Decreased Vertebral Artery Hemodynamics in Patients with Loss of Cervical Lordosis

Resolution of Sporadic Hemiplegic Migraine by Correcting a Cervical Spine Kyphosis Utilizing the Chiropractic BioPhysics® (CBP®) Technique: A Case Report With Long-Term Follow-Up

A 19-year-old male suffered from sporadic hemiplegic migraine (SHM) for several years and experienced significant pain and disability with sensory and motor disturbances during the migraine headaches. Weakness, abnormal vision, abnormal sensation, one-sided disabling motor weakness, and other signs of SHM were diagnosed. The patient had received previous physical therapy, chiropractic and over-the-counter medications, as well as migraine-specific prescriptions without lasting improvements. Chiropractic BioPhysics® (CBP®) spinal structural rehabilitation protocols were used to increase cervical lordosis and improve cervical muscular strength, mobility, and posture. These protocols include spine-specific prescriptions for Mirror Image® postural exercises, traction, and spinal manipulative therapy. After 24 treatments over eight weeks, all subjective and objective outcomes improved dramatically with a near resolution of all initial symptoms of SHM. There were a significant increase in cervical lordosis and a reduction in forward head posture. The neck disability index improved from 26% to 6%, and all pain scores for all regions improved following treatment. A 10-month follow-up exam showed the outcomes were maintained. SHM is rare and debilitating, is part of the global burden of disease, and is a major cause of disability in the world. Reports of successful conservative and non-conservative long-term treatments for SHM are rare, and there are no clinical trials showing successful treatments for SHM. This successful case demonstrates preliminary evidence that CBP spinal structural rehabilitation may serve as a treatment option for SHM. Future studies are needed to replicate the findings from this case.

Effect of Forward Head Posture on Resting State Brain Function

Forward head posture (FHP) is a common postural problem experienced by most people. However, its effect on brain activity is still unknown. Accordingly, we aimed to observe changes in brain waves at rest to determine the effect of FHP on the nervous systems. A total of 33 computer users (Male = 17; Female = 16; age = 22.18 ± 1.88) were examined in both FHP and neutral posture. For each session, brain waves were measured for 5 min, and then muscle mechanical properties and cranio-vertebral angle (CVA) were measured. Changes in brain waves between the neutral posture and FHP were prominent in gamma waves. A notable increase was confirmed in the frontal and parietal lobes. That is, eight channels in the frontal lobe and all channels in the parietal lobe showed a significant increase in FHP compared to neutral posture. Additionally, FHP changes were associated with a decrease in CVA (p < 0.001), an increase in levator scapulae tone (Right, p = 0.014; Left, p = 0.001), and an increase in right sternocleidomastoid stiffness (p = 0.002), and a decrease in platysma elasticity (Right, p = 0.039; Left, p = 0.017). The change in CVA was found to have a negative correlation with the gamma activity (P7, p = 0.044; P8, p = 0.004). Therefore, increased gamma wave activity in FHP appears to be related to CVA decrease due to external force that was applied to the nervous system and cervical spine.

Does Forward Head Posture Influence Somatosensory Evoked Potentials and Somatosensory Processing in Asymptomatic Young Adults?

The current investigation used somatosensory evoked potentials (SEPs) to assess differences in sensorimotor integration and somatosensory processing variables between asymptomatic individuals with and without forward head posture (FHP). We assessed different neural regions of the somatosensory pathway, including the amplitudes of the peripheral N9, spinal N13, brainstem P14, peak-to-peak amplitudes of parietal N20 and P27, and frontal N30 potentials. Central conduction time (N13-N20) was measured as the difference in peak latencies of N13 and N20. We measured these variables in 60 participants with FHP defined as a craniovertebral angle (CVA) < 50° and 60 control participants matched for age, gender, and body mass index (BMI) with normal FHP defined as CVA > 55°. Differences in variable measures were examined using the parametric t-test. Pearson's correlation was used to evaluate the relationship between the CVA and sensorimotor integration and SEP measurements. A generalized linear model (GLM) was used to compare the SEP measures between groups, with adjustment for educational level, marital status, BMI, and working hours per week. There were statistically significant differences between the FHP group and control group for all sensorimotor integration and SEP processing variables, including the amplitudes of spinal N13 (p < 0.005), brainstem P14 (p < 0.005), peak-to-peak amplitudes of parietal N20 and P27 (p < 0.005), frontal N30 potentials (p < 0.005), and the conduction time N13-N20 (p = 0.004). The CVA significantly correlated with all measured neurophysiological variables indicating that as FHP increased, sensorimotor integration and SEP processing became less efficient. FHP group correlations were: N9 (r = -0.44, p < 0.001); N13 (r = -0.67, p < 0.001); P14 (r = -0.58, p < 0.001); N20 (r = -0.49, p = 0.001); P27 (r = -0.58, p < 0.001); N30 potentials (r = -0.64, p < 0.001); and N13-N20 (r = -0.61, p < 0.001). GLM identified that increased working hours adversely affected the SEP measures (p < 0.005), while each 1° increase in the CVA was associated with improved SEP amplitudes and more efficient central conduction time (N13-N20; p < 0.005). Less efficient sensorimotor integration and SEP processing may be related to previous scientific reports of altered sensorimotor control and athletic skill measures in populations with FHP. Future investigations should seek to replicate our findings in different spine disorders and symptomatic populations in an effort to understand how improving forward head posture might benefit functional outcomes of patient care.

Post-concussion syndrome and concussion incidence improved in a pro rugby player following cervical spine rehab: case study and 6-year follow-up

Aim

To report improvements in post-concussion syndrome and concussion incidence following cervical spinal alignment correction.

Case presentation

A 27-year-old professional rugby player with 20 documented concussions presented with abnormal cervical spinal alignment and post-concussion syndrome. After 30 sessions of cervical rehabilitation, health outcomes improved. Post-treatment radiographs showed improved cervical lordosis from -13.5° to -37.4° (ideal is -42°) and right head translation from -22.7 to -11.3 mm (ideal is 0 mm). 2-year follow-up radiographs and 6-year follow-up health outcomes showed post-treatment improvements were maintained. The patient reported two documented concussions in the 6 years following treatment while maintaining the same lifestyle and professional rugby career.

Conclusion

Correction of abnormal cervical spinal alignment may help athletes with post-concussion syndrome and reduce risk of concussion.

Headache Characteristics in Chronic Neck Pain Patients with Loss of Cervical Lordosis: A Cross-Sectional Study Considering Cervicogenic Headache

BACKGROUND Loss of cervical lordosis and cervicogenic headache have similar tissue abnormalities, including weakness and atrophy in the neck muscles. Cervicogenic headache is mainly unilateral and is perceived in the occipito-temporo-frontal regions. However, it is not clear whether loss of cervical lordosis is a sign of headache with cervical origin. Herein, we aimed to assess and compare headache characteristics in patients with and without loss of cervical lordosis. MATERIAL AND METHODS This was a cross-sectional study conducted on chronic neck pain patients with (n=38; F/M: 28/10; mean age 33.34±7.73 yrs; range 18 to 45 yrs) and without loss of cervical lordosis (n=38; F/M: 29/9; mean age 33.13±6.41 years; range 20 to 45 years), between May 2019 and November 2019. The 2 groups were assessed and compared for headache characteristics such as frequency, severity, localization, lateralization, duration, and spread scores. Cervical lordosis was assessed on the lateral cervical radiographs by using posterior tangent technique measuring the C2-C7 total cervical spine angle. RESULTS The 2 groups were similar for individual features, including age, sex, employment status, and duration of neck pain (P>0.05). The duration of headache attack was longer in patients with loss of cervical lordosis (5.72±8.12) than in those with normal cervical lordosis (3.29±3.92) (P=0.009). However, there were no significant differences between the 2 groups for headache characteristics, including frequency, severity, localization, lateralization, and spread scores (P>0.05). CONCLUSIONS Patients with loss of cervical lordosis have longer duration of headache attack than those without. Loss of cervical lordosis may be a specific finding associated with longer cervicogenic headache attacks.

Loss of cervical lordosis in chronic neck pain patients with fibromyalgia: A cross-sectional study

BACKGROUND

Some interrelationships among fibromyalgia (FM), loss of cervical lordosis (LCL), and headache have been reported. Thus, it is sensible to examine LCL as a factor underlying FM and headache.

OBJECTIVE

In this study we aimed to assess LCL in chronic neck pain patients (CNPP) with FM and its association with headache features and FM severity.

METHODS

CNPP with (n= 55; mean age 40.0 ± 8.5; range 20 to 55 years) and without FM (n= 55; mean age 38.5 ± 8.9; range 20 to 55 years) were included in the study. Cervical lordosis was assessed by measuring the Cobb angle on the lateral cervical radiographs. The patients were asked about headache features within the last month. In addition, the CNPP with FM were evaluated by the Turkish version of the Revised Fibromyalgia Impact Questionnaire.

RESULTS

There were no statistically significant differences between the groups in terms of age, weight, height, body mass index, working status, and neck pain duration (p> 0.05 for each). The CNPP with FM had significantly reduced cervical lordosis angle compared with those without. The CNPP with FM had significantly higher headache frequency than those without (p= 0.008). There was statistically significant negative correlation between cervical lordosis angle and headache frequency in the CNPP with FM (r: -0.336; p= 0.012).

CONCLUSION

According to the results of this study, LCL may be associated with FM and headache frequency in the CNPP with FM.

Effects of a Traction Device for Head Weight Reduction and Neutral Alignment during Sedentary Visual Display Terminal (VDT) Work on Postural Alignment, Muscle Properties, Hemodynamics, Preference, and Working Memory Performance

The forward head posture of visual display terminal (VDT) users induces various physical and cognitive clinical symptoms. However, few studies have been conducted to identify and solve problems associated with VDT posture. This study aimed to examine the adverse effects of VDT posture and the positive effects of traction-combined workstations by measuring postural alignment, muscle properties, blood velocity, preference, and working memory. Thirty-four healthy VDT users (18 males and 16 females aged 20-30 years) participated in the experiment at three workstations, including conventional (VDT_C), head support (VDT_S), and upright (VDT_U) workstations. They conducted 2-back working memory task. The craniovertebral angle (CVA), muscle tone and stiffness, blood velocity and visual analogue discomfort scale (VADS) were measured to examine the influence of workstations. VDT_C showed increased muscle tone or stiffness in the levator scapulae (LS), suboccipital muscle (SM), and sternocleidomastoid muscle (SCM) and an increased reaction time (RT) in working memory. However, VDT_S showed decreased stiffness and tone of SM and improved comfort. In addition, VDT_U showed decreased stiffness or tone of the LS and SCM and improved blood velocity and RT. In conclusion, maintaining neutral alignment significantly improved working memory performance, muscle properties, and blood velocity.

Demonstration of central conduction time and neuroplastic changes after cervical lordosis rehabilitation in asymptomatic subjects: a randomized, placebo-controlled trial

A randomized controlled study was conducted to evaluate the effect of rehabilitation of the cervical sagittal configuration on sensorimotor integration and central conduction time in an asymptomatic population. Eighty (32 female) participants with radiographic cervical hypolordosis and anterior head translation posture were randomly assigned to either a control or an experimental group. The experimental group received the Denneroll cervical traction while the control group received a placebo treatment. Interventions were applied 3 × per week for 10 weeks. Outcome measures included radiographic measured anterior head translation distance, cervical lordosis (posterior bodies of C2–C7), central somatosensory conduction time (latency) (N13–N20), and amplitudes of potentials for spinal N13, brainstem P14, parietal N20 and P27, and frontal N30. Outcomes were obtained at: baseline, after 10 weeks of intervention, and at 3 months follow up. After 10 weeks and 3-months, between-group analyses revealed statistically significant differences between the groups for the following measured variables: lordosis C2–C7, anterior head translation, amplitudes of spinal N13, brainstem P14, parietal N20 and P27, frontal N30 potentials (P < 0.001), and conduction time N13–N20 (P = 0.004). Significant correlation between the sagittal alignment and measured variables were found (P < 0.005). These findings indicate restoration of cervical sagittal alignment has a direct influence on the central conduction time in an asymptomatic population.

Intraoperative surveillance of the vertebral artery using indocyanine green angiography and Doppler sonography in craniovertebral junction surgeries

OBJECTIVE

The authors sought to evaluate the usefulness of indocyanine green (ICG) angiography and Doppler sonography for monitoring the vertebral artery (VA) during craniovertebral junction (CVJ) surgery and compare the incidence of VA injury (VAI) between the groups with and without the monitoring of VA using ICG angiography and Doppler sonography.

METHODS

In total, 344 consecutive patients enrolled who underwent CVJ surgery. Surgery was performed without intraoperative VA monitoring tools in 262 cases (control group) and with VA monitoring tools in 82 cases (monitoring group). The authors compared the incidence of VAI between groups. The procedure times of ICG angiography, change of VA flow velocity measured by Doppler sonography, and complication were investigated.

RESULTS

There were 4 VAI cases in the control group, and the incidence of VAI was 1.5%. Meanwhile, there were no VAI cases in the monitoring group. The procedure time of ICG angiography was less than 5 minutes (mean [± SD] 4.6 ± 2.1 minutes) and VA flow velocity was 11.2 ± 4.5 cm/sec. There were several cases in which the surgical method had to be changed depending on the VA monitoring. The combined use of ICG angiography and Doppler sonography was useful not only to monitor VA patency but also to assess the quality of blood flow during CVJ surgery, especially in the high-risk group of patients.

CONCLUSIONS

The combined use of ICG angiography and Doppler sonography enables real-time intraoperative monitoring of the VA by detecting blood flow and flow velocity. As the arteries get closer, they provide auditory and visual feedback to the surgeon. This real-time image guidance could be a useful tool, especially for high-risk patients and inexperienced surgeons, to avoid iatrogenic VAI during any CVJ surgery.

Vertebral Body Sliding Osteotomy for Cervical Myelopathy With Rigid Kyphosis

Cervical spondylotic myelopathy is surgically demanding when associated with rigid kyphosis. Posterior surgery cannot restore cervical lordosis, and adequate decompression is not possible with rigid kyphosis. Vertebral body sliding osteotomy (VBSO) is a safe and novel technique for anterior decompression in patients with multilevel cervical spondylotic myelopathy. It is safe in terms of dural tear, pseudarthrosis, and graft dislodgement, which are demonstrated at high rates in anterior cervical corpectomy and fusion. In addition, VBSO is a powerful method for restoring cervical lordosis through multilevel anterior cervical discectomy and fusion above and below the osteotomy level. It may be a feasible treatment option for patients with cervical spondylotic myelopathy and kyphotic deformity. This is a technical note and literature review that describes the procedures involved in VBSO.

Improvement in cervical lordosis and sagittal alignment after vertebral body sliding osteotomy in patients with cervical spondylotic myelopathy and kyphosis

OBJECTIVE

Vertebral body sliding osteotomy (VBSO) is a safe, novel technique for anterior decompression in patients with multilevel cervical spondylotic myelopathy. Another advantage of VBSO may be the restoration of cervical lordosis through multilevel anterior cervical discectomy and fusion (ACDF) above and below the osteotomy level. This study aimed to evaluate the improvement and maintenance of cervical lordosis and sagittal alignment after VBSO.

METHODS

A total of 65 patients were included; 34 patients had undergone VBSO, and 31 had undergone anterior cervical corpectomy and fusion (ACCF). Preoperative, postoperative, and final follow-up radiographs were used to evaluate the improvements in cervical lordosis and sagittal alignment after VBSO. C0-2 lordosis, C2-7 lordosis, segmental lordosis, C2-7 sagittal vertical axis (SVA), T1 slope, thoracic kyphosis, lumbar lordosis, sacral slope, pelvic tilt, and Japanese Orthopaedic Association scores were measured. Subgroup analysis was performed between 15 patients with 1-level VBSO and 19 patients with 2-level VBSO. Patients with 1-level VBSO were compared to patients who had undergone 1-level ACCF.

RESULTS

C0-2 lordosis (41.3° ± 7.1°), C2-7 lordosis (7.1° ± 12.8°), segmental lordosis (3.1° ± 9.2°), and C2-7 SVA (21.5 ± 11.7 mm) showed significant improvements at the final follow-up (39.3° ± 7.2°, 13° ± 9.9°, 15.2° ± 8.5°, and 18.4 ± 7.9 mm, respectively) after VBSO (p = 0.049, p < 0.001, p < 0.001, and p = 0.038, respectively). The postoperative segmental lordosis was significantly larger in 2-level VBSO (18.8° ± 11.6°) than 1-level VBSO (10.3° ± 5.5°, p = 0.014). The final segmental lordosis was larger in the 1-level VBSO (12.5° ± 6.2°) than the 1-level ACCF (7.2° ± 7.6°, p = 0.023). Segmental lordosis increased postoperatively (p < 0.001) and was maintained until the final follow-up (p = 0.062) after VBSO. However, the postoperatively improved segmental lordosis (p < 0.001) decreased at the final follow-up (p = 0.045) after ACCF.

CONCLUSIONS

Not only C2-7 lordosis and segmental lordosis, but also C0-2 lordosis and C2-7 SVA improved at the final follow-up after VBSO. VBSO improves segmental cervical lordosis markedly through multiple ACDFs above and below the VBSO level, and a preserved vertebral body may provide more structural support.

Changes in Vertebral Artery Hemodynamics Associated With McKenzie Therapeutic Cervical Movements: An Exploration Using Duplex Ultrasound Imaging

OBJECTIVE

The purpose of this study was to explore vertebral artery hemodynamic changes associated with McKenzie therapeutic cervical movements in healthy individuals.

METHODS

A single-group repeated-measure design was used to examine 20 healthy participants aged 22.05 (1.69) years, mean (standard deviation). Vertebral artery volume flow, diameter, resistive index, time-averaged maximum velocity, and pulsatility index were measured using Duplex ultrasound. Vertebral artery hemodynamics were measured at cervical neutral positions then compared against vertebral artery hemodynamics measured during end-range loading and after repeated McKenzie therapeutic movements. Wilcoxon signed rank tests were used for comparisons, and standardized mean differences (SMDs) were calculated to quantify the changes in size.

RESULTS

Repeated retraction with extension in a sitting position and end-range retraction with extension in supine position were significantly associated with an increase in vertebral artery volume flow, P ≤ .01, and the SMD suggests small-medium changes in size. Statistical significant vertebral artery dilation was observed in the sitting position with protraction, combined retraction with extension, and flexion, P ≤ .01, yet the SMD suggested small changes in size. End-range flexion was significantly associated with a reduction in vertebral artery pulsatility index, and the SMD suggested large changes in size. Repeated retraction with extension in supine position was significantly associated with an increase in vertebral artery time-averaged maximum velocity, yet the SMD revealed no clinically important difference.

CONCLUSION

For the healthy participants in this study, McKenzie cervical movements were mostly associated with an increase in vertebral artery hemodynamics.

Increase in cerebral blood flow indicated by increased cerebral arterial area and pixel intensity on brain magnetic resonance angiogram following correction of cervical lordosis

CONTEXT

Loss of cervical lordosis is associated with decreased vertebral artery hemodynamics.

AIM

The aim of this study is to evaluate cerebral blood flow changes on brain magnetic resonance angiogram (MRA) in patients with loss of cervical lordosis before and following correction of cervical lordosis.

SETTINGS AND DESIGN

This study is a retrospective consecutive case series of patients in a private practice.

MATERIALS AND METHODS

Cervical lordosis of seven patients (five females and two males, 28-58 years) was measured on lateral cervical radiographs ranging from -13.1° to 19.0° (ideal is -42.0°). Brain MRAs were analyzed for pixel intensities representing blood flow. Pixel intensity of the cerebral vasculature was quantified, and percentage change was determined.

STATISTICAL ANALYSIS USED

A Student's t-test established significance of the percentage change in cerebral blood flow between pre- and postcervical lordosis adjustment images. Regression analysis was performed. An a priori analysis determined correlation between cervical lordosis and change in MRA pixel intensity. The statistician was blinded to the cervical lordosis.

RESULTS

Pixel intensity increased 23.0%-225.9%, and a Student's t-test determined that the increase was significant (P < 0.001). Regression analysis of the change in pixel intensity versus the cervical lordosis showed that as the deviation from a normal cervical lordosis increases, percentage change in pixel intensity on MRA decreases.

CONCLUSION

These results indicate that correction of cervical lordosis may be associated with an immediate increase in cerebral blood flow. Further studies are needed to confirm these findings and understand clinical implications.