Research news and notes

1. Evaluation of cervical facet dislocation 

Cervical facet dislocation is among the more common and serious traumatic injuries in the cervical spine. Instability and direct or delayed neurologic injury may result. Treatment options include closed or open surgical reduction, but the optimal choice for any particular patient remains controversial. Magnetic resonance imaging (MRI) is a useful adjunct because it can show ligamentous injury and neural element compression, but there is no consensus regarding the indications for MRI or how the imaging results influence decision making.

Grauer et al [1] from the Yale Department of Orthopedics surveyed the timing and influence of MRI on the management of patients with traumatic cervical facet dislocations. The authors devised a questionnaire with 10 vignettes of cases of facet dislocations and presented those to 25 spine surgeons, some of whom were neurosurgeons and others orthopedic surgeons. Each case was presented with 3 scenarios—intact, incomplete or complete spinal cord injury. Participants were free to choose what to do next: open reduction, closed reduction, or get an MRI first. There was a large variability among the surgeons. Neurosurgeons were more likely than orthopedic surgeons to order an MRI and, based on the MRI, were more likely to choose open surgical treatment as opposed to a closed reduction. The interrater reliability was particularly poor in cases with complete spinal cord injury when MRI was available.

I find this study interesting; it reveals how much of surgical decision making is subjective, probably based on authority, on whatever the resident or fellow learned in their training. It is possible that many viable options exist, which can produce good results in particular cases. Maybe there is really no difference in patient outcome regardless of the surgeon's choice, as long as it is reasonable. Alternatively, an optimal procedure may exist, but there are no adequate data, leading to “tradition-based” decision making.

It is difficult to study the natural history of a condition for which the treatment is often surgical. A prospective randomized study may fail because surgeons are not at equipoise regarding the imaging and treatment choices. As a first step, a prospective database of all spine surgery cases with long-term follow-up can provide more objective outcome data.

2. Does the addition of a choice of “alternative” therapies help patients with lower back pain? 

Both chronic and acute lower back pain are a major source of suffering, lost days of work, and a cause of many visits to physicians and a variety of other health care providers. Despite the proliferation of methods to treat patients with lower back pain, especially among the “alternative” medical therapies, objective data of cost and effectiveness are lacking. One of the few and more thorough studies was published in 2007 in Spine. Eisenberg et al [2] recruited 444 patients with acute LBP (<21 days), who were randomized into 2 groups: “usual care”, or a choice of acupuncture, chiropractic, or massage therapy. Outcomes included symptoms (bothersomeness), functional status (Roland), satisfaction between baseline and 5 weeks, and cost of medical care in the 12 weeks after randomization. There was no difference between the groups in symptoms or functional recovery. On the other hand, patients expressed greater satisfaction with their care if they were given a choice of adjunctive therapy. This came at a cost: a reduction of $99 in the average cost to the insurer for medical care was outweighed by an additional cost of $343 for complementary and alternative medical treatments per patient. This is a really good article; a randomized, controlled trial demonstrating that patients with acute LBP often improve, in this case regardless of what specific approach was used to treat them. Although “choice of additional treatment” did not improve their pain or function more than “usual medical care,” patients were more satisfied. This is probably expected; before there were many effective therapies, people valued their physicians and turned to them for help. Sometimes the feeling that someone is helping and doing something to you is important. I was actually surprised by the lack of a more pronounced placebo effect that could have given the “choice” group an advantage at the “harder” end points of symptomatic and functional recovery. The authors suggested that maybe alternative therapies will have a greater effect in patients with chronic back pain.

3. What can help patients with fibromyalgia? 

A neurosurgeon in spine practice often comes across patients referred for evaluation of neck or back pain, who have a diagnosis of fibromyalgia or symptoms consistent with the condition. Surgically treatable lesions may coexist with fibromyalgia, although the syndrome itself is not surgically treatable. As expected, these patients are offered many treatments, but the benefit of each is not clear. Fibromyalgia is often treated with conservative and nonpharmacologic modalities. A recent extensive review of literature by Schneider et al [3] aimed to find out which of them had more evidential support in the literature. The article was the outcome of a charge by the Scientific Commission of the Council on Chiropractic Guidelines and Practice Parameters to evaluate and report on the evidence base for chiropractic care. The authors looked into databases of medical and chiropractic literature. The found 8 systematic reviews, 3 meta-analyses, 5 published guidelines, and 1 consensus document. The review of chiropractic literature databases yielded an additional 38 articles regarding various nonpharmacologic therapies such as chiropractic, acupuncture, nutritional/herbal supplements, massage, and so on. They found no independent randomized trials. The authors say that there is strong evidence that supports aerobic exercise and cognitive behavioral therapy; moderate evidence supports massage, muscle strength training, acupuncture, and spa therapy (balneotherapy); limited evidence supports spinal manipulation, movement/body awareness, vitamins, herbs, and dietary modification. Given the dearth of published material, especially controlled trials, the term strong evidence may be too strong. The same goes for the other treatment modalities.

Extensive reviews of the literature are of course not the same as original research. However, when original research is limited, published in disparate sources, and information is not widely distributed, such reviews can be valuable. Patients with fibromyalgia sometimes show up in neurosurgical practice with complaints of back and neck pain. Although most neurosurgeons correctly choose not to operate for this diagnosis, as physicians, we should still be able to provide good medical advice. This article provides an interesting perspective. It comes from a journal that often publishes works by chiropractors. The authors found that the strongest evidence exists for cognitive therapy and exercise, probably the best choices for fibromyalgia patients. This finding is a bit of a surprise; even if acupuncture and chiropractic care only have a placebo effect, the latter should be stronger when something is done to the patient, more than just prescribing exercise; or maybe, like in the article about a choice of alternative therapies [1], having procedures done to them increased patient satisfaction without improving the outcome.