Mengchen Yin 1, Chongqing Xu 1, Junming Ma 1, Jie Ye 1 ... for...the cervical stenosis significantly lowers the need of the second-stage surgery. in contrast, if lumbar stenosis was

ONLINE WEBINAR WITH DR JAMES COX ‐ MYELOMALACIA 10/5/2020

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MYELOMALACIA: THE COMING EPIDEMIC & CHIROPRACTIC INVOLVEMENTJames M. Cox, DC, DACBR, FACO(H), FICC, HonDLittOCTOBER 7, 2020

What is Spinal Stenosis?NARROWING OF SPINE ORIF ICES DUE TO DISC DEGENERATION, ENDPLATE HYPERTROPHY, FACET ARTHROSIS , L IGAMENTUM FLAVUM HYPERTROPHY, DISC HERNIAT ION, SYNOVIAL CYST, DISCAL CYST, TARLOV CYST, OTHER PATHOLOGIES

VERTEBRAL CANAL – CENTRAL AND LATERAL

OSSEOLIGAMENTOUS CANALS (FORAMEN)

Mengchen Yin 1, Chongqing Xu 1, Junming Ma 1, Jie Ye 1, Wen Mo 1A Bibliometric Analysis and Visualization of Current Research Trends in the Treatment of Cervical Spondylotic Myelopathy. Global Spine J. 2020 Sep 1;2192568220948832. doi: 10.1177/2192568220948832. Online ahead of print.

A BIBLIOMETRIC ANALYSIS AND VISUALIZATION OF CURRENT RESEARCH TRENDS IN THE TREATMENT OF CERVICAL SPONDYLOTIC MYELOPATHY

CERVICAL SPONDYLOTIC MYELOPATHY (CSM) HAS BECOME THE MOST COMMON CAUSE OF SPINAL CORD DYSFUNCTION

A TOTAL OF 2367 PUBLICATIONS MET THE REQUIREMENT FOR STUDY

THE NUMBER OF PUBLICATIONS SHOWED AN UPWARD TREND WITH A STABLE RISE

CERVICAL SAGITTAL ALIGNMENT, PREDICTIVE FACTOR, DIFFUSION TENSOR IMAGING, AND THE NATURAL HISTORY OF CSM ARE THE RESEARCH HOTSPOTS IN THE RECENT YEARS

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76-year-old man underwent a two-level lumbar discectomy in mid December 2019.

Outcome: The patient walked normally from the December 2019 surgery until awaking one morning two months later unable to move his four limbs, developed bladder, bowel loss and has never walked since. He has lost arm strength and voluntary coordination and full sensation

Reflexes in all four limbs appears 45 percent of normal, not hyper yet with no muscle power.Pin prick, stroke is diminished at C2-8 levels 60 percent.

Basically he woke up a paraplegic 2 months after a relatively good lumbar surgery.CAT scan of head was normal prior to surgery.

Neurosurgeons have further depressed him saying the cervical surgery will kill him.

CASE LUMBAR SPINE SURGICALLY TREATED DECEMBER 2019 WITH POSITIVE RESULT DECEMBER 2019

CERVICAL SPINE STENOSIS 2 MONTHS FOLLOWING LUMBAR DECOMPRESSIOM

Luo CA1, Kaliya-Perumal AK1,2, Lu ML3, Chen LH1, Chen WJ1,4, Niu CC5. Staged surgery for tandem cervical and lumbar spinal stenosis: Which should be treated first? Eur Spine J. 2018 Oct 17. doi: 10.1007/s00586-018-5795-6. [Epubahead of print]

STAGED SURGERY FOR TANDEM CERVICAL AND LUMBAR SPINAL STENOSIS: WHICH SHOULD BE TREATED FIRST? FIRST-STAGE SURGERY FOR THE CERVICAL STENOSIS SIGNIFICANTLY LOWERS THE NEED OF THE SECOND-

STAGE SURGERY. IN CONTRAST, IF LUMBAR STENOSIS WAS TREATED FIRST, A DRAMATIC EXACERBATION OF THE SYMPTOMS RELATED TO THE CERVICAL STENOSIS CAN OCCUR SOON. THEREFORE, TREATMENT OF CERVICAL STENOSIS FIRST SEEMS TO BE MORE APPROPRIATE

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Myhrvold, BL, Irgens, P, Robinson, HS, et al. Visual trajectory pattern as prognostic factors for neck pain. Eur J Pain. 2020; 00: 1– 13. https://doi.org/10.1002/ejp.1622

HAVING A SEVERE PAIN HISTORY WAS ASSOCIATED WITH POOR PROGNOSIS, PARTICULARLY IF COMBINED WITH NEGATIVE EXPECTATIONS.

Marawar SV, Madom IA, Palumbo M, Tallarico RA, Ordway NR, Metkar U, Wang D, Green A, Lavelle WF. Surgeon Reliability for the Assessment of Lumbar Spinal Stenosis on MRI: The Impact of Surgeon Experience. Int J Spine Surg. 2017 Dec 5;11:34. doi: 10.14444/4034. eCollection 2017.

SPINAL STENOSIS IS A COMMON CONDITION AND THE MOST COMMON INDICATOR FOR SPINAL BACK SURGERY IN THE OVER-65 AGE GROUP. WITH THE GROWTH OF THIS GROUP, BY 2025 59% OF THEM ARE PREDICTED TO ACQUIRE SPINAL STENOSIS.

Feng Dai 1, Peng-Fei Yu 1, Jin-Tao Liu 1, Hong Jiang 1. [A 5 year follow-up study on non-surgical treatment of ruptured lumbar disc herniation]. Zhongguo Gu Shang. 2020 May 25;33(5):414-9.doi: 10.12200/j.issn.1003-0034.2020.05.005.

A 5 YEAR FOLLOW-UP STUDY ON NON-SURGICAL TREATMENT OF RUPTURED LUMBAR DISC HERNIATION IN 75 PATIENTS WITH SINGLE-SEGMENT RUPTURED LUMBAR DISC HERNIATION SHOWED 71 PATIENTS WERE FINALLY FOLLOWED UP AT 5 YEARS AFTER NON SURGICALTREATMENT.

THE VOLUME OF PROTRUSION DECREASED 45.65±2.83)%.

THE PROTRUSION WAS OBVIOUSLY ABSORBED IN 24 CASES, PARTIALLY ABSORBED IN 26 CASES, NOT ABSORBED IN 19 CASES, AND INCREASED IN 2 CASES.

A POSITIVE CORRELATION BETWEEN IMPROVEMENT RATE OF JOA SCORES AND PROTRUSION ABSORPTION RATE AT 5 YEARS AFTER NON SURGICAL TREATMENT WAS FOUND.

CONCLUSION: NON-SURGICAL TREATMENT OF RUPTURED LUMBAR DISC HERNIATION CAN ACHIEVE GOOD RESULTS, CLEAR THE CHARACTERISTICS OF THE RUPTURED LUMBAR DISC HERNIATION AND PROGNOSIS, AND SOME PATIENTS HAVE "REABSORPTION" PHENOMENON.

Adogwa, Owoicho; Davison, Mark A; Vuong, Victoria D; Khalid, Syed; Lilly, Daniel T; Desai, Shyam A; Moreno, Jessica; Cheng, Joseph; Bagley, Carlos: Long-Term Costs of Maximum Non-operative Treatments in Patients With Symptomatic Lumbar Stenosis or Spondylolisthesis that Ultimately Required Surgery. A 5-Year Cost Analysis. Spine 2019;44(6):424-430

0.8% OF 497,822 PATIENTS WITH SYMPTOMATIC LUMBAR STENOSIS OR SPONDYLOLISTHESIS ULTIMATELY REQUIRED SURGERY. THIS PAPER SAYS MORE PATIENTS SHOULD HAVE DECOMPRESSION SURGERY WITH OR WITHOUT FUSION IN ORDER TO LOWER THE COST OF NON OPERATIVE TREATMENT OF PAIN CAUSED BY LUMBAR SPINE STENOSIS

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Sharma H, Lee SW, Cole AA. The management of weakness caused by lumbar and lumbosacral nerve root compression. J Bone Joint Surg Br. 2012 Nov;94(11):1442-7. doi: 10.1302/0301-620X.94B11.29148. PMID: 23109619.

H. Sharma, MS(Orth), MCh(Orth), FRCS(Tr&Orth), Consultant Orthopaedic Spinal Surgeon Derriford Hospital, Plymouth, Devon PL6 8DH, UK. Correspondence should be sent to Mr H. Sharma; e-mail: [email protected] ©2012 British Editorial Society of Bone and Joint. Surgery doi:10.1302/0301-620X.94B11. 29148 $2.00

The main indication for surgical treatment in the management of patients with lumbosacral nerve root compression should be pain rather than weakness.

Muscle weakness has been reported to be as high as 30% to 50% in patients with disc herniation.7,8

Hakelius (12) reported that patients’ weakness ,managed non-operatively, reported 80% of disc-herniated patients showed a major improvement after six weeks; 90% had improved after 12 weeks and 93% had improved after 24 weeks. There was no advantage to be gained by operating on patients with a stable motor deficit: in the conservatively-treated group 45% improved compared with 53% in the operated group.12

Wielechowski A1, Keil A1, Hamstra-Wright K2. Referral patterns for surgical consult in the management of patients with foot drop due to acute lumbar disc herniation: a survey study of physical therapists in the United States. J Man Manip Ther. 2020 Jun 12:1-8. doi: 10.1080/10669817.2020.1776491. [Epub ahead of print]

REFERRAL PATTERNS FOR SURGICAL CONSULT IN THE MANAGEMENT OF PATIENTS WITH FOOT DROP DUE TO ACUTE LUMBAR DISC HERNIATION: A SURVEY STUDY OF PHYSICAL THERAPISTS IN THE UNITED STATES.

DEPENDING ON THE SEVERITY OF FOOT DROP, 34-61% WERE LIKELY TO REFER FOR IMMEDIATE NEUROSURGICAL CONSULT.

Khor S, Lavallee DC, Cizik AM, Bellabarba C, Dagal A, Hart RA, Howe CR, Martz RD, Shonnard N, Flum DR. Hospital and Surgeon Variation in Patient-reported Functional Outcomes After Lumbar Spine Fusion: A Statewide Evaluation. Spine (Phila Pa 1976). 2020 Apr 1;45(7):465-472. doi: 10.1097/BRS.0000000000003299. PMID: 31842110.

HOSPITAL AND SURGEON VARIATION IN PATIENT-REPORTED FUNCTIONAL OUTCOMES AFTER LUMBAR SPINE FUSION: A STATEWIDE EVALUATION

OF THE 737 PATIENTS WHO UNDERWENT LUMBAR FUSION (84% HAD STENOSIS; 70% HAD SPONDYLOLISTHESIS), 58.7% ACHIEVED FUNCTIONAL IMPROVEMENT AND 42.5% REACHED MINIMAL DISABILITY STATUS AT 1 YEAR.

AVOIDING OPERATION ON PATIENTS WITH <50% CHANCE OF FUNCTIONAL IMPROVEMENT MAY REDUCE CURRENT SURGICAL VOLUME BY 63%.

Carrasco-Martínez, Francisco & Ibañez-Vera, Alfonso & Martínez-Amat, Antonio & Hita-Contreras, Fidel & Lomas-Vega, Rafael. (2019). Short-term effectiveness of the flexion-distraction technique in comparison with high-velocity vertebral manipulation in patients suffering from low-back pain. Complementary Therapies in Medicine. 44. 10.1016/j.ctim.2019.02.012.

RCT OF 150 PATIENTS WITH LOW BACK PAIN TREATED WITH FLEXION-DISTRACTION TECHNIQUE SHOWED AN IMPROVEMENT OF AT LEAST 50% IN PAIN IN 56% AND HVLA IN 8% OF CASES

DISABILITY DECREASED 11% WITH COX DISTRACTION AND 6% HVLA

FLEXION-DISTRACTION OBTAINED BETTER RESULTS IN LOW BACK FUNCTION THAN HIGH VELOCITY LOW AMPLITUDE SPINAL MANIPULATION.

NUMBER TO TREAT WAS 2 WITH COX DISTRACTION MANIPULATION

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Kwon, Won-An ; Ryu, Young-Sang ; Ma, Sang-Yeol. The effects of Cox distraction manipulation on functional assessment measures and disc herniation index in patients with L4-5 herniated disc. Journal of the Korean Data and Information Science Society; Volume 23 Issue 4 Pages.727-738 2012 1598-9402(pISSN) https://doi.org/10.7465/jkdi.2012.23.4.727

The effect of a 4 week course of Cox® distraction manipulation (CDM) combined with therapeutic modalities on the treatment of 15 patients with L4-5 herniated nucleus pulposus (HNP) was delivered to the patients for 6 days per week for the first two weeks, and three times per week for two additional weeks. The entire treatment consisted of 18 visits over 4 week period.

Comparisons of changes in the muscle strengthening (MS), straight leg raise (SLR), and Oswestrydisability index (ODI) at pre-intervention, after two weeks treatment sessions, and at discharge (after 18 treatment sessions) were analyzed.

There were significant improvements in the outcome measures of MS Ibs, SLR test, and ODI score after 2 weeks and 4 weeks sessions of CDM combined with therapeutic modalities as compared with the pre-intervention. Cox Distraction Manipulation combined with therapeutic modalities appears to be a safe and efficacious, noninvasive treatment modality for patients with L4-5 HNP.

Oh H, Choi S, Lee S. Effects of the flexion-distraction technique and drop technique on straight leg raising angle and intervertebral disc height of patients with an intervertebral disc herniation. J Phys Ther Sci. 2019 Aug;31(8):666-669. doi: 10.1589/jpts.31.666. Epub 2019 Aug 9.

THE FLEXION-DISTRACTION TECHNIQUE AND THE DROP TECHNIQUE MAY SERVE AS EFFECTIVE INTERVENTIONS FOR THE STRAIGHT LEG RAISING ANGLE AND INTERVERTEBRAL DISC HEIGHT IN PATIENTS WITH INTERVERTEBRAL DISC HERNIATIONS.

Furqan Hassan , Muhammad Osama , Abdul Ghafoor , Muhammad Furqan Yaqoob. Effects of oscillatory mobilization as compared to sustained stretch mobilization in the management of cervical radiculopathy: A randomized controlled trial. Randomized Controlled Trial. J Back Musculoskelet Rehabil. 2020;33(1):153-158.doi: 10.3233/BMR-170914.

EFFECTS OF OSCILLATORY MOBILIZATION AS COMPARED TO SUSTAINED STRETCH MOBILIZATION IN THE MANAGEMENT OF CERVICAL RADICULOPATHY: A RANDOMIZED CONTROLLED TRIAL. OSCILLATORY MOBILIZATION TO BE SUPERIOR TO SUSTAINED STRETCH MOBILIZATION (P< 0.05) IN THE MANAGEMENT OF CERVICAL RADICULOPATHY EXCEPT FOR THE OUTCOMES OF PAIN AND SIDE BENDING.

CERVICAL SPONDYLOTIC MYELOPATHYJ.M. COX DC

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Pope DH, Mowforth OD, Davies BM, Kotter MRN. Diagnostic Delays Lead to Greater Disability in Degenerative Cervical Myelopathy and Represent a Health Inequality. Spine (Phila Pa 1976). 2020;45(6):368-377. doi:10.1097/BRS.0000000000003305

CSM ARE A COMMON FINDING ABOVE THE AGE OF 40 YEARS

CSM IS THE COMMONEST CAUSE OF SPINAL CORD IMPAIRMENT AND INCREASING

THERE IS SIGNIFICANT OVERLAP OF SYMPTOMATOLOGY WITH OTHER NEUROLOGICAL CONDITIONS WHICH MAY CAUSE DIFFICULTIES IN DIAGNOSIS.6

LONGER DELAYS DO NOT APPEAR TO AFFECT SURGICAL MANAGEMENT BUT ARE ASSOCIATED WITH GREATER DISABILITY.

McCormick JR, Sama AJ, Schiller NC, Butler AJ, Donnally CJ 3rd. Cervical Spondylotic Myelopathy: A Guide to Diagnosis and Management. J Am Board Fam Med. 2020;33(2):303-313. doi:10.3122/jabfm.2020.02.190195

THE HALLMARK SYMPTOMS OF CSM INCLUDE DECREASED HAND DEXTERITY AND GAIT INSTABILITY AS WELL AS SENSORY AND MOTOR DYSFUNCTION.

PATIENTS WITH MILD CSM MAY BE TREATED SURGICALLY OR NONOPERATIVELY, WHEREAS THOSE WITH MODERATE-SEVERE DISEASE ARE TREATED OPERATIVELY.

DUE TO THE LONG-TERM DISABILITY THAT MAY RESULT FROM A DELAY IN DIAGNOSIS AND MANAGEMENT, PROMPT REFERRAL TO A SPINE SURGEON IS RECOMMENDED FOR ANY PATIENT SUSPECTED OF HAVING CSM..

Ye X1, Sun Y. [Advances in research of cervical spondylotic amyotrophy]. Zhonghua Wai Ke Za Zhi. 2019 Sep 1;57(9):717-720. doi: 10.3760/cma.j.issn.0529-5815.2019.09.015.

CERVICAL SPONDYLOTIC AMYOTROPHY (CSA) HAS ATTRACTED MORE AND MORE ATTENTION IN RECENT YEARS, ACCORDING TO EARLY STUDIES, IT IS BASED ON CERVICAL DEGENERATION, AND MAINLY CHARACTERIZED BY SEGMENTAL, ASYMMETRIC AND STABLE MUSCULAR ATROPHY OF UPPER EXTREMITIES, WITH OR WITHOUT MILD SENSORY ABNORMALITIES AND SPINAL CORD LESIONS (MANIFESTED AS LOWER EXTREMITY SYMPTOMS AND GAIT ABNORMALITIES), ALSO KNOWN AS KEEGAN'S CERVICAL SPONDYLOSIS

ERVICAL SPONDYLOTIC AMYOTROPHY (CSA) HAS ATTRACTED MORE AND MORE ATTENTION IN RECENT YEARS, ACCORDING TO EARLY STUDIES, IT IS BASED ON CERVICAL DEGENERATION, AND MAINLY CHARACTERIZED BY SEGMENTAL, ASYMMETRIC AND STABLE MUSCULAR ATROPHY OF UPPER EXTREMITIES, WITH OR WITHOUT MILD SENSORY ABNORMALITIES AND SPINAL CORD LESIONS (MANIFESTED AS LOWER EXTREMITY SYMPTOMS AND GAIT

ABNORMALITIES), ALSO KNOWN AS KEEGAN'S CERVICAL SPONDYLOSIS

Nouri A, Patel K, Montejo J, Nasser R, Gimbel DA, Sciubba DM, Cheng JS. The Role of Vitamin B12 in the Management and Optimization of Treatment in Patients With degenerative Cervical Myelopathy. Global Spine J. 2019 May;9(3):331-337. doi: 10.1177/2192568218758633. Epub 2018 May 17.

PATIENTS AT THIS AGE HAVE ALSO BEEN REPORTED TO HAVE A HIGH PREVALENCE OF VITAMIN B12 DEFICIENCY, WITH ESTIMATES OF UP TO 20% IN THE ELDERLY. VITAMIN B12 DEFICIENCY CAN RESULT IN SUBACUTE COMBINED DEGENERATION OF THE SPINAL CORD (SACD), AND SEVERAL CASE REPORTS HAVE POINTED TO PATIENTS WITH BOTH DCM AND SACD.

BOTH SACD AND REVERSIBLE COMPRESSIVE INJURY DUE TO DCM NECESSITATE REMYELINATION IN THE SPINAL CORD, A PROCESS THAT REQUIRES ADEQUATE VITAMIN B12 LEVELS. BASIC SCIENCE RESEARCH ON NERVE CRUSH INJURIES HAVE SHOWN THAT VITAMIN B12 LEVELS ARE ALTERED AFTER NERVE INJURY AND THAT VITAMIN B12 ALONG WITH DEXAMETHASONE OR NONSTEROIDAL ANTI-INFLAMMATORY DRUGS CAN REDUCE WALLERIAN DEGENERATION. FURTHERMORE, IT HAS BEEN SUGGESTED THAT A COMBINATION OF B-VITAMINS CAN REDUCE GLUTAMATE-INDUCED NEUROTOXICITY.

THE ROUTINE ASSESSMENT OF VITAMIN B12 LEVELS IN PATIENTS CONSIDERED FOR DCM SURGERY SHOULD BE CONSIDERED.

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FOLLOWING IS THE KANG GRADING SYSTEM FOR CERVICAL CENTRAL CANAL STENOSIS FROM Kang Y, Lee JW, Koh YH, et al. New MRI grading system for the cervical canal stenosis. AJR Am J Roentgenol. 2011;197(1):W134-W140. doi:10.2214/AJR.10.5560

Fig. 1 —Schematic diagrams of grading system of cervical canal stenosis in sagittal scans of cervical spines. Grade 0 is normal. Grade 1 denotes obliteration of more than 50% of subarachnoid space without any sign of cord deformity. Grade 2 denotes central canal stenosis with spinal cord deformity; cord is deformed but no signal change is noted in spinal cord. Grade 3 denotes increased signal intensity of spinal cord near compressed level on T2-weighted images.

KANG GRADE 0 SAGITTAL MRI

Grade 0

Sagittal T2-weighted fast spin-echo image shows cervical spine without compromise of spinal canal. Normal CSF space is visible around spinal cord, and there is no evidence of cord deformity or signal change within cord.

KANG GRADE I STENOSIS

Sagittal T2-weighted fast spin-echo image shows grade 1 stenosis with obliteration of CSF space exceeding 50% of arbitrary subarachnoid space at C4–5, C5–6, and C6–7 levels (arrows).

KANG GRADE 2 CERVICAL SPINE STENOSIS

Sagittal T2-weighted fast spin-echo image shows grade 2 stenosis at C4–5 level (arrow). Spinal cord is compressed and deformed, but spinal cord shows no signal changes. Grade 1 stenoses were also seen at C5–6 and C6–7 levels.

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KANG GRADE 3 CERVICAL SPINE STENOSIS

Sagittal T2-weighted fast spin-echo image shows grade 3 cervical canal stenosis at C5–6 level (arrow). Spinal canal is significantly narrow at C5–6 level, and signal intensity of spinal cord is increased at corresponding level.

Kobayashi H, Sekiguchi M, Yonemoto K, et al. Reference values of the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire in patients with lumbar spinal stenosis and characteristics of deterioration of QOL: Lumbar Spinal Stenosis Diagnosis Support Tool: DISTO project. J Orthop Sci. 2019;24(4):584-589. doi:10.1016/j.jos.2018.11.022

Item

Q1 Numbness and/or pain in the thighs down to the calves and shins

Q2 Numbness and/or pain increase in intensity after walking for a while, but are relieved by taking a rest

Q3 Standing for a while brings on numbness and/or pain in the thighs down to the calves and shins

Q4 Numbness and/or pain are reduced by bending forward

Q5 Numbness is present in both legs

Q6 Numbness is present in the soles of both feet

Q7 Numbness arises around the buttocks

Q8 Numbness is present, but pain is absent

Q9 A burning sensation arises around the buttocks

Q10 Walking nearly causes urination

The LSS-DST consists of 10 question items and has a sensitivity and specificity of 84 and 78 %, respectively [11]. The items of a self-administered history questionnaire as the LSS-DST are shown in Table 1. Each item of the LSS-DST for diagnosis of LSS required a response either of “1 = yes” or “0 = no”. A total score of 4 on Q1–Q4 or a score >1 on Q1–Q4 and >2 on Q5–Q10 indicated the presence of LSS. The items of a self-administered, self-reported history questionnaire (SSHQ) as a diagnostic support tool for LSS.

CASE 175 –C4-C5 MYELOMALACIA

61 Y/O FEMALE SEEN 2-21-18 FOR C/C OF ACUTE NUMBNESS, PINS AND NEEDLES OF BOTH HANDS, LEFT WORST. VAS = 10. CANNOT WRITE OR SLEEP. BALANCE ISSUES

STARTED AFTER SURGERY FOR CTS AND HIP SURGERY, A TOTAL OF 6 TIMES

CTS SURGERY DID NOT HELP HER IN 2017

SHE ALSO HAS LEFT FOOT DROP FOLLOWING BACK SURGERY

NO HELP FROM CHIROPRACTIC NOR PT IN PAST.

GRIP STRENGTH WAS 31 LB IN LEFT HAND AND 55 IN RIGHT

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T2 sagittal MRI

Advanced C4-C5 DDD with anterolisthesis of C4 on C5. Also multilevel DDD and C7 anterolisthesis on T1. Note edema of myelomalacia of cord at the C4-C5 level. Always attention gaining.

Axial T2 image

Note the central and right foraminal stenosis due to endplate hypertrophy and disc protrusion at the C4-C5 level.

Reported also is central stenosis and lateral foraminal stenosis at the C3-4, 5-6 and 6-7 levels.

Sagittal T2 MRI L/S

DDD at all levels, degenerative spondylolisthesis L4 with stenosis due to disc bulge and ligamentum flavum thickening

Axial T2 image

Stenosis advanced due to ligamentum flavum thickening and facet arthrosis. Also not multifideesatrophy as seen in chronic LBP.

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Treatment plan

4-23-18 – Protocol 1 at foramen magnum pump, galvanic and tetanizing current, adjust and trigger point both arms

Discat Plus Enhanced at 3 am and pm, vitamin D and E and B

4-23-18 to 5-22-18 for a total of 13 visits results in acupuncture added on 7th visit and OCCIPITAL RESTRAINT C/S DISTRACTION ON THE 5TH VISIT.

On 8th visit the patient felt first real relief.

On 9th visit she c/o lbp and right hip pain. We start protocol 2 with careful tolerance testing at L3 level above the L4 deg. Spondylolisthesis

Acupuncture with f/d really changed the treatment success.

Treatment outcome

7-9-18 - Hands much better with VAS drop from 10 to 4 for pain and ability to write. UIT of lumbar spine with L3 restraint above L4 degenerative spondylolisthesis is given with tetanizing current from L4 to left anterior tibialis common peroneal nerve.

CONSIDER = TREATING TWO SPINE LEVELS LOWERS CYTOKINES GREATER THAN ONE LEVEL, IN THIS CASE WITH OCCIPITAL RESTRAINT FOR C/S AND LUMBAR RESTRAINT L3 LEVEL FOR DEGENERATIVE SPONDYLOLISTHESIS AND FOOT DROP

4 visits on July 12,16,19,23 with occipital restraint, acupuncture of C/T spine results in VAS pain of 5 for neck and arms from VAS of 10. She writes well and hands are stronger. LBP is VAS 4 with treatment of L4 degenerative spondylolisthesis.

COURSES

Workshops4 hours

Certified Doctors’ Offices

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2019 and 2020 Interdisciplinary Spine Conference: Spinal Stenosis11.5 hours CE (2019)

11.5 hours CE (2020)

RECORDINGS Available

ONLINE COURSES

www.coxtechnic.digitalchalk.com

Cox® Seminars14 CE hrs | Part I Lumbar – FW Nov 5-816 CE hrs | Part II Lumbar – WPB Oct 24-25

14 CE hrs | Part III Cervical – CA Nov 14-15

12 CE hrs | Part IV Thoracic

12 CE hrs | Part V Extremity/Sport/Rehab

www.coxtechnic.com/doctors/seminars-workshops-webinars

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Documents

Mengchen Yin 1, Chongqing Xu 1, Junming Ma 1, Jie Ye 1 ... for...the cervical stenosis significantly lowers the need of the second-stage surgery. in contrast, if lumbar stenosis was