Chiropractic care of a patient with vertebral subluxations and unsuccessful surgery of the cervical spine.

Plaugher G, Troyanovich SJ, Gatterman B, Alcantara J, Thornton R, Coleman RR. Chiropractic care of a patient with vertebral subluxations and unsuccessful surgery of the cervical spine. J Manipulative Physiol Ther. Letter to the Editor May 2002:283-284.

In Response: Dr. Winterstein notes a few criticisms of our case report: (1) a dispute that there was correction of vertebral subluxations, insofar as the lateral cervical radiograph is concerned; (2) he also disputes that there is any change to the cervical lordosis/kyphosis over the course of care, although he confines this criticism to segments C2-C6; and (3) in this patient, the kyphosis is an anatomic and developmental condition caused by posterior joint and central canal architecture and that no amount of adjusting or other clinical attempts would change this spine, which, in his words, is “anatomically kyphotic.”

We used and cited the definition for subluxation from a well-established dictionary of the English language (i.e., Oxford's). It is our reference 28. It states that subluxation is a partial dislocation, a sprain. Sprained joints sometimes show radiographic findings such as a cervical kyphosis from a motor vehicle collision injury. Sprained ankles typically do not demonstrate malalignment on conventional radiographs.

The clinician (RET) who cared for this patient used a combination of clinical findings (i.e., tenderness, edema, reduction of movement) combined with a radiographic analysis to determine the locus of the adjustment (e.g., C5). Dr. Winterstein chooses to define subluxation as a radiograph-only entity. We explicitly defined the subluxation. We described the clinical components to this sprain injury. in no way did we ever state that subluxation was a radiograph-only finding.

We stated with regard to the change in the cervical lordosis that this slight improvement was only detectable at the upper cervical segments. We never stated that there was a reduction in the kyphotic angulation of the mid-cervical spine; only that there was a slight change in extension position with also an apparent reduction in anterior head carriage. In the initial report, we did not include any roentgenometric (i.e., spinographic) assessment of the cervical lordosis. For the sake of thoroughness, one of us (SJT) measured the position of the atlas with respect to C2. He concluded that there is an 8° improvement in the position of C1 and C2 at 1 month and 9° improvement at 10 months. Our original study is in agreement with Dr. Winterstein's contention that the kyphosis in the mid-cervical spine is the same on each radiograph.

One of us (BG), a board-certified radiologist, concurred with our figure legend that there appears to be more lordosis in the upper cervical segments. He also measured the central spinal canal from the original radiographs. The method of Pavlov et al 1 was used, and indeed it shows that the spinal canal is narrowed. However, Dr. Winterstein appears to maintain that a narrowed spinal canal is correlated with anatomic hypolordosis or kyphosis. We could find no references to this contention.

Peterson et.al. 2 studied the prevalence of hyperplastic articular pillars and its relationship to the magnitude of the cervical lordosis. They concluded that facet architecture has an influence on the magnitude of the cervical lordosis. They did not state that this produces kyphosis of the cervical spine. In our opinion, the kyphotic angulation at C6-C7 is probably a direct result of the surgical fusion procedure. For example, Troyanovich et. al. 3 showed that single-level fusion without plating tends to produce a slight kyphosis after surgery versus plating techniques that produce a slight lordosis at the fused level.

Dr. Winterstein states that we apparently included these comparative radiographs to demonstrate change in the cervical lordosis. We did not. We included these radiographs because they are a part of the case file. If they had shown a worsening of the kyphosis (at the mid cervical spine) or lordosis (in the upper segments C0-C2) or no change at all, then they would have been included. Again, the article reported slight improvement in the lordosis of the upper cervical segments in this patient. No claim was made for change in the kyphosis at the mid-cervical segments.

We thank Dr. Winterstein for his interest in our work and hope that our response has helped to clarify the concerns that he has expressed.

References:

1. Pavlov H, Torg JS, Robie B, et al. Cercical spinal stenosis: determination with vertebral body ratio method. Radiology 1987;164:771-5.
2. Peterson CK, Kirk RJ, Isdahl M, Humphrey BK. Prevalence of hyperplastic articular pillars in the cervical spine and relationship with cervical lordosis. J Manipulative Physiol Ther 1999;22:390-4.
3. Troyanovich SJ, Stroink AR, Kattner KA, Dornan WA, Gubina I. Does anterior plating maintain cervical lordosis versus conventional fusion techniques? A retrospective analysis of patients receiving single-level fusions. J Spinal Disord 2002;15:69-73.