November « 2010 « Neck Solutions Blog

November 28, 2010

Neck pain with and without affection of nerve roots

Filed under: Neck Pain — Administrator @ 2:24 pm

Neck pain with and without affection of nerve roots

From: Tidsskr Nor Laegeforen. 2010 Nov 18;130(22):2252-2255

The prevalence of neck pain is 30-50 %, and those most affected are women and people in working age. Neck pain and other musculoskeletal complaints are among the most common causes for sick leave and disability pension in Norway, which emphasises the need for guidelines on diagnostic assessment and treatment of these patients.

This paper is based on a review of The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorder, Cohrane overviews and some additional sources. A classification of neck pain into grades I-IV is recommended as a tool for daily clinical work. Unspecific neck pain (grades I and II) is still a challenge and the various underlying conditions are not well defined. Diagnostics and assessment of neck pain is mainly directed towards nerve root affection (grade III) or serious neck disease (grade IV).

Treatment of neck pain is not sufficiently evidence-based, as there are few high-quality publications within this field. Research within the field is clearly needed and should be prioritized nationally.

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November 26, 2010

Reduction in segmental flexibility because of disc degeneration is accompanied by higher changes in facet loads than changes in disc pressure

Filed under: Arthritis,Disc Problems,Neck Pain — Administrator @ 7:26 am

Reduction in segmental flexibility because of disc degeneration is accompanied by higher changes in facet loads than changes in disc pressure: a poroelastic C5-C6 finite element investigation.

From: Spine J. 2010 Dec;10(12):1069-77.

Nerve fiber growth inside the degenerative intervertebral discs and facets is thought to be a source of pain, although there may be several other pathological and clinical reasons for the neck pain. It, however, remains difficult to decipher how much disc and facet joints contribute to overall degenerative segmental responses. Although the biomechanical effects of disc degeneration on segmental flexibility and posterior facets have been reported in the lumbar spine, a clear understanding of the pathways of degenerative progression is still lacking in the cervical spine.

To test the hypothesis that after an occurrence of degenerative disease in a cervical disc, changes in the facet loads will be higher than changes in the disc pressure. To understand the biomechanical relationships between segmental flexibility, disc pressure, and facet loads when the C5-C6 disc degenerates.

METHODS: A poroelastic, three-dimensional finite element (FE) model of a normal C5-C6 segment was developed and validated. Two degenerated disc models (moderate and severe) were built from the normal disc model. Biomechanical responses of the three FE models (normal, moderate, and severe) were further studied under diurnal compression (at the end of the daytime activity period) and moment loads (at the end of 5 seconds) in terms of disc height loss, angular motions, disc pressure, and facet loads (average of right and left facets).

Disc deformation under compression and segmental rotational motions under moment loads for the normal disc model agreed well with the corresponding in vivo studies. A decrease in segmental flexibility because of disc degeneration is accompanied by a decrease in disc pressure and an increase in facet loads. Biomechanical effects of degenerative disc changes are least in flexion. Segmental flexibility changes are higher in extension, whereas changes in disc pressure and facet loads are higher in lateral bending and axial rotation, respectively.

The results of the present study confirmed the hypothesis of higher changes in facet loads than in disc pressure, suggesting posterior facets are more affected than discs because of a decrease in degenerative segmental flexibility. Therefore, a degenerated disc may increase the risk of overloading the posterior facet joints. It should be clearly noted that only after degeneration simulation in the disc, we recorded the biomechanical responses of the facets and disc. Therefore, our hypothesis does not suggest that facet joint osteoarthritis may occur before degeneration in the disc. Future cervical spine-based experiments are warranted to verify the conclusions presented in this study.

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November 22, 2010

Ipsilateral atrophy of paraspinal and psoas muscle in unilateral back pain patients with monosegmental degenerative disc disease

Filed under: Back Pain,Disc Problems — Administrator @ 4:45 am

Ipsilateral atrophy of paraspinal and psoas muscle in unilateral back pain patients with monosegmental degenerative disc disease.

Br J Radiol. 2010 Nov 16. [Epub ahead of print]

To assess the cross sectional area of both paraspinal and psoas muscles in patients with unilateral back pain using MRI and to correlate it with outcome measures. 40 patients, all with informed consent, with a minimum of 3 months of unilateral back pain with or without sciatica and one-level disc disease on MRI of lumbosacral spine were included. Patients were evaluated with self-report measures regarding pain (Visual Analogue Score) and disability (Oswestry Disability Index). The cross sectional area of multifidus, erector spinae, quadratus lumborum and psoas was measured at the disc level of pathology and the two adjacent disc levels, bilaterally. Comparison of cross sectional areas of muscles between the affected vs symptomless side was carried with Student’s t-test and correlations were conducted with Spearman’s test.

The maximum relative muscle atrophy (% decrease in cross sectional area on symptomatic side) independent of the level was 13.1% for multifidus, 21.8% for erector spinae, 24.8% for quadratus lumborum and 17.1% for psoas. There was significant difference between sides (symptomatic and asymptomatic) in cross sectional area of multifidus, erector spinae, quadratus lumborum and psoas. However, no statistically significant correlation was found between the duration of symptoms (average 15.5 months), patient’s pain (average VAS 5.3) or disability (average ODI 25.2) and the relative muscle atrophy.

In patients with long-standing unilateral back pain due to monosegmental degenerative disc disease, selective multifidus, erector spinae, quadratus lumborum and psoas atrophy develops on the symptomatic side. Radiologists and clinicians should evaluate spinal muscle atrophy of patients with persistent unilateral back pain.

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November 19, 2010

A three-dimensional finite element model of the cervical spine: an investigation of whiplash injury

Filed under: Neck Pain,Whiplash — Administrator @ 4:34 am

A three-dimensional finite element model of the cervical spine: an investigation of whiplash injury

From: Med Biol Eng Comput. 2010 Nov 17. [Epub ahead of print]

Very few finite element models of the cervical spine have been developed to investigate internal stress on the soft tissues under whiplash loading situation. In the present work, an approach was used to generate a finite element model of the head (C0), the vertebrae (C1-T1) and their soft tissues. The global acceleration and displacement, the neck injury criterion, segmental angulations and stress of soft tissues from the model were investigated and compared with published data under whiplash loading. The calculated acceleration and displacement agreed well with the volunteer experimental data. The peak neck injury criterion was lower than the proposed threshold. The cervical S and C-shaped curves were predicted based on the rotational angles. The highest segmental angle and maximum stress of discs mainly occurred at C7-T1. Greater stress was located in the anterior and posterior regions of the discs. For the ligaments, peak stress was at anterior longitudinal ligaments. Each level of soft tissues experienced the greatest stress at the time of cervical S and C-shaped curves. The cervical spine was likely at risk of hyperextension injuries during whiplash loading. The model included more anatomical details compared to previous studies and provided an understanding of whiplash injuries.

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November 17, 2010

An Examination of Outcome Measures for Pain and Dysfunction in the Cervical Spine: A Factor Analysis.

Filed under: Neck Pain — Administrator @ 10:18 am

An Examination of Outcome Measures for Pain and Dysfunction in the Cervical Spine: A Factor Analysis.

From: Spine (Phila Pa 1976). 2010 Nov 12. [Epub ahead of print]

This study examined and compared the factorial structure of 4 validated neck pain and dysfunction scales. Neck pain and dysfunction is commonly measured using 1 of 4 validated self-reporting questionnaires: the Neck Disability Index, the Northwick Park Neck Pain Questionnaire, the Copenhagen Neck Functional Disability Scale, and the Neck Pain and Disability Scale.

Although used interchangeably in the literature, recent studies suggest that the 4 scales differ in the number and type of factors that they examine and the weighting of these factors. To date, there have been no direct comparisons made of these scales when applied simultaneously to the same patient population.

Data were collected from 88 patients with mechanical neck pain who completed all 4 questionnaires. Exploratory principal components factor analyses were conducted to expose the underlying factors within each of the scales. Identified factors were examined, characterized, and compared.

Factor analysis revealed a single factor for the Neck Disability Index, 2 factors for the Northwick Park Neck Pain Questionnaire, and 3 factors for both the Copenhagen Neck Functional Disability Scale and Neck Pain and Disability Scale. Factors identified include neck pain, dysfunction related to general activities, neck-specific function, cognition, emotion, and the influence of participation restriction on psychosocial functioning. The 3 Neck Pain and Disability Scale factors appear to assess the multidimensional nature of neck pain and dysfunction most comprehensively.

When selecting and interpreting a neck pain and dysfunction scale, clinicians and researchers are encouraged to take into account the factors measured by the Neck Disability Index, Northwick Park Neck Pain Questionnaire, Copenhagen Neck Functional Disability Scale, and Neck Pain and Disability Scale and their applicability to the specific neck patient population under examination. The decision of which factors are of greatest interest will influence the selection of an appropriate outcome instrument.

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November 15, 2010

Back muscle strength and spinal mobility are predictors of quality of life in middle-aged and elderly males

Filed under: Back Pain,General Health,Posture — Administrator @ 4:40 am

Back muscle strength and spinal mobility are predictors of quality of life in middle-aged and elderly males

From: Eur Spine J. 2010 Oct 31. [Epub ahead of print]

With aging of society, clarification of the relationship between quality of life and abnormal posture in the elderly may allow improvement of quality of life through any preventive methods and training. However, sagittal balance has not been studied widely and most studies have focused on postmenopausal patients with osteoporosis. In this report, we provide the first evaluation of the simultaneous effects of degenerative changes on radiograph, spinal range of motion, sagittal balance, and back muscle strength, and examine the influence of these effects on quality of life of the middle-aged and elderly male subjects.

The subjects were 100 Japanese males who underwent a basic health checkup. Lumbar lateral radiograph, sagittal balance and spinal mobility determined and back muscle strength were measured. The thoracic/lumbar angle ratio was used as an index of sagittal balance. SF-36 physical component summary scores showed a significant negative correlation with age, osteophyte score and thoracic/lumbar angle ratio, and a significant positive correlation with lumbar lordosis angle, thoracic spinal range of motion, and back muscle strength. Multiple regression analysis indicated that thoracic spinal range of motion and back muscle strength were significantly associated with SF-36 physical component summary.

In conclusion, quality of life of the middle-aged and elderly male subjects was related to sagittal balance, lumbar lordosis angle, spinal range of motion, and back muscle strength. Exercise including muscle strength and spinal range of motion may be able to influence these primary factors related to quality of life. Back muscle strength and thoracic range of motion impact on improvement of quality of life in the middle-aged and the elderly

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November 13, 2010

Are MRI high-signal changes of alar and transverse ligaments in acute whiplash injury related to outcome?

Filed under: Neck Pain,Whiplash — Administrator @ 7:48 am

Are MRI high-signal changes of alar and transverse ligaments in acute whiplash injury related to outcome?

From: BMC Musculoskelet Disord. 2010 Nov 11;11(1):260. [Epub ahead of print]

The alar and transverse ligaments are important stabilizers at the craniovertebral junction and can be injured during neck trauma. These ligaments can be visualised on magnetic resonance imaging (MRI). High-signal changes of the alar and transverse ligaments on high-resolution MRI have been reported to be more frequent in chronic whiplash associated disorders compared to non-injured controls. In the same study sample, such ligament changes were related to neck disability and trauma factors like impact direction and head position at the instant of collision. These results have not been confirmed by others, and high-signal changes of upper neck ligaments are reported to be frequent also in asymptomatic and symptomatic non-injured controls. Such changes thus have unclear cause and clinical relevance. They might be traumatic in some cases but might also represent pre-traumatic morphologic variants with loose connective tissue or fat interspersed between fibres. If such variants affect ligament strength and prognosis after neck trauma these MRI findings could represent a target for interventions to improve patients’ recovery.

The prognostic factors for developing chronic whiplash associated disorders after whiplash injury have not been established. Female gender, more severe post traumatic stress response, and reduced expectations of recovery have been found associated with poor outcome in whiplash associated disorders. In recent reviews, high score of initial pain has been pointed out as the most important predictor for delayed recovery. In prior MRI studies on whiplash associated disorders, traumatic findings in the acute phase of whiplash injury were rare and did not affect recovery. However, due to the magnetic field strength and MRI protocols chosen, the alar and transverse ligaments could not be assessed. Data on the prognostic role of MRI high-signal changes of these ligaments in acute whiplash associated disorders have been requested.

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November 11, 2010

Appropriateness of lumbar spine referrals to a neurosurgical service

Filed under: Back Pain,Disc Problems — Administrator @ 5:47 am

Appropriateness of lumbar spine referrals to a neurosurgical service

From: Can J Neurol Sci. 2010 Nov;37(6):843-8

Patients with lumbar spine complaints are often referred for surgical assessment. Only those with clinical and radiological evidence of nerve root compression are potential candidates for surgery and appropriate for surgical assessment. This study examines the appropriateness of lumbar spine referrals made to neurosurgeons in Edmonton, Alberta.

Lumbar spine referrals to a group of ten neurosurgeons at the University of Alberta were reviewed over three two month intervals. Clinical criteria for “appropriateness” for surgical assessment were as follows: Appropriate Referrals were those that stated leg pain was the chief complaint, or those that described physical exam evidence of neurological deficit, and imaging reports (CT or MRI) were positive for nerve root compression. Uncertain Referrals were those that reported both back and leg pain without specifying which was greater, without mention of neurologic deficit, and when at least possible nerve root compression was reported on imaging. Inappropriate Referrals contained no mention of leg symptoms or signs of neurological deficit, and/or had no description of nerve root compression on imaging.

Of the 303 referrals collected, 80 (26%) were appropriate, 92 (30%) were uncertain and 131 (44%) were inappropriate for surgical assessment. Physicians seeking specialist consultations for patients with lumbar spine complaints need to be better informed of the criteria which indicate an appropriate referral for surgical treatment, namely clinical and radiological evidence of nerve root compression. Avoiding inappropriate referrals could reduce wait-times for both surgical consultation and lumbar spine surgery for those patients requiring it.

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November 8, 2010

Biomechanical Influence of Disk Properties on the Load Transfer of Healthy and Degenerated Discs Using a Poroelastic Finite Element Model

Filed under: Arthritis,Disc Problems — Administrator @ 4:55 am

Biomechanical Influence of Disk Properties on the Load Transfer of Healthy and Degenerated Discs Using a Poroelastic Finite Element Model

J Biomech Eng. 2010 Nov;132(11):111006

Spine degeneration is a pathology that will affect 80% of the population. Since the intervertebral discs play an important role in transmitting loads through the spine, the aim of this study was to evaluate the biomechanical impact of disc properties on the load carried by healthy (Thompson grade I) and degenerated (Thompson grades III and IV) discs. A three-dimensional parametric poroelastic finite element model of the L4/L5 motion segment was developed. Grade I, grade II, and grade IV discs were modeled by altering the biomechanical properties of both the annulus and nucleus. Models were validated using published creep experiments, in which a constant compressive axial stress of 0.35 MPa was applied for 4 h. Pore pressure and effective stress were analyzed as a function of time following loading application (1 min, 5 min, 45 min, 125 min, and 245 min) and discal region along the midsagittal profile for each disc grade. A design of experiments was further implemented to analyze the influence of six disc parameters disc height, fiber proportion, drained Young’s modulus, and initial permeability of both the annulus and nucleus) on load-sharing for disc grades I and IV. Simulations of grade I, grade III, and grade IV discs agreed well with the available published experimental data. Disc height had a significant influence on the pore pressure and effective stress during the entire loading history for both healthy and degenerated disc models.

Young’s modulus of the annulus significantly affected not only effective stress in the annular region for both disc grades in the initial creep response but also effective stress in the nucleus zone for degenerated discs with further creep response. The nucleus and annulus permeabilities had a significant influence on the pore pressure distribution for both disc grades, but this effect occurred at earlier stages of loading for degenerated than for healthy disc models. This is the first study that investigates the biomechanical influence of both geometrical and material disc properties on the load transfer of healthy and degenerated discs. Disc height is a significant parameter for both healthy and degenerated discs during the entire loading. Changes in the annulus stiffness, as well as in the annulus and nucleus permeability, control load-sharing in different ways for healthy and degenerated discs.

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November 5, 2010

A research synthesis of therapeutic interventions for whiplash associated disorder

Filed under: Whiplash — Administrator @ 4:10 pm

A research synthesis of therapeutic interventions for whiplash associated disorder:

Pain Res Manag. 2010 Sep-Oct;15(5):287-334.

Part 1 – overview and summary

Whiplash associated disorder represents a significant public health problem, resulting in a substantial socioeconomic burden throughout the industrialized world, wherever costs are documented. While many treatments have been advocated for patients with whiplash associated disorder, scientific evidence of their effectiveness is often lacking. A systematic review was conducted to evaluate the strength of evidence supporting various whiplash associated disorder therapies. Multiple databases (including Web of Science, EMBASE and PubMed) were searched to identify all studies published from January 1980 through March 2009 that evaluated the effectiveness of any clearly defined treatment for acute (less than two weeks), subacute (two to 12 weeks) or chronic (longer than 12 weeks) whiplash associated disorder. The present article, the first in a five-part series, provides an overview of the review methodology as well as a summary and discussion of the review’s main findings. Eighty-three studies met the inclusion criteria, 40 of which were randomized controlled trials. The majority of studies (n=47) evaluated treatments initiated in the chronic stage of the disorder, while 23 evaluated treatments for acute whiplash associated disorder and 13 assessed therapies for subacute whiplash associated disorder. Exercise and mobilization programs for acute and chronic whiplash associated disorder had the strongest supporting evidence, although many questions remain regarding the relative effectiveness of various protocols. At present, there is insufficient evidence to support any treatment for subacute whiplash associated disorder. For patients with chronic whiplash associated disorder who do not respond to conventional treatments, it appears that radiofrequency neurotomy may be the most effective treatment option. The present review found a relatively weak but growing research base on which one could make recommendations for patients at any stage of the whiplash associated disorder continuum. Further research is needed to determine which treatments are most effective at reducing the disabling symptoms associated with whiplash associated disorder.

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