Download - Upper Cervical Manipulation Combined with Mobilization for the Treatment of Atlantoaxial Osteoarthritis: A Report of 10 Cases

CASE REPORTS

UPPER CERVICAL MANIPULATION COMBINED WITH

MOBILIZATION FOR THE TREATMENT OF ATLANTOAXIAL

OSTEOARTHRITIS: A REPORT OF 10 CASES

Hong Yu, MD,a Shuxun Hou, MD,b Wenwen Wu, MD,b and Xiaohua He, MD, MSc

a Attending PhyffiliatedHospitalb Professor andhe 1st Affiliatedeijing, China.c Professor, Parange, Fla.Submit requestsalmer College of Cort Orange, FL 3Paper submitted0161-4754/$36Copyright © 20doi:10.1016/j.jm

ABSTRACT

Objective: This study presents the outcomes of patients with idiopathic degenerative and posttraumatic atlantoaxialosteoarthritis who were treated with upper cervical manipulation in combination with mobilization device therapy.Clinical Features: A retrospective case review of 10 patients who were diagnosed with either degenerative orposttraumatic atlantoaxial arthritis based on histories, clinical symptoms, physical examination, and radiographicpresentations was conducted at a multidisciplinary integrated clinic that used both chiropractic and orthopedicservices. All 10 patients selected for this series were treated with a combination of upper cervical manipulation andmechanical mobilization device therapy. Outcome measures were collected at baseline and at the end of the treatmentperiod. Assessments were measured using patients' self-report of pain using a numeric pain scale (NPS), physicalexamination, and radiologic changes. Average premanipulative NPS was 8.6 (range, 7-10), which was improved to amean NPS of 2.6 (range, 0-7) at posttreatment follow-up. Mean rotation of C1-C2 at the end of treatment wasimproved from 28° (±3.1) to 52° (±4.5). Restoration of joint space was observed in 6 patients. Overall clinicalimprovement was described as “good” or “excellent” in about 80% of patients. Clinical improvements in pain andrange of motion were seen in 80% and 90% of patients, respectively.Conclusion: Chiropractic management of atlantoaxial osteoarthritis yielded favorable outcomes for these 10 patients.(J Manipulative Physiol Ther 2011;34:131-137)
Key Indexing Terms: Atlantoaxial Joint; Osteoarthritis; Intractable Pain; Manipulation; Chiropractic
A tlantoaxial osteoarthritis is an uncommon clinicalcondition that has been recognized as a distinctcause of severe neck pain and reduction of range of

motion (ROM) between the atlas and axis.1,2 It has aprevalence between 4% and 18%.2,3 Commonly, idiopathicdegenerative atlantoaxial osteoarthritis occurs in theelderly; however, posttraumatic atlantoaxial osteoarthritis

sician, Department of Orthopedics, The 1stof the GeneralMilitaryHospital, Beijing, China.Chief Physician, Department of Orthopedics,Hospital of the General Military Hospital,

lmer College of Chiropractic Florida, Port

for reprints to: Xiaohua He,MD,MS, Professor,hiropractic Florida, 4777 City Center Parkway,

2129 (e-mail: [email protected])January 22, 2010; in revised form June 9, 2010..0011 by National University of Health Sciences.

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TB

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pt.2010.12.005

occurs more often in younger patients. A search of theliterature revealed only a few reports on the diagnosis andthe treatment of this pathology. Conservative treatment wasthe most common approach,4,5 and only a few cases werereported that were treated with surgery.6,7 Conservativetreatment consists of nonsteroidal anti-inflammatory drugs,soft collar, and gentle traction, which can reduce pain to atolerable level. Steroid injections into the arthritic joint maybe successful for a limited period.8 No reports ofchiropractic manipulative therapy for the management ofatlantoaxial osteoarthritis were found. The purpose of thiscase series was to report the results of upper cervicalmanipulation combined with auxiliary spine instrumentadjuster therapy used as a conservative treatment of bothdegenerative and posttraumatic atlantoaxial osteoarthritis.

CASE SERIESA retrospective case review of 10 patients (5 men,

5 women) with neck pain and atlantoaxial osteoarthritiswho were managed at our institution for the previous 5

131

mailto:[email protected]

http://dx.doi.org/10.1016/j.jmpt.2010.12.005

Table 1. Demographic information, pretreatment conditions, and posttreatment results

Case

Sex, age(y) atmanipulation

Duration ofsymptomsbeforemanipulation(yr + mo)

History ofneck injurybeforemanipulation

Neurovascularpathologybeforemanipulation

Radiographicfindingsbeforemanipulation Side

Length oftreatment (mo)

Durationof follow-up(yr + mo)

Results

Reliefof pain

Radiologicimprovement

1 M, 37 0 + 1 + – L latC1-C2 fusion,L lat masses

Left 1.5 2 + 9 Excellent Partial

2 F, 70 0 + 2 – – R latC1-C2 fusion,R lat masses;osteoarthritis

Right 18 0 + 10 Fair Partial

3 M, 46 0 + 2 + – L latC1-C2 fusion;L lat masses

Left 1 6 + 6 Good Partial

4 M, 67 1 + 6 – – L latC1-C2 fusion,L lat masses;osteoarthritis

Left 6 1 + 10 Poor Partial

5 M, 54 0 + 9 – – R latC1-C2 fusion;R lat masses;osteoarthritis

Right 3 4 + 1 Poor None

6 F, 42 0 + 10 + – L latC1-C2 fusion;L lat masses;

Left 1.3 7 + 1 Excellent Partial

7 F, 43 0 + 1 + – L latC1-C2 fusion;L lat masses

Left 0.6 2 + 2 Excellent Full

8 F, 32 0 + 3 + – R latC1-C2 fusion;R lat masses

Right 0.5 1 + 9 Excellent Partial

9 F, 63 2 + 0 – – L latC1-C2 fusion;L lat masses;osteoarthritis


10 M, 46 2 + 0 + – L latC1-C2 fusion;L lat masses;osteoarthritis


M, male; F, female; L, left; lat, lateral; R, right.

132 Journal of Manipulative and Physiological TherapeuticsYu et alFebruary 2011Atlantoaxial Osteoarthritis and Upper Cervical Manipulation

years with the upper cervical manipulation combined withan auxiliary spine adjuster was conducted. The average ageof the patients was 50 years (range, 32-70 years). Sixpatients had a history of head or neck injuries. The averageage of these patients was below 50 years. Four patients hadno noticeable trauma, although radiographic evidence ofatlantoaxial osteoarthritis was presented. The chief com-plaint of these patients was unilateral neck pain occurringwith the slightest head rotation to the side of the lesion. TheROM between C1 and C2 was limited, especially in theplane of axial rotation. The physical examination usuallyrevealed tenderness at the C2 level. Neurologic status wasalso evaluated to exclude any signs of neurologicpathology. The diagnosis of atlantoaxial osteoarthritiswas confirmed by plain radiographs (anterior/posterior,open mouth, and lateral views) taken before treatment.Computed tomography (CT) scans were ordered in 4

patients to rule out tumor, fractures, upper cervicaldeformities, rheumatoid arthritis, and other postoperativeabnormalities. Transcutaneous Doppler ultrasound was alsoperformed to evaluate the condition of the vertebralarteries. Neck pain was evaluated before and aftermanipulation using the numeric pain scale (NPS) in allpatients (NPS: 0, no pain; 10, maximum pain).

Chiropractic manipulation was only provided to patientswho presented with no neurovascular deficits and had noacute injuries. The chiropractic manipulative techniqueconsisted of high-velocity, low-amplitude (HVLA) thrust tothe upper cervical spine. The frequency and intensity ofcervical manipulation was delivered on a case-by-case basis,largely depending on patients' tolerance to the manipula-tion. The age of the patient, cause, duration, and course ofthe arthritis were all taken into consideration when setting upthe frequency and intensity of manipulation. The following

Fig 1. A 46-year-old man who had a head or neck injury 2 monthsbefore treatment. His chief complaint was pain on the left side ofhis neck. Physical examination found a reduction in ROM ofC1-C2 for rotation. Plain film radiographs showed the narrowingjoint space of the left atlantoaxial joint. The patient was diagnosedas posttraumatic atlantoaxial osteoarthritis.

Fig 2. The same patient as in Figure 1 6 weeks after HVLAupper cervical adjustments combined with the device supple-mentary therapy. The patient indicated that he had relief of pain.Clinical examination also found improvement of C1-C2 rotation.Radiograph showed the restoration of joint space in the leftatlantoaxial joint.

133Yu et alJournal of Manipulative and Physiological TherapeuticsAtlantoaxial Osteoarthritis and Upper Cervical ManipulationVolume 34, Number 2

principles were used when making a decision for themanipulation: higher frequency and lower intensity wereusually applied to patients whose symptoms were at theinitial stage or who were in the early stage of recovery frominjury. Once the symptoms were under control a differentfrequency of care, such as once a week, was used. Whentaking age into consideration, younger patients usuallyreceived higher intensity manipulation than older patients. Itwas important to observe and record patients' responses tothe first adjustment. In an attempt to reduce muscle tensiondue to neck stiffness because of neck pain, gentle neckmassage several minutes before the upper cervical manip-ulation sometimes was carried out. Subsequent to the uppercervical HVLA manipulation, all patients received asupplementary therapy performed by a mechanical device,(S.M.A.R.T Adjuster, TM SA201; Sigma Instruments, Inc,Cranberry Twp, PA). The device consists of a lever-actuatedmechanical jig and a pressure sensor so that it can detecttissue changes (temperature and density) thought to be aresult of reduced spinal segmental motion. The device cantransmit up to 20 lb/inch2 force impulse through apiezoelectric force sensor to mobilize joints. Because ofrelatively weaker muscles and a lower tolerance of painbetween C1 and C2, we applied different intensities of thedevice to different patients with different ages, for example,20 lb/inch2 for younger patients and 15 lb/inch2 for elderly.

After a follow-up time (6-8 weeks), all patients underwentclinical and radiologic reevaluations. The following clinicaloutcomes were collected: pain location, if present; pain

intensity according to the NPS scale; cervical ROM of C1-C2rotation; and radiographic observations. Overall clinicalassessment was based on criteria,9 defined as “excellent” ifthe patient had no pain and C1-C2 activity was unlimited;good if there was slight pain and slight reduction in activity;“fair” if there was moderate pain, limiting daily activity; andpoor if there was no pain relief and symptoms were equal orworse than before treatment and severe limitation of activitybecause of pain. Pain assessment was evaluated using the NPSusing the following categories: noticeable improvement (NPSchange, N7), improvement (NPS change, 7-3), and non-improvement (NPS, no change). Open-mouth radiographicviews were used to assess the atlantoaxial facet joint space.

Upon initial presentation, these patients with atlantoaxialosteoarthritis typically described the existence of localizedneck pain, often ascending to the occiput and radiating tothe frontal and temporal sides (intractable occipitocervicalpain). The pain was predominantly on the side of theosteoarthritic atlantoaxial joint. Head rotation was painfuland almost completely blocked in 3 patients and restrictedby more than 50% in the other 7 patients. Pain intensity on

image of Fig 2

Fig 3. A 70-year-old woman developed progressive pain on theright side of her neck. Clinical examination found almost norotation between C1 and C2. Radiograph revealed the narrowingjoint space in the right atlantoaxial joint.

Fig 4. A CT scan of the same patient in Figure 3 showed erosionof the joint surface of the right atlantoaxial joint.


the NPS scale was more than 7 in all patients. All thepatients were neurologically intact. The standard open-mouth radiographic view before manipulation revealedunilateral atlantoaxial joint space narrowing with subchon-dral sclerosis. On the coronal CT scan in 3 patients, theaffected C1-C2 facet joint space showed narrowing withirregular margin.

The patients were treated with HVLA upper cervicalmanipulation and followed with a mobilization devicesupplement treatment. After a series of treatments, thepatients reported pain relief. Average premanipulative NPSwas 8.6 (range, 7-10), which improved to a mean NPS of2.6 (pain relief differed from patient to patient, ranging from0 to 7) in posttreatment follow-up. Mean rotation of C1-C2at the end of treatment was improved from 28° (±3.1) to 52°(±4.5). Two patients were graded as noticeable improve-ment in NPS pain assessment; both of them were youngpatients with posttraumatic atlantoaxial osteoarthritis.Overall, pain relief was more evident and faster in youngerpatients (n = 6) and in posttraumatic atlantoaxial osteoar-thritis (n = 6). These patients usually achieved excellent andgood ratings of criteria. Open-mouth radiograph of somepatients revealed recovery of joint space.

In contrast, idiopathic degenerative atlantoaxial osteo-arthritis in more elderly patients (n = 4) required longer andmore intense treatment. Although temporary pain reliefcould be achieved after each manipulation, full pain relieftook as long as 10 months to achieve. Two patients in thisgroup were graded as nonimprovement in NPS painassessment. Generally, these patients could achieve good

or fair results, but that required longer treatment period. Inaddition, radiographic recovery of joint space was notnecessarily associated with the relief of symptoms.

Overall, 6 patients (4 traumatic and 2 degenerative cases)had substantial improvement in pain as well as partialrestoration of joint space after manipulation and supple-mentary therapy. There were no complications or adverseevents reported that were related to the therapy for these 10patients. Table 1 shows the demographic information,pretreatment conditions, and posttreatment results.

Typical Posttraumatic Atlantoaxial Osteoarthritic CaseA 46-year-old man had a history of head/neck injury 2

months before admission. He presented with left diffusemusculoskeletal pain in the neck and temporal regions. Theleft neck pain was rated as NPS 8 of 10; this was associatedwith reduced ROM of cervical vertebral, especially C1-C2rotation, tenderness in the left neck region, and musclespasm. Radiograph revealed complete narrowing of the leftatlantoaxial joint space (Fig 1). The patient was diagnosedas posttraumatic atlantoaxial osteoarthritis and receivedupper cervical manipulation combined with mobilizationtherapy. The patient had pain relief 1 week after thetreatment (NPS, 3/10) and continued improving during thefollowing weeks of therapy (NPS, 0-1/10). Evidentimprovement of ROM was found at the follow-up visit 6weeks later. Radiographic reevaluation also showed partialrestoration of the atlantoaxial joint space (Fig 2). Thepatient continued to receive the therapy until the outcomewas reported as excellent.

Typical Idiopathic Degenerative Atlantoaxial Osteoarthritic CaseA 70-year-old woman had progressive development of

right-sided neck pain 2 months before admission that wasassociated with simultaneous onset of stiffness in the neck.There was no history of neck or head injury and any other

image of Fig 3

image of Fig 4

Fig 5. Eight weeks after HVLA upper cervical adjustmentscombined with the device supplementary therapy, the patient inFigures 3 and 4 indicated slight improvement of pain. Clinicalexamination also suggested a little improvement of ROM betweenC1-C2. Radiograph revealed the partial restoring of joint space.

Fig 6. The patient in Figures 3-5 6 months after treatment. A CTscan showed that the joint surface erosion still existed.


precipitating event. The right-sided neck pain was describedas being a 9 of 10 when upright; within 30 seconds ofbecoming supine position, neck pain would lessen to 4 to 5of 10. The findings of clinical examination included aslightly tilted head and reduced ROMof cervical movement.The radiograph showed narrowing of the right atlantoaxialjoint space (Fig 3) and erosion of the joint surface (Fig 4).The treatment included upper cervical manipulation com-bined with mobilization therapy. Slight pain relief (7/10)and improvement of ROM was found after 4 weeks oftreatment. Eight-week, 6-month, and 18-month clinicalfollow-ups showed partial recovery of ROM and joint space(Fig 5); however, joint surface erosion did not showtremendous changes (Fig 6). This patient was rated as fair.

DISCUSSION

To the best of our knowledge, this is the first report toreview the outcomes of cervical manipulation combinedwith the supplementary therapy on the management of neckpain due to atlantoaxial osteoarthritis. The pathology ofdegenerative changes of the atlantoaxial osteoarthritis isbelieved to be similar to that of other common osteoarthritisaffecting the lumbar and subaxial cervical spine,6 such asthe development of degenerative fibrosis. However,degenerative fibrosis arising from the atlantoaxial facetjoint is less well recognized than other common osteoar-thritis. Because of their uncommon presentation, degener-

ative fibrosis of atlantoaxial osteoarthritis can be confusedwith other pathologic entities, including rheumatoidfibrosis, tumors, and migrated disc herniation. A CT scancan be used to rule out the above pathologic entities andassess the anatomical details of C1/C2 before the treatment.

Currently, 2 types of treatment options are clinically usedto manage atlantoaxial osteoarthritis: operative and nonop-erative managements. Kuklo et al10 suggested nonoperativemanagement as the first option as long as it was effective andthe symptoms were tolerable. Surgical treatment such asatlantoaxial arthrodesis is only indicated when pain isintractable after conservative treatment.9 Although mostpatients obtain pain relief after surgery, a significantpercentage of patients developed late complications becauseof the surgery and required revision surgery.11 Existingliterature about nonoperative management is sparse. Therewas a report of the intraarticular C1/C2 blocks that weresuggested to be helpful in delineating pain.12 Rehabilitationusing cervical traction and immobilization with a collar wasalso reported.13 One study also reported the use of orientalalternative herbal medicine.14 However, no chiropracticmanagement was ever been reported.

Literature review revealed that although both operativeand nonoperative managements could relieve pain in somedegree, both managements might not be effective enough toachieve long-term sustained improvement and eliminate thecomplications. For example, cervical traction and immobi-lization are nonspecific treatments that may relieve paintemporally; reoccurrence of symptoms were often seen aftera period. Intraarticular cortisol injection may reduceinflammation and may lead to pain relief; however, thistherapy often induces more joint degenerative changes suchas joint adhesion. Most surgical procedures involve C1/C2joint fixation and sacrifice joint mobility. Late complica-tions can cause worse pain and require revision surgery. Incontrast, spinal manipulative therapy differs greatly fromthe aforementioned nonoperative and operative treatments.Spinal manipulation has been shown to mobilize z joints

image of Fig 5

image of Fig 6


and increase z joint space,15 which not only relieves thepain caused by joint degeneration but also restores jointmobility and lessens the degenerative process.

Because of the advantages of spinal manipulation, weapplied HVLA spinal adjustment in treating patients withatlantoaxial osteoarthritis in our clinic. High-velocity, low-amplitude spinal adjustment could precisely mobilize theC1/C2 joint; yet, it would maintain the integrity ofadjacent soft tissues. Our results documented painimprovement on the NPS, overall clinical improvement,and radiographic improvement in most of patients after aperiod of C1/C2 joint manipulation supplemented by themobilization device.

To accomplish maximal benefit of spinal manipulativetreatment, we also applied mobilization with a device as asupplementary treatment. Instrument-assisted manipulationhas been shown effectively to increase the ROM in a varietyof cases.16 The device was used to mobilize the surroundingsoft tissues and ease muscle spasm; the goal was to furtherreinforce the effect of upper cervical adjustment on thetreatment of atlantoaxial osteoarthritis.

It is noticed in this case series that restoration of theatlantoaxial joint space after manipulation in follow-upradiographs was associated with symptomatic improvementin some patients. This evidence suggests that spinalmanipulation combined with instrument-assisted therapymay have a positive impact on the degenerative process ofatlantoaxial osteoarthritis.

Finally, the existence of posttraumatic atlantoaxialosteoarthritis may be controversial because most of theexisting literature about atlantoaxial osteoarthritis relates toidiopathic degenerative atlantoaxial osteoarthritis. None-theless, posttraumatic atlantoaxial osteoarthritis usuallyoccurs in younger patients. A careful history may revealthe history of neck or head injuries. The symptoms andradiographic presentations are similar to those of idiopathicdegenerative atlantoaxial osteoarthritis such as neck pain,reduction of ROM, and narrowing C1-C2 joint space. Wealso noticed that posttraumatic patients often respondedwell to the manipulative therapy. These patients requiredrelatively shorter duration of therapy and had betterprognosis when compared to patients with idiopathicdegenerative atlantoaxial osteoarthritis.

LimitationsA limitation of this study was that it is a retrospective

case review, and there were only a small number of patients;therefore, no major conclusions can necessarily be appliedto other patients. In addition, the patients were selectedbased upon their findings; thus, there is likely some bias inpatient selection for this study. The wide range of ages andinclusion of both idiopathic and posttraumatic degenerativeatlantoaxial osteoarthritic cases may have also led tovariability in the change of NPS scores. Another limitation

includes the interpretation of radiographic reevaluation.Although great efforts were made to keep the patients'position consistent in all radiographic evaluations, we couldnot rule out the possibility of a small difference inradiographic positioning from one time to another, whichmay have influences joint space measurement. The currentstudy did not consider the style or quality of HVLA cervicalspinal manipulation delivered to the patients. Futureprospective studies and clinical trials to determine ifchiropractic management of atlantoaxial osteoarthritis isbeneficial are warranted.

CONCLUSION

This case series suggests that some of the signs andsymptoms of atlantoaxial facet osteoarthritis, which canoccur in the elderly because of degenerative disorder andyounger patients because of trauma, may be improved byupper cervical spinal manipulation combined with mobili-zation with a mechanical device.

FUNDING SOURCES AND POTENTIAL CONFLICTS OF INTERESTNo funding sources or conflicts of interest were reported

for this study.

ACKNOWLEDGMENT

The authors thank KennethWebber II, DC, for reviewingthe manuscript and offering his recommendations.

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