Diagnosis and Treatment of Pain of Vertebral Origin PDF

PREFACE

The purpose of this book is to invite the reader to take a new look at common pains of spinal origin. My first book, Les manipulations vertebrales, published in 1960, aimed at recognition of this therapeutic method by the medical profession. At that time, manipulation was widely criticized, rejected, and even considered a kind of charlatanism. It is true that manipulation was used as the only form of treatment by certain nonmedical schools that considered hypothetic vertebral microdisplacements the sources of all disease. However, experience convinced me of their potential. Therefore, I attempted to present their indications and contraindications precisely, to select the reliable techniques, describe them in an objective way, and assign clear rules of application. I proposed the "rule of pain-free and opposite motion." That is to say that the manipulation must be performed in a direction in which the range of motion is free and opposite to the direction in which the motion is painful, rather than simply attempting to restore a real or supposed limitation of the mobility of a vertebral segment.

This rationale for manipulation achieved recognition by the Faculty of Medicine, and in 1969, a diploma of Orthopaedic Medicine and Manual Therapeutics was created at the University of Paris VI (Broussals Faculty, Hôtel Dieu). I was offered the directorship of the program — a program that extended far beyond the simple teaching of these techniques and covered broadly common vertebral pathology. During the following 20 years, teaching founded on the same model was organized in other medical schools in France; Marseille was the first in 1975.

My second book, Douleurs d'origine vertebrale et traitements par manipulations, had the subtitle, Les derangements intervertebraux mineurs. The sometimes surprising results of these treatments compelled one to reflect. Often, in a very spectacular way, vertebral manipulation relieved a certain pain, whose spinal origin was evident (although the mechanism of action was not clear), and other pains, apparently unrelated to the spine, would disappear. However, when inappropriately executed, these techniques could provoke both types of pain.

Traditional practitioners of manipulation, coming for the most part from osteopathy, maintained that the loss of mobility of specific vertebral segments, which according to them was detectable by palpation, could explain and justify their maneuvers. In fact, I noticed that the segments at the origin of a local or referred pain were themselves tender when certain maneuvers of direct pressure (segmental examination) were carried out. After a successful manipulation, these same segments became pain-free on segmental examination. The key point, then, was the segmental tenderness and not the hypothetic loss of mobility; this finding corresponded perfectly with the application of manipulation according to the rule of pain-free and opposite motion.

I therefore proposed the term painful minor intervertebral dysfunction (PMID [English]; DIM [French]) for this painful, benign, self-sustained dysfunction of the spinal segment. Frequently resulting from trauma, exertion, false movement, or secondary to static or postural problems, these painful minor intervertebral dysfunctions are usually reversible and have no radiologic findings. They can affect radiologically normal segments as well as segments with signs of degeneration.

While PMID originally served merely as a hypothesis about the indications and actions of manipulation, it has now become an uncontested clinical reality extending far beyond the frame of manipulation, even though the underlying pathophysiology has not yet been clearly established. The frequent appearance of PMID shows us that it is at the origin of most common intervertebral pain syndromes.

Another element became apparent, both confirming and clarifying the role played by manipulation. With systematic palpation of the skin folds, muscles, and tendons, I realized that a PMID was associated frequently with abnormal tissue reflexes in the homologous spinal segment. These changes became apparent through modifications in tissue consistency and sensitivity: painful thickening of the skin folds to pince-roule (pinch-roll) throughout all or part of the dermatome, areas of focal muscular hypertonus among certain muscles of the myotome, and hypersensitivity to palpation of the tenoperiosteal insertion. Moreover, I also found these neurotrophic disturbances in the same distribution in other spinal segmental pain syndromes, for example, disc herniation, facet joint capsulitis, and synovitis. These manifestations, which I group under the term segmental celluloperiosteomyalgic syndrome, can be the origins of certain misleading pains such as pseudoradicular, pseudoarticular, and pseudovisceral syndromes.

Furthermore, their topography is rather consistent for a given spinal segment, particularly in the case of cellulalgia, which allows one to demonstrate objectively the role played by the posterior rami in a number of painful syndromes of the back, such as cervicogenic dorsalgia and low back pain with an origin in the upper lumbar spine, and to describe some frequent but misunderstood conditions such as thoracolumbar or other junctional syndromes.

Radiographic imaging has made marked progress in recent years. It provides a nearly perfect means of detecting many of the serious spinal lesions — inflammatory, infectious, neoplastic, traumatic, or otherwise. However, it is not as useful in the domain of common pain syndromes. While this imaging technique provides a sophisticated means of delineating degenerative lesions and other structural anomalies, the relationship between these images and a patient's pain complaint is often difficult to establish. While it has been known for quite some time that significant vertebral spondylosis and disk degeneration can be entirely painless, it is now readily apparent that there are also some cases of frank disk herniation, clearly visible on CT or MRI, that produce no discomfort whatsoever. Conversely, many patients who present with significant degrees of painful symptoms have normal imaging studies or studies that disclose lesions so benign that it is difficult to identify them as causative agents.

It is especially in these cases that the guidelines developed for PMID and segmental celluloperiosteomyalgic syndrome are of great value. These guidelines provide us with an understanding of many pains that are not well defined and, therefore, are not well treated. They furnish us with a kind of "Ariadne's thread" to help us find our way through the maze of all these pains with which a physician is confronted daily. The guidelines also broaden the semiology and restore to the clinical examination all its superiority.

Nevertheless, we shall neglect neither the traditional repertoire of the well established semiologic, classic, and pathogenic notions nor the recent advances that facilitate diagnosis and treatment of common painful syndromes of the spine. Indeed, it is not sufficient merely to diagnosis; one must treat as well. For this reason, a significant segment of this book deals with treatment, particularly by use of manual therapies that when well executed are so often effective.

Authro: Maigne, Robert