The Cervical Spine Challenge

The 2001 Biennial COCA Conference was held for the first time this year in Sydney in October. It was entitled “The Cervical Spine Challenge”.

The Conference explored the most recent evidence based practice on whiplash injury, red flags for the cervical spine, neurological complications of cervical spine manipulation, radiofrequency neurotomy and cervical spine stabilisation and rehabilitation. This naturally required a diverse approach and the list of presenters was impressive. The quality of the presentations was high and adequate question time was allocated. Altogether there were 14 presenters and 15 presentations.

Dr Margaret Torode is the Head of School of Exercise & Sport Science at the University of Sydney. She began the conference with a discussion on the functional anatomy of the cervical spine and the clinical features associated with whiplash. Dr Philip Bolton then discussed the neurophysiological mechanisms underlying whiplash associated disorders (WAD). Anatomical and physiological data from animals and humans were presented showing that a variety of receptors in the neck signal the mechanical events associated with whiplash injury.

We were then fortunate to have the down to earth and humorous Dr Lindsay Rowe present for us. Dr Rowe discussed the various forms of imaging available for the cervical spine. He showed that fatty infiltration was evident on MRI as a precursor to sclerosis and was present 2 years before sclerosis became visible. He stated that fatty infiltration was also a precursor to pain. Dr Rowe reported that CT Scanning gave a 25% false negative result in the cervical spine and is not very useful.

Over the course of the weekend we had 3 speakers present on various aspects of the Guidelines for the Management of WAD. Ms Suzanne Lulham discussed the NSW Motor Accidents Authority Guidelines in which WAD were divided into 5 grades.

The second part of this presentation was Trudy Rebbeck presenting An Evidence Based Approach to the Management of WAD. Ms Rebbeck underlined the lack of evidence for certain treatments. Within the Guidelines the following were not recommended: prolonged rest and prolonged use of collars (both of which may delay recovery); cervical pillows; spray and stretch; steroid injections; magnetic necklaces; Pilates; and Feldenkrais. Prof Rodney Bonello was the third presenter addressing the NSW Guidelines and he discussed The Chiropractor’s & Osteopath’s Role in the Management of WAD.

Dr Simon French discussed the Evidence for the Conservative Management of Neck Pain. Dr French presented a literature review of the evidence and gave references to a large number of papers. He pointed out that systematic reviews consistently called for further high quality clinical trials.

It was very pleasing, particularly for the osteopaths attending, to have osteopath Assoc Prof Peter Gibbons presenting for the weekend. He presented a study he had conducted with a student of his from VUT on High Velocity Low amplitude Manipulation of the Atlanto-Axial Joint: The Effect on Atlanto-Axial and Cervical Spine Rotation Asymmetry in Asymptomatic Subjects. Prof Gibbons presented the results of this study which showed that HVLA thrust was associated with an increased range of rotation, but that this was short lasting and returned to the previous range of motion at review after an hour.

A COCA conference is not complete without Mr David de la Harpe. Mr de la Harpe was in fine form discussing Red Flags for the Cervical Spine. He presented red flags for manipulation and stated that the most important red flag is the presence of myelopathy indicated by long track or upper motor neurone signs. Mr De la Harpe also discussed Cervical Spine Surgery stating that the most common operations in the cervical spine are decompression operations for degenerative disease.

Assoc Prof Allan G J Terrett discussed Neural Complications of Spinal Manipulative Therapy. Dr Terrett stated that 10% of Americans consult chiropractors with approx 250 million patient visits per year. He reported that critics of spinal manipulative therapy emphasize the possibility of neurological injury, which fall into 3 categories: cerebrovascular stroke syndromes and incidents; lumbar disc syndromes; and miscellaneous neurological syndromes. Brief reference was made to the possibility of exacerbating symptoms in patients who had lumbar radicular signs.

Dr Jay Govind presented on Radiofrequency Neurotomy for the Treatment of Occipital Headache. Jay described head pain referred from C2-3 zygapophyseal joint via the 3rd occipital nerve. He stated that it is the basis of 27% of headaches suffered by patients with whiplash. It is diagnosed by diagnostic block of the 3rd occipital nerve. Percutaneous radiofrequency neurotomy has been validated as a treatment for neck pain stemming from the cervical zygapophyseal joints but not from C2-3. The differences in the anatomy of this nerve were described and data presented showing very favourable outcomes. The technique was also described.

Dr Peter Tuchin discussed the Chiropractic Treatment of Cervicogenic Migraine. Dr Tuchin presented a study of 640 migraine sufferers who could be diagnosed as having cervicogenic migraine. Those who qualified were treated twice a week for 8 weeks. Pain relief was achieved only for short periods immediately following treatment. However, there was a marked reduction in the use of medication.

Mr Orso Osti is a popular presenter at COCA conferences and this conference he presented on The Epidemiology of Whiplash and the Principles of Treatment. Mr Osti presented data from a study in Adelaide of 600 whiplash victims, which suggested that socio-economic factors such as the presence of workers compensation claim, legal representation and past history of neck injury, were significantly associated with disability. Conversely, he stated that changes in legislation and capping of compensation payouts may lead to significant reduction in the incidence of chronic pain associated with whiplash. Mr Osti stated that surgery is almost invariably inappropriate unless neurological injury and/or deficit are present.

Assoc Prof Gwendolen Jull presented on Cervical Spine Stabilisation and Rehabilitation. Prof Jull presented results of a study of the effect of WAD on muscle function. She also discussed a form of therapeutic exercise called stabilisation training. The effectiveness of a specific exercise program was tested in a randomised controlled trial of cervicogenic headache patients and found to be successful in reducing neck pain.

Being an osteopath in New Zealand, I hadn’t had the chance to attend a COCA conference before this one. I would encourage osteopaths and chiropractors to attend a COCA conference and consider joining the College. Most practitioners struggle to keep informed with recent evidence based practice. This conference provided an enjoyable method of doing so. Clearly evident at the end of this conference was the need for practitioners of manual medicine to expand our database of evidence based practice and produce good quality research.

Thank you to the organisers for the opportunity this conference provided.

Cynthia Baker, Osteopath