyperoxia. Furthermore, acute hyperoxia elevated blood pressure, arterial oxygen partial pressure, and peripheral oxyhemoglobin saturation. These results suggest that normobaric hyperoxia can significantly improve spinal cord oxygenation and circulatory function in the acute phase after cervical spinal cord injury. We propose that adjuvant normobaric hyperoxia combined with other hemodynamic optimization strategies may prevent secondary damage after spinal cord injury and improve functional recovery.
Topics: Animals; Spinal Cord Injuries; Rats, Sprague-Dawley; Male; Hyperoxia; Rats; Oxygen; Spinal Cord; Cervical Cord; Blood Pressure; Oxyhemoglobins; Heart Rate
PubMed: 38780270
DOI: 10.4103/EJPI.EJPI-D-23-00003 -
Revista Da Associacao Medica Brasileira... 2024Diabetes mellitus, per se, is a global health concern, which is often accompanied by complications such as diabetic neuropathy. This prospective observational study... (Observational Study)
Observational Study
OBJECTIVE
Diabetes mellitus, per se, is a global health concern, which is often accompanied by complications such as diabetic neuropathy. This prospective observational study purposed to assess the durations of spinal sensory block and motor blocks in individuals with and without diabetes mellitus who had undergone spinal anesthesia.
METHODS
This study incorporated 80 cases, which were evenly divided into spinal sensory block without diabetes mellitus and spinal sensory block with diabetes mellitus. Various parameters were recorded at different time points, including heart rate, mean arterial blood pressure, SpO2, and spinal block characteristics. Notable measures included maximum spinal sensory block onset time, time to reach the 10th thoracic vertebra (T10), maximal spinal sensory block, time for Bromage scores, and block regression while controlling for age-related variations.
RESULTS
Patients in the diabetic group exhibited extended block durations, with significant differences in heart rate noted at specific time points. Regarding the spinal block characteristics, the "maximum onset of SSB" and the "time to reach the T10" were more prolonged in the SSBwDM without significance. Maximum sensory spinal sensory block did not differ. However, some cases in the SSBwDM displayed blocks extending up to the T6. The times to achieve Bromage motor block scores 1-3 were shorter in SSBwDM and lost significance regarding age. Notably, the regression time was longer in SSBwDM, which held significance for both parameters.
CONCLUSION
Diabetic cases commonly encounter prolonged block durations post-subarachnoid intervention, potentially linked to nerve sensitivity, age-related changes, and glycemic control. As such, attenuated local doses for diabetic neuropathic cases may enhance early mobilization, attenuate thromboembolic events, and expedite gastrointestinal recovery.
Topics: Humans; Prospective Studies; Male; Female; Middle Aged; Time Factors; Aged; Adult; Anesthesia, Spinal; Diabetic Neuropathies; Heart Rate; Diabetes Mellitus
PubMed: 38775536
DOI: 10.1590/1806-9282.20231727 -
Journal of Neurosurgery. Case Lessons May 2024Resection remains the optimal treatment for hemangioblastomas, highly vascular tumors commonly located in the cerebellum or spinal cord. Preoperative embolization can be...
BACKGROUND
Resection remains the optimal treatment for hemangioblastomas, highly vascular tumors commonly located in the cerebellum or spinal cord. Preoperative embolization can be used with caution to reduce intraoperative blood loss and promote gross-total resection while reducing neurological morbidity.
OBSERVATIONS
The authors report a case of a 44-year-old male who presented with worsening dizziness, gait imbalance, and diplopia. Imaging revealed a large vascular cerebellar mass with brainstem compression and hydrocephalus, concerning for hemangioblastoma. The patient underwent preoperative embolization of the main arterial supply from the right superior cerebellar artery, which devascularized the tumor and reduced the early venous shunting, followed by gross-total resection of the tumor. Preoperative embolization helped to facilitate safe microsurgical resection because this main arterial supply was deep to the planned surgical approach, and the Onyx cast served as a landmark of the dorsal midbrain and remaining arterial supply. This resulted in minimal intraoperative blood loss. At 2-year follow-up, the patient's diplopia and vertigo had resolved, and his gait continues to improve.
LESSONS
Despite controversy regarding the use of preoperative embolization for hemangioblastoma resection, the authors emphasize its safety and utility during resection of a large cerebellar hemangioblastoma. Onyx embolization provided benefit in both reducing the tumor blood supply and serving as intraoperative visual guidance.
PubMed: 38768516
DOI: 10.3171/CASE24100