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M Swanepoel
10-28-1998, 01:43 AM
Hello All,

I have been following the discussion on spinal "adjustments" with
great interest, as I have dissected 23 lumbar motion segments, and studied
the facet joint anatomy in some detail. We should ask:

1 What spinal pathologies can be present?
2 Which of these could be meaningfully addressed by spinal
manipulation? (Or "adjustments" or whatever is currently politically
correct.)

Firstly there are acute spinal conditions. Among these are:
1 Rare unilateral apophyseal joint dislocation with hemi-paralysis
of the lower extremities, (Goldthwait, 1911). I know of one other
suspected case, but it is not in the literature.
2 Tears of spinal ligaments.
3 Microfractures of the facet joints (Burk 1908, Koch 1923, Mitchell 1933,
Mensor 1937 etc - I have seen two such fractures myself).
4 Vertebral endplate fractures (or Schmorl's nodes), (e.g. Malmivaara et al., 1986)
5 Acute disc prolapse, (the only acute condition that tends to result in chronic
pain).
6 Nipping of adipose villi between the facet joints, as originally
suggested by Putti and Logroscino (1937). Despite some doubt as
to the authenticity of these adipose villi situated at the
apices of the facet joints, I observed two of them myself, and
have a photograph of a fine specimen of one, which fitted into
pockets in the facet cartilage, and I have a photograph of these
hollows for another specimen. (Incidentally Putti and Logroscino's
dissection of 70 lumbar spines is a fine study that is sadly neglected.)
7 Tears of the facet joint capsules.
8 Paraspinal muscular sprains.
9 Major vertebral fractures.

Goldthwait proved that condition (1) could be cured by appropriate
spinal distraction, while it seems extremely likely to me that
condition (6) might also be cured by spinal manipulation, such that
the villli move back to their proper positions in apical facet
pockets.

As for the chronic conditions - these are numerous indeed:

1 Spinal metastases of cancers.
2 Chronic IV disc prolapses (bulging), (Mixter and Barr, 1934) and even
some ruptures.
3 IV disc narrowing upon ageing, followed by facet joint apical
impaction and hence tissue being nipped.
4 IV disc narrowing followed by pressure on the nerve roots (Hadley
1961).
5 IV foraminal osteophytosis followed by nerve root pressure.
6 Spondylolisthesis, especially at L5/S1.
7 Tuberculous spines (especially in poverty stricken regions).
8 Congenital abnormalities, e.g. spinal canal stenosis.
9 Genetically associated conditions, e.g. scoliosis, ankylosing
spondylitis.
10 Restriction of the spinal vascular circulation.
11 Inflammation of paraspinal tissues, abcesses due to ingrowing
hair, bacterial infections and the like.

There are (of course) others. The only conditions that would be
amenable to spinal manipulation, are those that put pressure on tissues
in a cephalo-caudal direction, calling for cephalo-caudal distraction,
(which will provide temporary relief). Long duration halo-pelvic
spinal distraction has been shown to produce the adverse side effect
of softening cervical facet joint cartilage, inducing later damage
(Tredwell and O'Brien, 1980) -however there is no reason not to
allow intermittent chiropractic cephalo-caudal distraction.

As for twisting motions of the lumbar spine, I found in my own
studies that the facets are extraordinarily congruent, and that very
little motion can occur between adjacent vertebra. No surprise!
Gregersen and Lucas (1967) and Gunzburg et al. (1991) inserted steel
pins into the spinous processes of subjects in vivo, and found that
the maximum possible twist was 1-2 degrees. Adams and Hutton
(1981) found that facet joint cartilage may be crushed by rotations
greater than 1-2 degress. Admittedly lumbar flexion may increase
this angle to 7-8 degrees (Pearcy and Hindle, 1991) - but I would
suggest from my own experience of dissecting lumbar motion segments
that anyone who imposes large twists and flexion simultaneously on
the lumbar spine, deserves to be barred from practice - if done with
sufficient torque I have little doubt that such movement can inflict
damage on the facet joint capsule, can fracture the edges of the
facets, and can tear surrounding soft tissues. (I am uncertain about
the effect it would have on the IV disc pressure and stresses.)

So - is the 1-2 degrees of intervertebral rotation that can possibly be
imposed on an infrequent basis by a chiropractor on the lumbar spine
of a patient, of physical significance for the treatment of chronic
back pain? It couldn't be. However it might cause some overloading
of facet joint cartilage, ill-adapted to bear such loads. Is the
"laying on" of hands by chiropractors on the backs of patients who
may be suffering from conditions that are psychosomatic in nature, of
clinical significance? (There is nothing untoward about suffering
from a psychosomatic condition - it can be as real as a somatic
condition, and as a psychological condition.) Yes, of course!
Chiropractors serve an extremely valuable role, in an area where
mainstream medicine has failed. They are relieving medical
practitioners of an enormous burden that they would otherwise have to
carry, and provided they are inflicting no harm, and the patients
retain the right to give or withdraw permission for treatment, does
it really matter what they are doing? Should we withdraw permission for
astrologers to write, because we can show they are non-scientific?
Come off it! Patients seek therapies and therapists that are most
efficacious for them, and long may they continue to have the right
to do so. Biomechanists should not "pull the rug".

(If anyone wants I will provide the full citations for the references
I have quoted - just ask me which one you would like.)

Mark W Swanepoel, PhD
School of Mechanical Engineering
University of the Witwatersrand
Johannesburg
South Africa

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