Halswirbelsäulenbeteiligung bei Patienten mit rheumatoider Arthritis

Background

The incidence of rheumathoid arthritis (RA) is 3 times higher for women as compared to men. Within 10 years some 40–50 % of the patients lose the ability to work and life expectancy is reduced by approximately 10 years. Patients often show cervical spine involvement in particular at the atlantoaxial joint, which can result in instability of the cervical spine.

Methods

An x-ray of the cervical spine including dynamic images is the most important follow-up examination. Any widening of the ventral atlantodental interval >?3 mm is pathological. Computed tomography (CT) scans can detect bony erosions or fractures and magnetic resonance imaging (MRI) can detect possible pannus formation and myelopathy.

Results

Of the patients suffering from RA 40 % showed cervical spine involvement. Unspecific symptoms may be neck pain, sense of instability, radicular symptoms, vertebrobasilar insufficiency or bulbar symptoms.

Conclusions

Patients without neurological deficits are treated with anti-inflammatory medication and immobilization but those with deficits or instability need spinal surgery. Regular follow-up including cervical spine evaluation is mandatory.     

Undetected hangman's fracture in a patient referred for physical therapy for the treatment of neck pain following trauma

BACKGROUND AND PURPOSE: This case report describes a patient referred for physical therapy treatment of neck pain who had an underlying hangman's fracture that precluded physical therapy intervention. CASE DESCRIPTION: This case involved a 61-year-old man who had a sudden onset of neck pain after a motor vehicle accident 8 weeks before his initial physical therapy visit. Conventional radiographs of his cervical spine taken on the day of the accident did not reveal any abnormalities. Based on the findings at his initial physical therapy visit, the physical therapist ordered conventional radiographs of the cervical spine to rule out the possibility of an undetected fracture. OUTCOMES: The radiographs revealed bilateral C2 pars interarticularis defects consistent with a hangman's fracture. The patient was referred to a neurosurgeon for immediate review. Based on a normal neurological examination, a relatively low level of pain, and the results of radiographic flexion and extension views of the cervical spine (which revealed no evidence of instability), the neurosurgeon recommended that the patient continue with nonsurgical management. DISCUSSION: In patients with neck pain caused by trauma, physical therapists should be alert for the presence of cervical spine fractures. Even if the initial radiographs are negative for a fracture, additional diagnostic imaging may be necessary for a small number of patients, because they may have undetected injuries that would necessitate medical referral and preclude physical therapy intervention.     

Awake intubation using fast-track laryngeal mask airway as an alternative to fiberoptic bronchoscopy: a case report

Patients with rheumatoid arthritis (RA) pose a unique challenge to the anesthetist. The manifestations of RA may include cervical spine instability, limited range of motion, and temperomandibular joint involvement limiting mouth opening. Therefore, securing the airway while maintaining the head and neck in a neutral position is of particular concern to the anesthetist. While this is most commonly accomplished using an awake fiberoptic technique, the following case is presented as a safe and efficient initial alternative to the primary use of fiberoptic bronchoscopy in the appropriate patient population.     

Spinal cord injury in partial Down syndrome

Spinal cord injury is well documented in Down syndrome, and is commonly associated with atlantoaxial instability and ligamentous laxity. A case of partial Down syndrome is presented in which a cervical spine injury resulted in an incomplete quadriplegia. Possible factors leading to increased risk of SCI in partial Down syndrome are ligamentous laxity, atlantoaxial subluxation or odontoid abnormalities, neck inflammatory changes, and age below eight years.     

Immediate effects of thoracic manipulation in patients with neck pain: a randomized clinical trial

Mechanical neck pain is a common occurrence in the general population resulting in a considerable economic burden. Often physical therapists will incorporate manual therapies directed at the cervical spine including joint mobilization and manipulation into the management of patients with cervical pain. Although the effectiveness of mobilization and manipulation of the cervical spine has been well documented, the small inherent risks associated with these techniques has led clinicians to frequently utilize manipulation directed at the thoracic spine in this patient population. It is hypothesized that thoracic spine manipulation may elicit similar therapeutic benefits as cervical spine manipulation while minimizing the magnitude of risk associated with the cervical technique. The purpose of this randomized clinical trial was to investigate the immediate effects of thoracic spine manipulation on perceived pain levels in patients presenting with neck pain. The results suggest that thoracic spine manipulation results in immediate analgesic effects in patients with mechanical neck pain. Further studies are needed to determine the effects of thoracic spine manipulation in patients with neck pain on long-term outcomes including function and disability.     

Subjective and objective descriptors of clinical lumbar spine instability: a Delphi study

Accurate ability to diagnose lumbar spine clinical instability is controversial for numerous reasons, including inaccuracy and limitations in capabilities of radiographic findings, poor reliability and validity of clinical special tests, and poor correlation between spinal motion and severity of symptoms. It has been suggested that common subjective and objective identifiers are specific to lumbar spine clinical instability. The purpose of this study was to determine if consensual, specific identifiers for subjective and objective lumbar spine clinical instability exist as determined by a Delphi survey instrument. One hundred and sixty eight physical therapists identified as Orthopaedic Clinical Specialists (OCS) or Fellows of the American Academy of Orthopaedic Manual Physical Therapists participated in three Delphi rounds designed to select specific identifiers for lumbar spine clinical instability. Round I consisted of open-ended questions designed to provide any relevant issues. Round II allowed the participants to rank the organized findings of Round I. Round III provided an opportunity to rescore the ranked variables after viewing other participant's results. The results suggest that those identifiers selected by the Delphi experts are synonymous with those represented in related spine instability literature and may be beneficial for use during clinical differential diagnosis.     

Clinical instability of the lumbar spine

Instability of the lumbar spine, as a clinical entity, is poorly understood. Clinical instability appears to be the symptomatic presentation during the degenerative phase that occurs between segmental dysfunction and segmental restabilization, as defined by Kirkaldy-Willis. A typical case of clinical instability of the lumbar spine is presented, along with suggested conservative therapy measures.     

Lumbar instability: an evolving and challenging concept

Identification and management of chronic lumbar spine instability is a clinical challenge for manual physical therapists. Chronic lumbar instability is presented as a term that can encompass two types of lumbar instability: mechanical (radiographic) and functional (clinical) instability (FLI). The components of mechanical and FLI are presented relative to the development of a physical therapy diagnosis and management. The purpose of this paper is to review the historical framework of chronic lumbar spine instability from a physical therapy perspective and to summarize current research relative to clinical diagnosis in physical therapy.     

Case study: acceleration/deceleration injury with angular kyphosis

OBJECTIVE: To discuss the case of a patient who received upper cervical chiropractic care after trauma-induced arcual kyphosis in the cervical spine. A practical application of conservative management for posttrauma cervical spine injury in the private office setting is described. Clinical Features: A 17-year-old female patient suffered an unstable C3/C4 motor segment after a lateral-impact motor vehicle collision. Additional symptoms on presentation included vertigo, tinnitus, neck and shoulder pain, and confusion. Intervention and Outcome: Conservative management consisted exclusively of upper cervical-specific adjustments guided by radiographic analysis and paraspinal bilateral skin temperature differential analysis of the cervical spine. During 10 weeks of care and 22 office visits, all symptoms subsided and the instability of C3/C4 motor segment appeared to be completely resolved. CONCLUSION: This study provides support for the use of upper cervical chiropractic management in cervical spine trauma cases. The clinical work-up consisted of physical examination, radiographic analysis, computer-administered and scored cognitive function testing, and audiometric examination. After conservative care, these examinations were repeated and demonstrated that the objective findings concurred with the subjective improvements reported by the patient.     

Clinical algorithm for preventing missed diagnoses of occult cervical spine instability after acute trauma: A case report

BACKGROUNDMissed or delayed diagnosis of cervical spine instability after acute trauma can have catastrophic consequences for the patient, resulting in severe neurological impairment. Currently, however, there is no consensus on the optimal strategy for diagnosing occult cervical spine instability. Thus, we present a case of occult cervical spine instability and provide a clinical algorithm to aid physicians in diagnosing occult instability of the cervical spine.CASE SUMMARYA 57-year-old man presented with cervical spine pain and inability to stand following a serious fall from a height of 2 m. No obvious vertebral fracture or dislocation was found at the time on standard lateral X-ray, computed tomography, and magnetic resonance imaging (MRI). Subsequently, the initial surgical plan was unilateral open-door laminoplasty (C3-7) with alternative levels of centerpiece mini-plate fixation (C3, 5, and 7). However, the intraoperative C-arm fluoroscopic X-rays revealed significantly increased intervertebral space at C5-6, indicating instability at this level that was previously unrecognized on preoperative imaging. We finally performed lateral mass fixation and fusion at the C5-6 level. Looking back at the preoperative images, we found that the preoperative T2 MRI showed non-obvious high signal intensity at the C5-6 intervertebral disc and posterior interspinous ligament.CONCLUSIONMRI of cervical spine trauma patients should be carefully reviewed to detect disco-ligamentous injury, which will lead to further cervical spine instability. In patients with highly suspected cervical spine instability indicated on MRI, lateral X-ray under traction or after anesthesia and muscle relaxation needs to be performed to avoid missed diagnoses of occult cervical instability.     

Cervical spine position versus e.m.g. activity in neck muscles during maximum isometric neck extension

The aim of the study was to describe the relationships between cervical spine positions and neck muscle activity during maximum isometric neck extension. Ten healthy women participated (mean age 25·6 years). Maximum isometric neck extensions were performed in 12 different neck positions with resistance applied againstthe back of the head. Surface e.m.g. was recorded from posterior neck muscles at six locations. The e.m.g. signals were rectified, low-pass filtered and normalized. The position of the upper cervical spine did not influence the e.m.g. levels, whereas the lower cervical spine positions did. The e.m.g. levels, in the cervical erector spinae/trapezius were higher in the slightly flexed lower cervical spine position than in the neutral (despite an approximately similar magnitude of muscular moment developed), when the upper cervical spine was in the neutral position. However, when the lower cervical spine was much flexed the e.m.g. level was about the same as that of the neutral lower cervical spine position (with upper cervical spine neutral). The e.m.g. levels of the splenius and the thoracic erector spinae/rhomboids varied in a similar way, but less pronouncedly. These findings are of interest for the method of normalization of e.m.g,. e.g. in studies of work postures and/or movements.     

Dry needling for the management of thoracic spine pain

Abstract

Thoracic spine pain is as disabling as neck and low back pain; however, it has not received as much attention as the cervical and lumbar spine in the scientific literature. Among the different structures that can refer pain to the thoracic spine, muscles often play a relevant role. In fact, myofascial trigger points (TrPs) from several neck, shoulder and spinal muscles can induce pain in the region of the thoracic spine. There is a lack of evidence reporting the presence of myofascial TrPs in the thoracic spine, but clinical evidence suggests that TrPs can be a potential source of thoracic spine pain. The current paper discusses the role of myofascial TrPs in the thoracic spine and summarises the proper and safe application of dry needling (DN) for the management of myofascial TrPs in two main spinal muscles involved in thoracic spine pain: the thoracic multifidi and longissimus thoracis. In addition, this paper discusses the application of DN in other tissues such as tendons, ligaments and scars.     

Past and Future: Responsibility and Opportunity

Abstract

Identification and management of chronic lumbar spine instability is a clinical challenge for manual physical therapists. Chronic lumbar instability is presented as a term that can encompass two types of lumbar instability: mechanical (radiographic) and functional (clinical) instability (FLI). The components of mechanical and FLI are presented relative to the development of a physical therapy diagnosis and management. The purpose of this paper is to review the historical framework of chronic lumbar spine instability from a physical therapy perspective and to summarize current research relative to clinical diagnosis in physical therapy.     

飞行人员颈部酸痛与颈椎不稳关系的临床研究

目的研究飞行人员常见临床症状颈部酸痛与颈椎不稳的关系，以及这种关系对预防和治疗颈部酸痛的意义。方法回顾性分析56例飞行人员颈部酸痛的动态X线表现，观察颈椎不稳情况，并与同期56例无颈部异常感觉的飞行人员比较。结果颈部酸痛患者中，10例存在节段性颈椎不稳（18％）；对照组2例存在节段性颈椎不稳（4％）；两组间差异显著（P〈0．01）。结论颈部酸痛患者颈椎存在失稳倾向，颈椎失稳可能在颈部酸痛的发生发展过程中起重要作用。     

Assessment of the "nearly normal" cervical spine radiograph: C2-C3 pseudosubluxation in an adult with whiplash injury

C2-C3 pseudosubluxation is a well recognized normal anatomical variant in children and this physiological spondylolisthesis often makes the interpretation of paediatric cervical spine radiographs difficult. In direct contrast, this finding is rare in adults and has not been reported as a diagnostic difficulty following neck injury. We report a case of C2-C3 pseudosubluxation occurring in a 27 year old woman presenting with neck pain 1 week after a road traffic accident. Although there are effective radiological guidelines for cervical spine radiograph evaluation in children, there is no evidence that these can be applied to the adult cervical spine. Flexion and extension cervical spine views have limitations. In such cases, magnetic resonance imaging is required to definitively exclude pathological injury.     

Criteria to Screen for Traumatic Cervical Spine Instability: A Consensus of Chiropractic Radiologists

Objective

The purpose of this study was to establish consensus on a radiographic definition for cervical instability for routine use in chiropractic patients who sustain trauma to the cervical spine.

实验性大鼠颈椎不稳椎动脉ICAM-1、VCAM-1表达的研究

[目的]探讨实验性大鼠颈椎不稳时细胞间粘附分子-1（ICAM-1）、血管细胞粘附分子-1（VCAM-1）在椎动脉局部的表达.[方法]60只SD大鼠分为对照组（18只）与实验组（42只）,实验组结扎并切断颈椎C4/5节段颈后肌群,然后切断C4/5节段的棘上及棘间韧带,同时行前路手术损伤C4/5前纵韧带和椎间盘结构; 对照组仅切开显露并缝合颈部前后侧皮肤,切口长度与实验组相同.两组均于术后第4、8、12周处死动物并取椎动脉标本,检测并比较ICAM-1、VCAM-1在椎动脉内皮和平滑肌细胞的表达.[结果]实验组椎动脉ICAM-1、VCAM-1在术后4周有微量表达,与对照组比较其差异无统计学意义（P〉0.05）;术后8周及12周表达量明显上调（P〈0.05）且有时间正相关性,同时与对照组比较均有显著性差异（P〈0.05）.[结论]颈椎不稳会导致粘附分子ICAM-1、VCAM-1在椎动脉的局部表达.     

Chiropractic care of a patient with vertebral subluxations and unsuccessful surgery of the cervical spine

OBJECTIVE: The chiropractic care of a patient with vertebral subluxations, neck pain, and cervical radiculopathy after a cervical diskectomy is described. CLINICAL FEATURES: A 55-year-old man had neck pain and left upper extremity radiculopathy after unsuccessful cervical spine surgery. INTERVENTION AND OUTCOME: Contact-specific, high-velocity, low-amplitude adjustments (i.e., Gonstead technique) were applied to sites of vertebral subluxations. Rehabilitation exercises were also used as adjunct to care. The patient reported a decrease in neck pain and left arm pain after chiropractic intervention. The patient also demonstrated a marked increase in range of motion (ROM) of the left glenohumeral articulation. CONCLUSION: The chiropractic care of a patient with neck pain and left upper extremity radiculopathy after cervical diskectomy is presented. Marked resolution of the patient's symptoms was obtained concomitant with a reduction in subluxation findings at multiple levels despite the complicating history of an unsuccessful cervical spine surgery. This is the first report in the indexed literature of chiropractic care after an unsuccessful cervical spine surgery.     

The assessment of the cervical spine. Part 1: Range of motion and proprioception

Neck pain and headache of cervical origin are complaints affecting an increasing number of the general population. Mechanical factors such as sustained neck postures or movements and long-term "abnormal" physiologic loads on the neck are believed to affect the cervical structures and compromise neck function. A comprehensive assessment of neck function requires evaluation of its physical parameters such as range of motion, proprioception, strength and endurance/fatigue. The complicated structure of the cervical spine however, makes it difficult for any clinician to obtain reliable and valid results. The aim of the first part of this systematic critical review is to identify the factors influencing the assessment of range of motion and proprioception of the cervical spine.     

An electromyography-assisted biomechanical cervical spine model: Model development and validation

BackgroundIn spite of the prevalence of occupational neck disorders as a result of work force fluctuating from industry to sedentary office work, most cervical spine computational models are not capable of simulating occupational and daily living activities whereas majority of cervical spine models specialized to simulate crash and impact scenarios. Therefore, estimating spine tissue loads accurately to quantify the risk of neck disorders in occupational environments within those models is not possible due to the lack of muscle models, dynamic simulation and passive spine structures.MethodsIn this effort the structure, logic, and validation process of an electromyography-assisted cervical biomechanical model that is capable of estimating neck loading under three-dimensional complex motions is described. The developed model was designed to simulate complex dynamic motions similar to work place exposure. Curved muscle geometry, personalized muscle force parameters, and separate passive and (electromyography-driven) active muscle force components are implemented in this model.FindingsCalibration algorithms were able to reverse-engineer personalized muscle properties to calculate active and passive muscle forces of each individual.InterpretationThis electromyography-assisted cervical spine model with curved muscle model is capable to accurately predict spinal tissue loads during isometric and dynamic head and neck activities. Personalized active and passive muscle force algorithms will help to more robustly investigate person-specific muscle forces and spinal tissue loads.