The effect of chiropractic care for a 30-year-old male with advanced ankylosing spondylitis: a time series case report

BACKGROUND: Manipulative treatment for ankylosing spondylitis is a controversial subject, and no literature on using this therapy for advanced cases with fusion of the spine could be found. OBJECTIVE: To discuss the case presentation of a patient with advanced ankylosing spondylitis who was treated with chiropractic manipulation and mobilization.Clinical features The patient was a 30-year-old Asian male who was first diagnosed with ankylosing spondylitis at age 12. Despite medical intervention, a series of exacerbations had fused his sacroiliac joints and the facet joints in his lumbar and cervical spine. He presented with local moderate-to-severe pain in his low back and neck and lack of mobility.Intervention and outcome The patient was treated with grade 5 manipulation of his thoracic spine and grade 3 mobilization of his lumbar and cervical spine, along with physical therapy and stretches for a period of 12 weeks. He reported some improvement of his condition as measured by the SF-36 Health Survey and several measures of spinal flexibility. CONCLUSIONS: This case shows that even advanced cases of ankylosing spondylitis may show a favorable response to chiropractic manipulative therapy.     

胸主动脉夹层动脉瘤介入治疗中数字减影血管造影技术的应用分析

目的探究数字减影血管造影(DSA)摄影技术应用于胸主动脉夹层动脉瘤介入治疗中的临床价值。方法分析2009年1月至2011年9月间应用DSA影像对51例胸主动脉夹层动脉瘤患者进行介入治疗的资料。结果对病患的采集参数、体位以及注射参数、图像后处理进行适当选择,即能够确切显示胸主动脉夹层动脉瘤部位、破口以及真假腔内血流差别、与相邻血管的关系。结论数字减影血管造影摄影技术应用于胸主动脉夹层动脉瘤介入治疗临床价值很高,具有重要意义。     

“一站式”杂交手术方法治疗胸主动脉瘤及夹层动脉瘤的介入护理

目的探讨“一站式”杂交手术治疗胸主动脉瘤及夹层动脉瘤的术中护理配合的经验及管理。方法对10例胸主动脉瘤和夹层动脉瘤患者,在导管室行杂交手术,术中护士与医生的默契配合,严密生命体征监护,充分的各种抢救药品、器械的准备,保证手术顺利进行,防止各种并发症的发生。结果通过介入护理,患者均成功顺利完成杂交手术,术中无并发症发生。结论严格的护理管理,介入专科护士技能的培训,对杂交手术治疗胸主动脉瘤和夹层动脉瘤患者护理是安全有效的,术中介入护士与医生的默契、熟练配合,严密的生命体征监护对保证手术成功有重要作用。     

Use of Doppler ultrasound in dissecting aortic aneurysm

Immediate intensive therapy is of major importance in the initial management of patients with dissecting aortic aneurysm. The Doppler ultrasound stethoscope is a noninvasive tool which may be used in the diagnosis and management of this disease. A case is presented in which this instrument was used to diagnose and follow the progress of a patient with acute aortic dissection. Further use of this device for similar disorders can be expected.     

Sudden death caused by dissecting thoracic aortic aneurysm in a patient with autosomal dominant polycystic kidney disease

Among the fatal vascular complications associated with autosomal dominant polycystic disease (ADPKD), ruptured intracerebral aneurysm and ruptured abdominal aortic aneurysm are widely known. However, there are few reports on the dissecting thoracic aortic aneurysm as a fatal complication of ADPKD. We report a case of a 58-year-old man with a history of ADPKD who presented to the emergency department with out-of-hospital cardiac arrest. Immediate cardiopulmonary resuscitation restored a spontaneous circulation successfully and subsequent image study revealed a type I dissecting thoracic aortic aneurysm. Emergency aortic grafting was performed--but he died from postoperative haemorrhage. The surgical specimen of the aorta showed cystic medial necrosis. This rare case emphasizes the need to consider such a diagnosis in a patient with ADPKD who presents to the emergency department with sudden cardiac arrest. In addition, the histological finding indicates the aetiological role of a collagen defect in addition to chronic hypertension in the pathogenesis of aortic dissection in ADPKD patients.     

Acute Aortic Dissection With ST Segment Myocardial Infarction Following Masturbation

BackgroundAcute aortic dissection is the most common life-threatening disorder affecting the aorta, and can mimic other disease processes. We describe an unusual presentation of a critically ill patient with initial hematospermia diagnosed with a type A acute aortic dissection.Case ReportA 68 year old man presented to a community ED after masturbation and report of blood in his ejaculate, followed by rapid development of severe low back, chest and hip pain with shock. ECG showed evidence of ST segment elevation, but suspicion remained high for thoracic or abdominal aortic catastrophe. Bedside ultrasound demonstrated no pericardial effusion, a severely hypokinetic myocardium and a question of fluid in the left perinephric space. Attempts were made to resuscitate the patient, and an ED chest/abdomen/pelvis CT showed a type A acute thoracic aortic dissection. Unfortunately, the patient remained profoundly unstable, with multiple arrests. He was transferred to a tertiary care facility, but expired shortly after arrival.Why Should an Emergency Physician Be Aware of This?An emergency physician needs to be aware of the myriad of presentations of acute aortic dissection. Although hematospermia was felt ultimately to be an incidental symptom, sexual activity may bring about a significant transient increase in blood pressure, which could contribute to sheer force causing aortic injury. Awareness of this trigger and a careful sensitive history may aid the clinician in early diagnosis.     

胸主动脉瘤的外科治疗

目的:总结7例胸主动脉瘤病人的外科治疗经验.方法:7例病人中胸降主动脉瘤2例,主动脉根部瘤(马凡综合征)2例,夹层动脉瘤3例,均为Ⅱ型夹层动脉瘤,其中1例合并冠心痛,前降支单支病变.胸降主动脉瘤在低温体外循环下行人工血管置换术.升主动脉瘤和Ⅱ型夹层动脉瘤在低温体外循环下行Bentall手术,其中1例采用带管道无支架生物瓣,同时行冠脉搭桥手术.结果:6例存活,1例死于低心排综合征.结论:在胸主动脉瘤的外科治疗中,Bentall手术是治疗升主动脉瘤较好的手术方法.外科手术技术是手术成功的重要因素.体外循环管理,良好的心肌保护和血液保护是保证手术成功的重要手段.带管道无支架生物瓣对老年人及抗凝有禁忌或主动脉根部较小者更适宜,对合并冠心病的患者宜同期行冠脉搭桥术.     

血管内带膜支架治疗主动脉夹层动脉瘤6例

目的:观察血管内带膜支架在主动脉夹层中应用的有效性、可行性和安全性。方法:选择2005-03/2006-03在赣南医学院第一附属医院心内科收治的6例主动脉夹层动脉瘤患者,男3例,女3例;年龄32～67岁,平均50岁。均经胸部MRI检查及主动脉造影确诊,且符合DeBakey分型为Ⅲ型主动脉夹层。瘤体直径最大4.3cm,最小3.2cm。所有患者对手术项目均知情同意。患者发病2周后,控制血压在90～110/60～70mmHg,心率在60～65次/min情况下全麻状态下进行分别置入直筒和分叉支架(均为愈恒佳公司生产,覆膜类型为单裸头,支架均以镍钛记忆合金为材料,外覆薄层国产人造血管)。采用血管照影观察患者术后胸主动脉夹层消失情况并观察患者术后一般情况,于术后3,12个月螺旋CT复查患者恢复情况。结果:纳入患者6例均进入结果分析。①术后胸主动脉夹层消失及一般情况:6例选择的支架直径选择恰当,术后造影4例夹层消失,假腔内血栓形成,2例患者胸主动脉段夹层消失,仍可见少量造影剂内漏至假腔,但血流较缓慢。术后患者一般情况良好,生命体征平稳,均于7￣10d出院。②CT复查结果:术后3个月复查螺旋CT显示原假腔明显缩小,真腔增大接近正常。病例3可见支架折曲远端与支架血管内壁相连的小块状不规则附壁血栓形成,随访血栓增大不明显。术后12个月患者支架位置及形态均未见明显改变,生活质量明显好转。结论:血管内带膜支架在主动脉夹层中的应用是有效、可行和安全的。     

Neurologic symptoms in acute thoracic aortic dissection--a case report

Acute thoracic aortic dissection is a life-threatening illness. It is often difficult to diagnose preclinically due to its many possible symptoms. One out of three patients has neurological deficits. The prognosis depends on rapid diagnosis and immediate adequate therapy. Therefore, every emergency physician should know the signs and risk factors of this disease. The most important goals of prehospital therapy are management of pain and anxiety and pharmacological control of the systolic blood pressure and heart rate. We report on a 46-year-old female patient who developed neurological deficits caused by an acute thoracic aortic dissection.     

Treatment of severe glaucomatous visual field deficit by chiropractic spinal manipulative therapy: a prospective case study and discussion

OBJECTIVE: To discuss the case of a patient with severely reduced visual fields arising from terminal glaucomatous retinal damage and the treatment of this condition by spinal manipulation. CLINICAL FEATURES: A 25-year-old uniocular female patient with congenital glaucoma sought chiropractic treatment for spinal pain, headache, and classic migraine. Advanced optic disk cupping was present, and loss of vision was near complete. A 3-degree island of central vision and a small area of peripheral light sensitivity had remained relatively stable for 3 years after a trabeculectomy procedure that had resulted in intraocular hypotony. INTERVENTION AND OUTCOME: It was considered possible that chiropractic spinal manipulative therapy may have a positive outcome in visual performance. Before commencing chiropractic spinal manipulative therapy, an ophthalmologic examination was performed, and visual performance was monitored through a course of treatment. Immediately after the first treatment, significant visual field improvement was recorded in the remaining eye. Maximal improvement of vision was achieved after 1 week (4 treatment sessions). Total monocular visual field had increased from approximately 2% to approximately 20% of normal. Corrected central acuity had improved from 6/12 to 6/9. Independent reexamination by the patient's regular ophthalmic surgeon confirmed the results. CONCLUSION: Recovery of vision in this patient was an unexpected and remarkable outcome, raising the question of whether chiropractic spinal manipulative therapy may be of value in the management of glaucomatous visual field loss. More intensive research is required.     

Dissection of the aorta.

Our approach to management, both initial and definitive, is summarized in Table 2. Patients with proximal dissection require surgical intervention after medical stabilization, unless prior debilitating illness precludes general anesthesia or prolonged vascular surgery. If myocardial infarction or cerebrovascular accidents has complicated the dissection, results are extremely poor, regardless of therapy. Patients with distal dissection have a good prognosis with medical therapy alone, unless aortic rupture or impending rupture, hematoma progression despite a maximal drug program, vital organ compromise, or inability to control pain or blood pressure medically supervene. Dissecting aneurysm of the aorta, while potentially a promptly fatal event, is amenable to aggressive therapy provided that one is alert to the possibility of this disease. Despite all technical advances, the single most important factor in making the diagnosis of dissecting aortic aneurysm is a strong index of suspicion on the part of the physician.     

Review article: Accuracy of emergency physician performed point-of-care ultrasound of the thoracic aorta: A systematic review and narrative synthesis of the literature

Point-of-care ultrasound (POCUS) is becoming ubiquitous in emergency medicine. POCUS for abdominal aortic aneurysm is well established in practice. The thoracic aorta can also be assessed by POCUS for dissection and aneurysm and transthoracic echocardiography is endorsed by international guidelines as an initial test for thoracic aortic pathologies. A systematic search of Ovid Medline, PubMed, EMBASE, SCOPUS and Web of Science from January 2000 to August 2022 identified four studies evaluating diagnostic accuracy of emergency physician POCUS for thoracic aortic dissection (TAD) and five studies for thoracic aortic aneurysm (TAA). Study designs were heterogeneous including differing diagnostic criteria for aortic pathology. Convenience recruitment was frequent in prospective studies. Sensitivity and specificity ranges for studies of TAD were 41–91% and 94–100%, respectively when an intimal flap was seen. Sensitivity and specificity ranges for studies of thoracic aorta dilation >40 mm were 50–100% and 93–100%, respectively; for >45 mm ranges were 64–65% and 95–99%. Literature review identified that POCUS is specific for TAD and TAA. POCUS reduces the time to diagnosis of thoracic aortic pathology; however, it remains insensitive and cannot be recommended as a stand-alone rule-out test. We suggest that detection of thoracic aorta dilation >40 mm by POCUS at any site increases the suspicion of serious aortic pathology. Studies incorporating algorithmic use of POCUS, Aortic Dissection Detection Risk Score and D-dimer as decision tools are promising and may improve current ED practices. Further research is warranted in this rapidly evolving field.     

急性主动脉夹层动脉瘤的急救及护理干预

目的探索、总结迅速识别、早期诊断、及时抢救、有效护理急性主动脉夹层动脉瘤的方法,提高抢救成功率。方法总结夹层动脉瘤临床救治与护理经验,运用护理程序对病人实施早期护理干预,制定护理计划、落实护理措施。结果与结论提高患者的认知水平,防止意外;早期诊断,缓解疼痛;严密监测血压;安全转运;以及积极有效的护理对策能降低主动脉夹层动脉瘤患者在急性期的病死率。     

系统性红斑狼疮合并胸主动脉瘤破裂

报告1例18岁男性系统性红斑狼疮（SLE）患者，死于夹层主动脉瘤破裂。尸检显示主动脉根部至胸主动脉夹层动脉瘤，长17cm，主动脉滋养血管炎及小血管周围炎。本例与以往文献报告的类似病例共31例的临床资料及病理情况汇总分析，显示长期激素治疗可能在SLE患者主动脉瘤形成中起重要作用，动脉粥样硬化、主动脉炎、滋养动脉炎、高血压等可参与其形成。     

腔内隔绝术治疗主动脉夹层及胸主动脉瘤

目的探讨腔内隔绝术治疗DeBakeyⅢ型主动脉夹层及胸主动脉瘤的手术时机及操作技巧。方法10例DeBakeyⅢ型主动脉夹层及胸主动脉瘤(DeBakeyⅢ型主动脉夹层9例、胸主动脉瘤1例)患者行腔内隔绝术,术前行CTA或MRA及主动脉造影检查,判断主动脉夹层裂口位置与数量及胸主动脉瘤范围、左锁骨下动脉开口左侧胸主动脉直径、近端裂口至左锁骨下动脉开口的距离、真腔直径以及腹主动脉主要分支血管的血供来源,选支架规格及输送路径,然后在全麻下行右股动脉切开,透视引导下置入支架释放系统,定位准确后释放覆膜支架,完成腔内隔绝术。1例因破裂口位于左颈总动脉与左锁骨下动脉之间而先行右颈总动脉-左颈总动脉-左锁骨下动脉转流术。结果10例患者腔内隔绝术均获得成功。近端裂口距左锁骨下动脉开口距离平均3.5cm,出现Ⅱ型内漏1例。随访1~24个月,术后无截瘫发生,胸背部疼痛症状消失。1例胸主动脉瘤破裂伴食道瘘患者术后1个月死于感染。结论腔内隔绝术治疗DeBakeyⅢ型主动脉夹层和胸主动脉瘤是一种创伤小、疗效确切的方法。但远期效果仍有待进一步观察。     

腔内隔绝术治疗胸腹主动脉瘤的临床应用

目的探讨腔内隔绝术治疗胸腹主动脉瘤的疗效和安全性。方法2000年5月～2004年10月,采用腔内隔绝术治疗胸腹主动脉瘤7例,其中4例胸主动脉夹层动脉瘤、1例胸主动脉假性动脉瘤、2例肾下型腹主动脉瘤,术后随访采用彩超和增强CT检查。结果7例病人共成功置入10个支架。随访2～28个月,所有支架位置、形态正常。4例胸主动脉夹层动脉瘤的内膜破裂口封闭,胸降主动脉和腹主动脉真腔扩大,假腔内血栓形成。1例胸主动脉假性动脉瘤和2例肾下型腹主动脉瘤的瘤体缩小。2例术后出现微小内漏,分别在2个月、6个月后内漏自行封闭,1例术后出现髂外动脉夹层经PTA和Wallstent治疗。结论腔内隔绝术能有效治疗胸腹主动脉瘤,具有创伤小、疗效确切和并发症少等优点。     

Progress in the diagnosis and management of aortic dissection

A 36-year-old man sought medical attention because of pressure in his head and distention of the veins in his neck. Physical examination disclosed a murmur of aortic insufficiency, and a chest roentgenogram showed a dilated ascending aorta. Two-dimensional echocardiography and angiography demonstrated a large intimal tear in the ascending aorta and aortic insufficiency. The patient underwent a surgical procedure, which revealed that his symptoms were caused by compression of the superior vena cava by the dilated ascending aorta. The aortic dissection was successfully repaired by replacement of the aortic root with a composite graft into which the coronary ostia were reimplanted. After further assessment of the patient, including elicitation of a similar history in some paternal relatives, Marfan's syndrome was diagnosed. Physicians should be aware of the clinical manifestations, pathogenesis, and treatment of aortic dissection. With aggressive treatment, 60 to 90% of patients survived aortic dissection in 1985, whereas only 40 years ago, this entity was rarely recognized premortem or treated successfully.     

Missed cervical spine fracture: chiropractic implications

OBJECTIVE: To discuss the case of a patient with an anterior compression fracture of the cervical spine, which had been overlooked on initial examination. CLINICAL FEATURES: A 36-year-old man was seen at a chiropractic clinic 1 month after diving into the ocean and hitting his head on the ocean floor. He chipped a tooth but denied loss of consciousness. Initial medical examination in the emergency department did not include radiography, but an anti-inflammatory medication was prescribed. Radiographs taken at the chiropractic clinic 1 month later revealed an anterior compression fracture of the C7 vertebra, with migration of the fragment noted on flexion and extension views. INTERVENTION AND OUTCOME: The patient was referred back to his medical doctor for further evaluation and management.He was instructed to wear a Philadelphia collar for 4 weeks. During this time period, he reported "shooting" pain and tingling from his neck into his arms. The patient reported resolution of his neck and arm symptoms at 2.5 months after injury. Follow-up radiographs at 6 months after injury revealed fusion of the fracture fragment with mild residual deformity. At that time, the patient began a course of chiropractic treatment. CONCLUSION: After head trauma, it is essential to obtain a radiograph of the cervical spine to rule out fracture. Chiropractors should proceed with caution, regardless of any prior medical or ancillary evaluation, before commencing cervical spine manipulation after head and neck trauma.     

Recognition of prodromal cervical spondylotic myelopathy presenting in a U.S. Veteran referred to chiropractic for acute thoracic pain: A case report

ObjectiveTo highlight a patient who was referred to a VA chiropractic clinic for thoracic pain and upon physical exam was found to be myelopathic, subsequently requiring surgery.Clinical featuresA 58-year-old male attended a telephone interview with the VA chiropractic clinic for thoracic pain of 4 months duration; he denied neck pain, upper extremity symptoms or clumsiness of the feet or hands. At his in-person visit, he acknowledged frequently dropping items. The physical examination revealed signs of myelopathy including positive Hoffman's bilaterally, 3+ brisk patellar reflexes, and 5+ beats of ankle clonus bilaterally. He also had difficulty walking heel/toe.Intervention and outcomeCervical and thoracic radiographs were ordered and a referral was placed to the Physical Medicine and Rehabilitation (PM&R) Clinic for evaluation of the abnormal neurologic exam and suspicion of cervical spondylotic myelopathy (CSM). He was treated for 2 visits in the chiropractic clinic for his thoracic pain, with resolution of thoracic symptoms. No treatment was rendered to the cervical spine.The PM&R physician ordered a cervical MRI which demonstrated severe central canal stenosis and increased T2 signal within the cord at C5–C6, representing myelopathic changes. The PM&R specialist referred him to Neurosurgery which resulted in a C5-6, C6-7 anterior cervical discectomy and fusion.ConclusionThe importance of physical examination competency and routine thoroughness cannot be overstated. Swift identification of pathologic signs by the treating chiropractor resulted in timely imaging and surgical intervention.