Manipulative treatment of the spinal region is the art, science, and practice of the non-operative restoration of the function of bones, joints, muscles, tendons and ligaments. This requires a thorough knowledge of the anatomy, physiology and pathological changes of the joints and their surrounding tissues.
In chronic back pain when the patient has received regular manipulative treatment over a long enough period of time to produce results and no improvement either symptomatic or in character or range of articular motion has occurred, manipulation under an anesthetic may be desirable.
Three very important principles must be carefully followed if manipulation under anesthesia or conscious sedation is to be successful. (1) Careful selection of the cases. (2) Careful application of the technique. (3) Careful, well planned post manipulative care.
Indications
The general indications for manipulative procedures under anesthesia and conscious sedation are primarily conditions in which manipulation is the therapy of choice, but which do not respond satisfactorily to manipulation without anesthesia.
Some of the conditions in which manipulation under anesthesia or conscious sedation has produced satisfactory results are nerve entrapment, chronic myositis, chronic fibrositis, anomalies with restricted motion following trauma, chronic muscle contracture, acute muscle spasm associated with subluxation, chronic productive arthritis such as spondylosis, spondylarthritis, spondylarthrosis, lumbarization, sacralization, chronic disc change, old compression fractures, and traumatic torticollis.
Manipulation under anesthesia of these conditions may afford relatively quick relief for the patient with a so-called intractable musculoskeletal disorder. The type of case most amenable to treatment by manipulation is that in which the main pathological cause is the interference with joint motion by the presence of adhesions.
Contraindications
Specific contraindications to manipulation of the spine under anesthesia or conscious sedation are malignancy with metastasis to bone, tuberculosis of the bone, fractures, acute arthritis, acute gout, uncontrolled diabetic neuropathy, syphilitis articular or periarticular lesions, gonorrheal spinal arthritis, excessive spinal osteoporosis, evidence of cord or caudal compression by tumor, ankylosis, and malacic bone disease.
Evaluation of the Patient
In general, patients selected for manipulation under anesthesia or conscious sedation are those who have received regular manipulation over a sufficient period of time to obtain results but show no improvement in symptoms, character, or range of motion. In testing, these patients appear to have a very rigid vertebral column and the spinal musculature is spastic. The rigidity and spasticity is increased when motion is attempted. The duration of conservative manipulation without anesthesia or conscious sedation may vary from one day to six weeks. Patients must be selected for manipulation under anesthesia after one has obtained an adequate history, thorough physical examination and the appropriate x-ray and laboratory procedures necessary for an accurate diagnosis of the underlying condition that has manifested the current problem. Following manipulation under anesthesia, the patient must be initiated into a program of rehabilitation, physical therapy and exercise to prevent the reformation of fibrotic adhesions in the soft tissues. If the initial pathological changes (inflammation, edema and fibrous reaction), that led to the joint dysfunction are allowed to reoccur, then fibrous reaction will again lead to limited mobility. Therefore, without the initiation of an aggressive rehabilitation program, the patient's original problem will once again manifest itself.
History
In obtaining an adequate history, the investigator needs to differentiate as to whether the patient's pain is increased or decreased by activity. Generally speaking, the pain and symptoms increased by activity may be related to a traumatically induced condition, while pain and symptoms that decreased temporarily with activity and then intensify may be related to an arthritic condition. Specific localization of pain may be suggestive of infections, fractures and malignancies. A metabolic disturbance or arthritic condition present with a generally dispersed picture of the patient in pain.
Physical Exam
In addition to routine physical examination procedures, motion palpation of the spine should be utilized. Examiners should look for hyper or hypo mobility at each level. The examiner should visually inspect and palpate the skin for manifestations of sympathetic nervous system changes including edema, changes in tissue texture, increase or decrease of moisture on the skin, temperature or lack of tone in the muscles and facia which would lead to altered body mechanics. In diagnosing the appropriate spinal level one is then able to apply manipulative procedures specifically and competently rather than indiscriminately.
Laboratory Examination
Laboratory examinations should include a complete blood count, sedimentation rate, thyroid function tests, urinalysis and blood uric acid, creatinine, blood sugar, RA latex, C-reactive protein antiserum agglutination, and electrophoretic serum protein determinations. If the patient is a female past 35 years of age, a Papanicolaou smear should be done. If the patient is a male past 40 years of age, serum alkaline and acid phosphatase determination should be done. After completion of the preliminary work, other laboratory procedures such as isotope scanning, et cetera may be indicated.
Radiograph Examination
The minimum x-rays should be anterior-posterior and lateral views of the joints involved. Additionally, right and left oblique views of the lumbar and thoracic spines should be obtained as well as flexion, extension and oblique views of the cervical spine. Weight bearing views of the lumbar spine and pelvis should be formed in the anterior posterior position. Any leg length discrepancy would be apparent on standing views. Many times one will want detailed studies of the joints which are to be manipulated under anesthesia. Motion studies on videofluroscopy may be helpful. One should repeat the studies after a serial manipulation under anesthesia to see what changes have been affected by the manipulative procedures. When warranted, CT-Scan and/or MRI of the spine should be employed to rule out or confirm suspected pathology.
Electro-Diagnostic Studies
Electro-diagnostic studies of the appropriate spinal out-flows should be performed to rule out specific neurologic dysfunction, and to confirm or differentiate whether it is radicular or peripheral.
Manipulative Procedures
In the practice of manipulation, the forces used in restoring function are operator forces, patient forces, inherent or intrinsic forces, and any combination of the above. Routine manipulations performed in the doctor's office usually involve a combination of applied forces.
Conservative forces are generally qualified in two areas. (1) A high velocity/low amplitude force (thrust), (2) A low velocity/high amplitude force passively taking a joint to its full range of motion. Although high velocity/low amplitude forces break up adhesions, the low velocity high amplitude forces are particularly suited for stretching periarticular tissues. When the vectors of force are applied discriminately and carefully, less force is required to overcome restriction and produce normal motion. Patient forces such as contracting certain muscles and inhaling or exhaling, as the operator applies the mobilizing force cannot be used under anesthesia. The doctor must depend entirely upon operator forces to restore normal function to the affected vertebral segment. The doctor should select an appropriate combination of traction, rotation and side bending and combine that with the appropriate velocity and amplitude for the problem at hand.
No amount of experience in the office will qualify a physician for manipulation of the patient under a general anesthetic. In addition to the problems known to be associated with general anesthesia, are the possible complications of the manipulative experience alone. When the patient is fully and properly anesthetized, he has no voluntary or reflex protection against the forcible low amplitude/high velocity techniques that often are required. Fracture, dislocation, or even disc herniation may result accidentally, or if the operator is not particularly skillful. Permanent paralysis can result from overly forceful manipulation in any spinal area, but especially in the cervical and lumbosacral regions. Fracture of ribs is possible with certain thrust techniques in the thoracic area. On the other hand, inadequate manipulative therapy during general anesthesia may result in prolonged disability and a never-ending search by the attending physician for another cause for the patient's problem. Improper postoperative care may result in recurrence of the disturbance.
Postoperative Care
Postoperative care varies from operator to operator. In an effort to minimize the reformation of adhesions, passive and active exercises are prescribed from two to four times a day. Some use electric muscle stimulation, hot moist packs, and massage. Vitamin E is given daily to combat the reformation of adhesions and fibrosis. The most important postoperative care is spinal manipulation. The frequency is determined by the individual patient's condition and is usually daily to three times for the first week, decreasing thereafter.
Anesthesia and Conscious Sedation
Why Anesthesia?The answer lies in the physiology of anesthesia. Postural tone of the muscles is abolished. The muscle function of joint stabilization and the splinting action of the muscles of the joint structures is lost. Under anesthesia there remains only ligamentous action and articular changes to limit joint motion. This enables the physician to put an articulation through its normal range of motion, reduce the restrictive adhesions, thereby correcting the involved subluxated vertebrae.
Why Conscious Sedation?
Conscious sedation is a technique whereby the patient is given intravenous hypnotics and/or narcotics, but unlike general anesthesia, remains awake enough to preserve protective reflexes.
Versed is the most widely used intravenous sedative for procedures in which the patient does not need to be fully anesthetized. It is three to four times as potent per mg as valium. It should be administered only by trained qualified personnel because of the potential serious cardiopulmonary side effects. Strict patient monitoring guidelines should be followed.
Conclusions and Summary
Manipulation of the spine under anesthesia has a definite place in the treatment of some common problems in carefully selected cases. Manipulation under anesthesia is only for a select group of patients who fulfill certain requirements. The procedure should only be performed by or under the supervision of an experienced operator. Carrying out manipulation with the patient under anesthesia is satisfying to the physician and usually rewarding to the patient, though the patient frequently approaches the procedure with a degree of unspoken trepidation. Articulations are accomplished that were impossible in the patient by office procedures. As a physician's skill and confidence in his personal techniques increases, he becomes increasingly adept at relieving pain and can shorten the periods of disability considerably.