Case reports: headache caused by a spinal cord stimulator in the upper cervical spine

New Onset Tinnitus after High-Frequency Spinal Cord Stimulator Implantation

The most common complications of spinal cord stimulation (SCS) therapy are generally related to surgical site infection and hardware malfunction. Less well understood are the adverse neurological effects of this therapy. We present the case of a patient who underwent placement of a Senza HF10 high-frequency spinal cord stimulator with subsequent development of tinnitus, vertigo, intermittent involuntary left facial twitches, and perioral numbness. These symptoms resolved following deactivation of her device. To further explore these less common neurologic complications of SCS therapy, a review of literature and a review of the U.S. Food and Drug Administration Manufacturer and User Facility Device Experience database are included. Further research and investigation in this area are needed so that clinicians and patients may have more complete knowledge and understanding of the potential treatment-limiting complications of spinal cord stimulation.

An investigation of cervical spinal posture in cervicogenic headache

BACKGROUND

Cervicogenic headache (CGH) is defined as headache symptoms originating from the cervical spine. Cervical dysfunction from abnormal posture has been proposed to aggravate or cause CGH, but there are conflicting reports as to whether there is an association between posture and CGH.

OBJECTIVE

The purpose of this study was to evaluate differences in cervical spinal posture, measured on radiographs, between patients with probable CGH and asymptomatic control participants.

DESIGN

A single-blinded comparative measurement design was used.

METHODS

Differences in postural variables from radiographs between participants with CGH (n=30) and age- and sex-matched asymptomatic control participants (n=30) were determined using paired t tests or the nonparametric equivalent. Postural variables were general cervical lordosis (GCL, Cobb angle C2-C7), upper cervical lordosis (UCL, sagittal alignment C2 compared with C3-C4), and C2 spinous process horizontal deviation. Logistic regression determined postural variables, increasing the likelihood of CGH.

RESULTS

There were no significant differences in posture between the CGH and control groups. The mean GCL was 10.97 degrees (SD=7.50) for the CGH group and 7.17 degrees (SD=5.69) for the control group. The mean UCL was 11.86 degrees (SD=6.46) for the CGH group and 9.44 degrees (SD=4.28) for the control group. The mean C2 spinous process horizontal deviation was 3.00 mm (SD=1.66) for the CGH group and 2.86 mm (SD=2.04) for the control group. However, there was a significant association between greater GCL and an increased likelihood of having CGH (odds ratio=1.08; 95% confidence interval=1.001, 1.191).

LIMITATIONS

The findings are limited to an association between GCL and posture, as cause and effect cannot be determined.

CONCLUSIONS

The association between greater GCL and increased likelihood of having CGH suggests that GCL might be considered in the treatment of patients with CGH. However, as the data do not support posture as a cause of CGH, it is unknown whether addressing posture would reduce CGH.

Noninvasive treatments for headache

Primary headache disorders are often accompanied by neck pain or other symptoms referable to neck muscles. Therefore, physical therapy and other physical treatments are commonly prescribed for headache management. A medical literature review was completed in order to gather information regarding the efficacy of selected physical modalities in the treatment of primary and cervicogenic headache disorders. After analyzing the collected data, expert opinions were developed regarding the utility and efficacy of selected physical modalities in the management of primary and cervicogenic headaches. Based on this review, the following four expert opinions are presented: physical therapy is more effective than massage therapy or acupuncture for the treatment of tension-type headache and appears to be most beneficial for patients with a high frequency of headache attacks. Physical therapy is most effective for the treatment of migraine when combined with other treatments such as thermal biofeedback, relaxation training and exercise. Chiropractic manipulation demonstrated a trend towards benefit in the treatment of tension-type headache, but evidence is weak. Chiropractic manipulation is probably more effective in the treatment of tension-type headache than it is in the treatment of migraine. In general, strong evidence is lacking regarding the efficacy of these treatments in reducing headache frequency, intensity, duration and disability in many commonly encountered clinical situations. Many of the published case series and controlled studies are of low quality. Physical treatments are unlikely to pose a significant risk, with the exception of high velocity chiropractic manipulation of the neck. Consideration must be given to financial costs and lost treatment opportunity by prescribing potentially ineffective treatment. In the absence of clear evidence regarding their role in treatment, physicians and patients are advised to make cautious and individualized judgments about the utility of physical treatments for headache management. In most cases, the use of physical modalities should complement rather than replace better validated forms of therapy. The evidence base to determine the safety and efficacy of physical treatments in the management of headache disorders would be substantially improved by using standard scientific rigor in the development and conduct of future clinical studies.

Diagnosis and pathophysiology of migraine

Over the past 10 years there has been an explosion of knowledge about headache, particularly migraine. Fueled by new, highly effective therapeutic agents, vast resources have been invested in improving diagnostic accuracy and attempting to understand the mechanisms by which this symptom is generated. Public awareness has increased as has that of the medical community. Tools are now available to help diagnose particular types of headache and measure/monitor disability. Numerous pathophysiologic changes have been studied which may in turn increase the therapeutic armamentarium. With approximately 10% of the public suffering from migraine and with most of these cases remaining undiagnosed, it is likely that this segment of the healthcare market will continue to expand in the future.

Physical treatments for headache: a structured review

BACKGROUND

Primary headache disorders, especially migraine, are commonly accompanied by neck pain or other symptoms. Because of this, physical therapy (PT) and other physical treatments are often prescribed. This review updates and synthesizes published clinical trial evidence, systematic reviews, and case series regarding the efficacy of selected physical modalities in the treatment of primary headache disorders.

METHODS

The National Library of Medicine (MEDLINE), The Cochrane Library, and other sources of information were searched through June 2004 to identify clinical studies, systematic reviews, case series, or other information published in English that assessed the treatment of headache or migraine with chiropractic, osteopathic, PT, or massage interventions.

RESULTS

PT is more effective than massage therapy or acupuncture for the treatment of TTH and appears to be most beneficial for patients with a high frequency of headache episodes. PT is most effective for the treatment of migraine when combined with other treatments such as thermal biofeedback, relaxation training, and exercise. Chiropractic manipulation demonstrated a trend toward benefit in the treatment of TTH, but evidence is weak. Chiropractic manipulation is probably more effective in the treatment of tension-type headache (TTH) than it is in the treatment of migraine. Evidence is lacking regarding the efficacy of these treatments in reducing headache frequency, intensity, duration, and disability in many commonly encountered clinical situations. Many of the published case series and controlled studies are of low quality.

CONCLUSIONS AND RECOMMENDATIONS

Further studies of improved quality are necessary to more firmly establish the place of physical modalities in the treatment of primary headache disorders. With the exception of high velocity chiropractic manipulation of the neck, the treatments are unlikely to be physically dangerous, although the financial costs and lost treatment opportunity by prescribing potentially ineffective treatment may not be insignificant. In the absence of clear evidence regarding their role in treatment, physicians and patients are advised to make cautious and individualized judgments about the utility of physical treatments for headache management; in most cases, the use of these modalities should complement rather than supplant better-validated forms of therapy.

The effects of bite line deviation on lateral cervical radiographs when upper cervical joint dysfunction exists: a pilot study

PURPOSE

To demonstrate the impact of inconsistent bite line positioning during pre and post lateral cervical radiographic examinations and to suggest certain additional imaging studies if the bite line cannot be consistently maintained.

METHODS

Radiographic measurements of relative flexion and extension in the atlantal-occipital (AO) and atlantal-axial (AA) joints were taken from neutral lateral cervical and cervical flexion and extension radiographs of 20 subjects.

RESULTS

The average relative AO flexion was -0.9 degrees and 12.0 degrees of extension, while the average relative AA flexion and extension values were 8.5 degrees and 2.8 degrees, respectively. In addition, 12 (60%) of the 20 subjects exhibited paradoxical motion at the AO joint during cervical flexion. Of these 12 subjects, 10 also displayed excessive relative AO extension (beyond 7.5 degrees ).

CONCLUSIONS

If a bite line deviation exists in pre and post lateral cervical radiographic examinations, dynamic cervical flexion and extension radiographs should be taken to calculate the maximum tolerances in the upper cervical spinal joints. If these tolerances are exceeded, the measurement of the cervical lordosis from the back of the second cervical vertebra and seventh cervical vertebra may be altered, thus incorporating the possibility of a 20.3% measurement error on the post lateral cervical radiograph.