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  • Re: Chiropractice

    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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