Manipulations cervicales et principe de précaution

Cervical spine manipulation and the precautionary principle. Cervical manipulations can cause severe neurological complications, which are both exceedingly rare and generally unpredictable. To meet the requirements of the principles of prevention and precaution, we believe the number of cervical manipulations should be reduced. To this end, we suggest that five recommendations developed by consensus be followed: unwanted effects, however minor, of previous manipulation should be looked for routinely and taken as absolute contraindications to further manipulation; a thorough physical examination, including a neurological evaluation, should be performed prior to manipulation; all known contraindications and indications should be followed; manipulation should be performed only by physicians experienced in this technique; and special caution should be exercised when performing first-line cervical manipulation.     

Spinal Instrumentation With A Low Complication Rate

Background

Spinal instrumentation has become an increasing part of the armamentarium of neurosurgery and neurosurgical training. For noncontroversial indications for spine fusion the arthrodesis rate seems to be better. For both noncontroversial and controversial indications, the reported complication rate with spinal instrumentation tends to be greater than that with noninstrumented spine surgeries. These reported complications include a 2–3% neurologic injury rate, 3–45% reoperation rate for implant failure, and infection rates of 5–10%. Therefore, we report on 299 cases that have undergone spinal instrumentation placed exclusively by neurosurgeons with a very low complication rate.

Methods

Two hundred ninety-nine consecutive spinal instrumentation cases performed exclusively by neurosurgeons at Indiana University Medical Center were analyzed for complications related to spinal instrumentation. The spinal instrumentation placed consisted of 195 anterior cervical locking plates, 22 cases of posterior cervical instrumentation, 9 cases of combined anterior locking plates with posterior cervical instrumentation, 14 anterior thoraco-lumbar plates, 51 posterior thoraco-lumbar instrumentation cases, and 8 combined anterior/posterior thoraco-lumbar instrumentation cases.

Results

The mean follow-up is 40 months (6–95). There was one perioperative death unrelated to the spinal instrumentation. There were no neurologic injuries and there has been no hardware infection to date. There were two dural tears, three superficial wound infections, and three minor wound breakdowns successfully treated. Hardware complications included three cervical plate/screw extrusions reoperated, one cervical plate fracture reoperated, one posterior cervical screw backout not reoperated, one case of broken pedicle screws not reoperated, one vertebral body failure not reoperated, and one posterior rod case reoperated for excessive rod length and protrusion. The overall complication rate attributable to placement of spinal instrumentation was 10/299 (3%) with a reoperation rate of 2%. The arthrodesis rate was 298/299 (99%).

Conclusion

The complication rate for using spinal instrumentation can be less than previously reported. Lessons learned and discussed should reduce the rate even more. Spinal instrumentation is a safe and useful adjunct to fusion in treating degenerative, traumatic, infectious, and neoplastic diseases of the spine.     

Steroid injections: effect on pain of spinal origin

Pain originating from the spine is a common clinical problem that is often difficult to manage. This chapter considers the evidence supporting the use of corticosteroid injections for pain of spinal origin. Clinical problems considered in this review are radicular pain, zygapophyseal joint pain, discogenic pain and non-specific pain from the cervical, lumbar and thoracic spine. Issues of efficacy and adverse events are considered.No useful data were found concerning the treatment of any type of thoracic pain with corticosteroid injections. In the lumbar spine, there is evidence to support the use of transforaminal injections for radicular pain. Intradiscal and intra-articular injections in both lumbar and cervical spines have not been shown to be effective. Sacroiliitis responds well to intra-articular corticosteroids. There is insufficient evidence to support the use of atlanto-axial or atlanto-occipital joint injections.     

Osteoporotic fracture of the dens revealed by cervical manipulation

Osteoporotic vertebral fractures selectively affect the thoracolumbar junction, usually sparing the cervical spine. A 65-year-old woman with documented osteoporotic fractures and chronic alcohol abuse presented with neck pain and occipital neuralgia that started after she suddenly flexed then extended her neck. Following several sessions of cervical manipulation, her pain became more severe, and she was admitted. Imaging studies showed multiple fractures in the dens, C6 and C7. These apparently spontaneous fractures suggested a bone tumor, for which investigations were negative. Osteoporosis was the only identifiable cause. The spinal manipulations probably worsened the lesions which were performed by a chiropractor who is not a physician and did not obtain cervical spine radiographs before treating the patient. Osteoporosis contraindicates spinal manipulation at any level, including the cervical spine.     

Cervical spine manipulation and the precautionary principle

Cervical manipulations can cause severe neurologic complications, which are both exceedingly rare and generally unpredictable. To meet the requirements of the principles of prevention and precaution, we believe the number of cervical manipulations should be reduced. To this end, we suggest that five recommendations developed by consensus be followed: unwanted effects, however minor, of previous manipulation should be looked for routinely and taken as absolute contraindications to further manipulation; a thorough physical examination, including a neurological evaluation, should be performed prior to manipulation; all known contraindications and indications should be followed; manipulation should be performed only by physicians experienced in this technique; and special caution should be exercised when performing first-line cervical manipulation.     

Komplikationen bei operativen Eingriffen an der Wirbelsäule

The number of surgical interventions for spinal diseases has greatly increased due to rapid improvements in surgical techniques. The close anatomical relationship between neural and bony structures and the various anatomical approaches to the spinal column lead to a large variety of possible surgical complications. Therefore, it seems helpful to differentiate the complications with respect to their origin. An incorrect positioning of the patient can result in palsy or even blindness. Surgical access to the spine depends on the pathology and the surgical target. Typical complications can be explained by the anatomical situation, such as the vicinity of the esophagus in the anterior approach to the cervical spine or the great vessels in anterior procedures to the lumbar spine. Complication during the surgical manipulation of the spine can be related to either decompression procedures of neural structures or spinal implants. The correction of spinal deformities can result in very specific complications.     

Fracture ostéoporotique de l’apophyse odontoïde révélée par une manipulation cervicale

Osteoporotic vertebral fractures selectively affect the thoracolumbar junction, usually sparing the cervical spine. A 65-years-old woman with documented osteoporotic fractures and chronic alcohol abuse presented with neck pain and occipital neuralgia that started after she suddenly flexed then extended her neck. Following several sessions of cervical manipulation, her pain became more severe, and she was admitted. Imaging studies showed multiple fractures in the dens, C6, and C7. These apparently spontaneous fractures suggested a bone tumor, for which investigations were negative. Osteoporosis was the only identifiable cause. The spinal manipulations probably worsened the lesions; they were performed by a chiropractor who was not a physician and did not obtain cervical spine radiographs before treating the patient. Osteoporosis contra-indicates spinal manipulation at any level, including the cervical spine.     

Complications of sublaminar wiring

Complications of sublaminar wiring are reported, including four cases that involved the cervical spine and one case that included the thoracolumbar spine. The complication rate at our institution involving the cervical spine was about 7% and less than 1% for the thoracic spine. A direct correlation exists between the degree of anterior bowing, number of consecutive laminae the wire passes beneath, and the complication rate. The clinical presentations, radiologic findings, and indications for surgical removal of the wires are discussed. To our knowledge, nothing has been reported in the literature regarding the complications caused by sublaminar wiring of consecutive vertebrae.     

Complications of non-endoscopic percutaneous laser disc decompression and nucleotomy with the neodymium: YAG laser 1064 nm

In this review, we discuss how nonendoscopic percutaneous laser disc decompression (PLDD) and nucleotomy, using the YAG laser 1064, now has reinforced itself as a minimally invasive procedure in discogenic, vertebral pain syndromes, created by bulging, protrusions, and contained and uncontained extrusions in all areas of the spine. The rate of complication is an important criterion of the application of this new method. 3377 patients were treated with this method in the period of November 11, 1989 to April 30, 2002. While 356 patients' cervical spine was operated on, a further 38 patients had their thoracic spine operated on. Six weeks later, a prospective, consecutive control followed with an uninterrupted recording. Subsequently, all complications that occurred in this time frame were recorded. A comparison was carried out between the complication rate as covered by the literature of other intradiscal percutaneous methods and open disc surgery. Using the Nd-YAG laser 1064 nm, PLDD is generally evaluated with a complication rate of 0.5%. In the cervical spine area, the complication rate was 1.0%. No significant complications followed the thoracic intervention. In comparison to figures suggested by the relevant literature regarding possible complications with other procedures, this particular procedure is relative risk-free. In conjunction with the satisfying results regarding pain and paralysis removal, the extraordinarily low complication density of Nd-YAG PLDD culminates in the recommendation that the procedure should be applied to patients who are between unsuccessful conservative therapy and other operative methods.     

Percutaneous pulsed radiofrequency in the treatment of cervical and lumbar radicular pain

BACKGROUND: Previous reports of the efficacy of percutaneous pulsed radiofrequency have been confounded by fewer case numbers, poor patient selection, and limited data on cervical or lumbar radicular pain. We used percutaneous pulsed radiofrequency for cervical and lumbar radicular pain, and the study has more than 100 cases for the analysis of the efficacy of percutaneous pulsed radiofrequency. METHODS: We collected 154 cases of patients with lumbar or cervical radicular pain due to a herniated intervertebral disk or previous failed surgery. They underwent pulsed radiofrequency therapy in 2 to 4 spinal levels unilaterally. Follow-up period was from 1 week to 1 year postoperatively. RESULTS: Twenty-six (53.06%) of 49 patients and 59 (50.86%) of 116 patients after cervical and lumbar pulsed radiofrequency stimulation, respectively, had an initial improvement of 50% or more in the first week of follow-up. Twenty-seven (55.10%) of 49 patients and 52 (44.83%) of 116 patients after cervical and lumbar pulsed radiofrequency stimulation, respectively, had pain relief of 50% or more at the follow-up period of 3 months. In the analysis of patients with pain relief of 50% or more for at least 1 month, the most effective period was during postoperation 1 month later. No complication was found among these patients. CONCLUSIONS: The results of this retrospective analysis showed that the application of pulsed radiofrequency is a safe and useful intervention for cervical and lumbar radicular pain. The satisfactory pain relief obtained by most of our patients justifies the start of this study for at least 6 months. Although pulsed radiofrequency appears to provide intermediate-term relief of pain, further studies with long-term follow-up are necessary.     

颈椎前路自锁钢板临床应用及失误原因分析

临床应用颈椎前路自锁钢板治疗颈椎损伤、颈椎病和颈椎肿瘤共23例,其中17例存在内固定力学缺陷或手术并发症。对颈椎前路钢板的固定原理、手术近期并发症及由于安装不妥造成力学缺陷的几种情况进行分析。认为正确选择手术适应证和规范的手术操作是取得疗效、减少并发症的关键。     

Cervical spine surgery: Complications and considerations

Surgery is a successful treatment option for traumatic or degenerative mechanical pathologies of the cervical spine. These surgeries can be performed from either an anterior or posterior approach. Each approach has its own indications and associated potential complication profile. The anterior approach is the work horse of degenerative spinal pathologies but is associated with unique proximity related visceral complications like dysphagia, dysphonia, esophageal or oropharyngeal injury, and sympathetic chain injuries. The posterior approach to the cervical spine has fewer indications relative to the anterior approach but again has its own unique complication profile including C5 palsies and epidural hematomas.     

Prehospital stabilization of the cervical spine for penetrating injuries of the neck - is it necessary?

The purpose of this study was to assess the specific indications, benefits and risks associated with cervical spine stabilization during pre-hospital care of penetrating neck injuries. We retrospectively reviewed hospital charts and autopsy reports of 44 military casualties in Israel with a penetrating neck injury during a period of 4.5 years. A review of the literature was also carried out. In eight of 36 hospitalized casualties (22%) a life-threatening sign was diagnosed in the exposed neck - large or expanding haematoma, or subcutaneous emphysema. Surgical stabilization of the cervical spine was not performed for any of the casualties. It was concluded that life threatening complications due to penetrating neck injury are common and may be overlooked if the neck is covered by a stabilization device. It is extremely rare for a penetrating injury to result in an unstable cervical spine. New management guidelines concerning pre-hospital stabilization are suggested.     

Transforaminal steroid injections in the treatment of cervical radiculopathy. A prospective outcome study

Summary Background. The aim of this study was to assess if transforaminal steroid injections applied to cohort of patients waiting for cervical disc surgery, reduce the pain of cervical radiculopathy and hence reduce the need for surgical intervention. Cervical radiculopathy due to cervical disc herniation or spondylosis is a common indication for cervical disc surgery. Surgery is however not always successful, and is not done without risk of complications. Transforaminal injection of steroids has gained popularity due to the rationale that inflammation of the spinal nerve roots causes radicular pain, and therefore steroids placed locally should relieve symptoms. Methods. During a 12-month period, 21 secondary referral patients with unilateral cervical radiculopathy entered the study. Cervical disc herniation or spondylosis affecting the corresponding nerve root was demonstrated by appropriate investigation (MRI or myelography). The patients then received 2 transforaminal steroid injections, at 2 weeks interval, while waiting for operative treatment. The pain intensity (VAS), Odom’s criteria and operative indications were registered at 6 weeks and 4 months. Findings. After receiving injection treatment 5 of the 21 patients decided to cancel the operation due to clinical improvement. A statistically significant reduction (0.02) in radicular pain score was simultaneously measured. This corresponds well with the reduction in operative requirements since radicular pain is the main indication for operative treatment. The responders experienced a long-lasting effect. Those responding positively however improved neck pain to the same extent as radicular pain, and patients with cervical spondylosis responded as positively as those with disc herniation. Interpetation. This prospective cohort study indicates a reduction in the need for operative treatment due to injection treatment. The clinical effect is measurable, and a statistically significant improvement of the radicular pain is registered. Routine transforaminal injection treatment prior to surgery seems rewarding, but the complication risk must be taken into consideration.     

Clinical perceptions of the risk of vertebral artery dissection after cervical manipulation: the effect of referral bias.

BACKGROUND CONTEXT: The growing recognition of cervical manipulation as a treatment of neck pain and cervicogenic headaches has lead to increased interest in potential complications that may result from this treatment approach. Recent surveys have reported that many neurologists will encounter cases of vertebral artery dissection that occur at various times after cervical manipulation, whereas most practitioners of spinal manipulation are of the opinion that these events are extremely rare. We asked the question whether these differences in perception could be explained in part by referral or selection bias. PURPOSE: To assess the effect of referral bias on the differences in perceived incidence of vertebral artery dissection after cervical manipulation between neurologists and chiropractors in Canada. STUDY DESIGN: This study was a retrospective review of cases where neurological symptoms consistent with cerebrovascular ischemia were reported by chiropractors in Canada. METHODS: An analysis of data from a chiropractic malpractice insurance carrier (Canadian Chiropractic Protective Association [CCPA]) and results of a survey of chiropractors was performed to determine the likelihood that a vertebral artery dissection after cervical manipulation would be reported to practicing chiropractors. This was compared with the likelihood that a neurologist would be made aware of such a complication. RESULTS: For the 10-year period 1988 to 1997, there were 23 cases of vertebral artery dissection after cervical manipulation reported to the CCPA that represents 85% of practicing chiropractors in Canada. Based on the survey, an estimated 134,466,765 cervical manipulations were performed during this 10-year period. This gave a calculated rate of vertebral artery dissection after manipulation of 1:5,846,381 cervical manipulations. Based on the number of practicing chiropractors and neurologists during the period of this study, 1 of every 48 chiropractors and one of every two neurologists would have been made aware of a vascular complication from cervical manipulation that was reported to the CCPA during their practice lifetime. CONCLUSIONS: The perceived risk after cervical manipulation by chiropractors and neurologists is related to the probability that a practitioner will be made aware of such an incident. The difference in the number of chiropractors (approximately 3,840 in 1997) and neurologists (approximately 4,000 in 1997) in active practice and the fact that each patient who has a stroke after manipulation will likely be seen by only one chiropractor but by three or more neurologists partly explains the difference in experience and the perception of risk of these two professions. This selection or referral bias is important in shaping the clinical opinions of the various disciplines and distorts discussion on the true incidence of these complications of cervical manipulation. The nature of this study, however, describes the likelihood that a clinician will be made aware of such an event and cannot be interpreted as describing the actual risk of stroke after manipulation.     

Herniated disc with radiculopathy following cervical manipulation: nonsurgical management.

BACKGROUND CONTEXT: Spinal manipulation applied to the cervical spine is a relatively safe and effective treatment for neck pain and headache. However, complications of this form of treatment have been reported and these can at times be disabling and on rare occasions can be devastating. A postmanipulation complication being treated with a different form of manipulation has not previously been reported. PURPOSE: To report a case of a patient who was treated with manipulation and who developed neck, scapular, and arm pain and arm numbness after the sixth visit, which was later attributed to three herniated discs. The patient was subsequently treated with a nonsurgical approach that included, but was not limited to, a different form of manipulation with apparent resolution of the problem. STUDY DESIGN/SETTING: The patient was a 38-year-old banker who began seeing a chiropractic physician for treatment that included cervical manipulation. On the sixth visit, he developed pain immediately after treatment which became severe and was accompanied by numbness in his arm. He saw a neurosurgeon who recommended surgery, but was subsequently seen by a different chiropractic physician and was treated nonsurgically. METHODS: The patient was found to have clinical signs of radiculopathy, including motor loss. Magnetic resonance imaging revealed disc herniations at C3-C4, C4-C5, and C5-C6. RESULTS: The patient was treated by the author with an alternate approach that included non-high-velocity, low-amplitude manipulation and exercise with resolution of the problem. CONCLUSION: This paper reports a case of a patient with radiculopathy secondary to multilevel disc herniations that appeared to be precipitated by cervical manipulation and who was treated nonsurgically with resolution of the problem. It is doubtful that the manipulation actually caused the disc herniations, but it is possible that it caused preexisting asymptomatic disc herniations to become symptomatic. Consideration should be given to nonsurgical referral of patients who have postmanipulative complications but do not need immediate surgery.     

Infectious damage to the intervertebral disk--before and following discotomy

Bad results after discotomy for treatment of herniated lumbar disc are caused either by postoperative complications or by preoperative diagnostic errors. Very often other degenerative changes of the "Bewegungssegment" are involved and misunderstood. But also septic lesions of the intervertebral disc following pyogenic hematogenous osteomyelitis of the spine are confused with degenerative lesions. They are even treated operatively as a ruptured intervertebral disc. When pyogenic osteomyelitis may no longer by overlooked after discotomy due to her progression, she is misinterpreted as discitis following removal of intervertebral disc. Only 9 of 97 verified patients with vertebral osteomyelitis suffered from true postoperative infection of the intervertebral space after removal of a herniated disc. In 14 patients the signs of hematogenous osteomyelitis of the spine have been missed or have been explained by degenerative changes of the spine. In none of the patients the wrong diagnosis was perioperatively revised. The common confusion of osteomyelitis and degenerative disc changes can be explained by several reasons: the predilection of lumbar spine and the similarity of local signs of both diseases, the unknown or underestimated frequence of radicular lesions in osteomyelitis of the spine and the difficulties to assess osteomyelitis in early stages by X-ray examination and the frequency of accessory degenerative changes. It may be supposed that many of the reported disc space inflammations after diagnostic or therapeutic means have not been caused by these manipulations but have given occasion for them.(ABSTRACT TRUNCATED AT 250 WORDS)     

Outcomes of interlaminar and transforminal spinal injections

Epidural spinal injections can be administered via a translaminar or transforaminal route, depending on the clinical scenario. When it is more desirable to target a specific nerve root, a transforaminal approach is typically used, and when the target is more diffuse, a translaminar method is chosen. Both are commonly used and can be utilized similarly in the lumbar or cervical spine. However, it is essential that the clinician understand the risks and benefits of these injections. In the lumbar spine, both translaminar epidural steroid injections (TLESI) and transforaminal epidural steroid injections (TFESI) have been shown to provide up to 6 months of pain relief, though long-term benefits are less reliable. In the cervical spine, translaminar injections may provide longer relief and have a lower complication rate than cervical transforaminal injections. Proper technique is essential to minimize the rate of these rare but occasionally severe complications.     

An analysis of the reasons for relaparotomy in the surgical clinic]

The results of surgical treatment of 4,078 patients who underwent operation in 1985-1989 were studied. Due to the occurrence of complications in the early postoperative period, 182 relaparotomies were carried out in 164 patients. The main indications for relaparotomies were advanced underlying disease, surgical errors (tactical, technical), changes of the patients' immune status. Early diagnosis, timely operation with the use of technically correct manipulations, and the application of a full complex of intensive therapy measures in the postoperative period are important in the prevention of complications.     

Revisionschirurgie nach Bandscheibenprothesenimplantation

Assessment of the revisability of surgery after the endoprosthetic replacement of vertebral discs shows that the surgical approach depends on the time of revision surgery and the reason why it is carried out. Our experience is based on nine revision operations out of 152 cervical vertebra prostheses of the Bryan and Prodisc C types implanted from 2003 to 2007 and 312 endoprostheses of the Charité and Prodisc types implanted from 1999 to 2007. Our own results show differing approaches in perioperative or late postoperative revision operations. Operations to exchange implants were not possible, whereas a change of surgical procedure is the rule. The same access route can usually be selected in the cervical spine, but in the lumbar spine this can only be done perioperatively; if revision surgery is carried out at a later date, an alternative access route must be used. Using strict indications for the primary implant is the only way to prevent postoperative revision surgery that is due to an inaccurate primary assessment and not to the vertebral endoprosthesis (e.g. post-discotomy syndrome, facet joint arthropathy, rotation instability, vertebral slip). The next generation of vertebral disc endoprostheses must incorporate reduced load of the zygapophyseal joints and improved revisability.