Evaluating the Relationship Among Cavitation, Zygapophyseal Joint Gapping, and Spinal Manipulation: An Exploratory Case Series

Abstract

Purpose This IRB-approved project determined the feasibility of conducting larger studies assessing the relationship between cavitation and zygapophysial (Z) joint gapping following spinal manipulative therapy (SMT). Methods Five healthy volunteers (average age 25.4 years) were screened and examined against inclusion and exclusion criteria. High signal MRI markers were fixed to T12, L3, and S1 spinous processes. Scout images were taken to verify the location of the markers. Axial images of the L4/L5 and L5/S1 levels were obtained in the neutral supine position. Following the first MRI, accelerometers were placed over the same spinous processes and recordings were made from them during side-posture positioning and SMT. The accelerometers were removed and each subject was scanned in side-posture. The greatest central A-P Z joint spaces (gap) were measured from the first and second MRI scans. Values obtained from the first scan were subtracted from those of the second, a positive result indicating an increase in gapping following SMT (positive gapping difference). Gapping difference was compared between the up-side (SMT) joints vs. the down-side (non-SMT) joints and between up-side cavitation vs. up-side non-cavitation joints. Results Greater gapping was found in Z joints that received SMT (0.5 ±0.6 mm) vs. non-SMT joints (−0.2 ±0.6 mm), and vertebral segments that cavitated gapped more than those that did not cavitate (0.8 ±0.7 mm vs. 0.4 ±0.5 mm). Conclusions A future clinical study is quite feasible. Forty subjects (30 SMT and 10 Control) would be needed for appropriate power (0.90). Partial funding by NIH/NCCAM (#2R01AT000123).

A Feasibility Study to Assess Vibration and Sound From Zygapophyseal Joints During Motion Before and After Spinal Manipulation

“…Those who passed the initial screening were scheduled for an examination where a research chiropractic physician conducted a thorough history and physical examination that included orthopedic and neurological tests to ensure subjects were selected who met stringent inclusion and had none of the exclusion criteria. Separate criteria that had been previously developed and implemented for healthy 19,20 and LBP subjects 37 were used in this study. Generally, healthy subjects had no current LBP, known spinal pathology, or spinal surgery; and no previous history of LBP lasting more than 2 weeks, or no more than 3 episodes of LBP of brief duration (one week) in any given year.…”

Understanding inhibitory mechanisms of lumbar spinal manipulation using H-reflex and F-wave responses: A methodological approach

“…Although articular crepitus is an empirical indicator of "successful" delivery of HVLA SM treatment, the relationship between the therapeutic benefit and articular crepitus (audible release or "cracking" "popping" sound) during HVLA SM lacks sufficient evidence to date (Ross et al, 2004;Evans and Breen, 2006;Herzog, 2010;Cramer et al, 2011). In addition, the location of the articular crepitus during side-posture lumbar HVLA SM is only generally accurate in identifying the spinal segment receiving the manipulative thrust (Ross et al, 2004).…”

Manipulation Under Anesthesia for Lumbopelvic Pain: A Retrospective Review of 18 Cases

“…The effects of cavitation at the spinal Z-joint have been studied extensively. [10][11][12][13] The audible separation of these joints is associated with release of tissue adhesions, stimulation of the afferent nerve to the Z-joint and spinal muscles, and reflex neurologic and possibly immunologic sequelae and inflammatory chemical downregulation. [10][11][12][13][14] There are a percentage of patients in whom cavitation of the spinal facet joint is not possible because of spasm, guarding, and inhibitory mechanisms [15][16][17] despite meeting clinical criteria for its use.…”

“…[10][11][12][13] The audible separation of these joints is associated with release of tissue adhesions, stimulation of the afferent nerve to the Z-joint and spinal muscles, and reflex neurologic and possibly immunologic sequelae and inflammatory chemical downregulation. [10][11][12][13][14] There are a percentage of patients in whom cavitation of the spinal facet joint is not possible because of spasm, guarding, and inhibitory mechanisms [15][16][17] despite meeting clinical criteria for its use. [18][19][20] Manipulation under anesthesia (MUA) is a pain management procedure using passive stretches combined with spinal manipulation under conscious sedation or general anesthesia with the goal of relieving musculoskeletal pain.…”

“…[15][16][17][21][22][23][24][25][26][27][28][29] Anesthesia minimizes pain, muscle spasm, and protective guarding that may occur during manipulation. Manipulation on a sedated patient is purported to enhance the practitioner's ability to break apart adhesions and repair segmental dysfunction, 11,15,17,30 leading to increased ligament, tendon, muscle, and articular flexibility. 22 Manipulation under anesthesia has been used as an intervention for back pain in some form for more than 80 years.…”