Manipulation under anesthesia for pain

This procedure, manipulation under anesthesia (MUA), is a non-invasive procedure increasingly offered for acute and chronic conditions, including: neck pain, back pain, joint pain, muscle spasm, shortened muscles, fibrous adhesions and long term pain syndromes. It is generally considered safe and is utilized to treat pain arising from the cervical, thoracic and lumbar spine as well as the sacroiliac and pelvic regions.

Manipulation under anesthesia uses a combination of specific short lever manipulations, passive stretches and specific articular and postural kinesthetic maneuvers in order to break up fibrous adhesions and scar tissue around the spine and surrounding tissue.

The manipulation procedures can be offered in any of the following ways:

· Under general anesthesia

· During mild sedation

· Following the injection of anesthetic solutions into specific tissues of the spine.

The treatment is performed in a hospital or surgery center by licensed physicians with specialized training and certification specifically for the procedure. A team approach is required to have a safe and successful outcome.

The team includes the anesthesiologist, the prime physician/surgeon/chiropractor who performs the manipulation, and the first assistant, also a physician/chiropractor certified in manipulation under anesthesia. The procedure is commonly performed in a hospital or surgical center.

The combination of manipulation and anesthesia is not new, as this treatment has been part of the manual medical arena for more than 60 years.Manipulation Under Anesthesia is an established medical procedure with a CPT Code designate of 22505. This is noted in the American Medical Association’s Current Procedural Terminology Publication.

Which patients should be considered for manipulation under anesthesia? Certain neck, mid back, low back or other spinal conditions respond poorly to conventional care. One proposed theory for this is that, as a result of past or present injury, adhesions and scar tissue have built up around spinal joints and within the surrounding muscles and causes chronic pain.

Patients often undergo various treatments, such as physical therapy, chiropractic care, epidural injections, back surgery, or other treatments that do not address fibrous adhesions. Some patients feel temporarily better with these treatments, but their pain often returns.

In general, patients selected for manipulation under anesthesia are those who have received conservative care for six to eight weeks. If limited or no improvements in symptoms or objective findings have occurred, then manipulation under anesthesia may be an appropriate alternative.

Prior to treatment, protocols of diagnostic testing should document the nature of the diagnosis, support the need for treatment and eliminate questions of psychosocial factors that can influence pain responses. In addition to X-ray, MRI scan or CT scan, a musculoskeletal sonogram or nerve conduction velocity test may be ordered.

Proposed effects

The proposed effects of manipulation under anesthesia therapy include the following:

Breaking up scar tissue (adhesions) both in and around the spinal joints, commonly caused by multiple injuries or failed back surgery
Decreasing chronic muscle spasm
Overcoming super sensitivity of injured areas, making the patient unable to cooperate for effective treatment
Stretching persistent shortened muscles, ligaments and tendons
Relieving pain and radiating symptoms from damaged intervertebral discs. Some disc injuries are serious enough to require surgery, but these types of injuries are relatively infrequent.

Chrisman et al: “A study of the results following manipulation in lumbar disc syndrome.” Journal of bone and Joint Surgery 46A, 1964.
Saal et al: “The natural history of lumbar disc extrusions treated non-operatively.: Spine, Vol 15, 1990.
Kohlbeck FJ, Haldeman S, “Medication-assisted spinal manipulation.” The Spine Journal, Volume 2 (4), 2002.

Anesthesia and Manipulation
Of course, when movement of the spine is extremely and intolerably painful to the patient, the benefit of being under anesthesia and unconscious is obvious. In addition, the anesthesia performs other equally important functions, such as:

Shutting off the muscle spasm cycle to allow spinal movement
Sedating the pain-perceiving nerves that have been irritated due to the dysfunctional spine
Allowing complete muscle relaxation to allow the doctor to stretch shortened muscle groups and to break up adhesions caused by scar tissue.

Indications and contraindications

In general, patients selected for manipulation under anesthesia have received a minimum of six to eight weeks of conservative care. Additionally, there are a number of specific indications and contraindications that need to considered prior to undertaking manipulation under anesthesia, including:

Indications

Neck, mid back and low back pain
Chronic muscle pain and inflammation
Acute and chronic muscle spasm
Decreased spinal range of motion
Chronic fibrositis
Nerve entrapment
Pseudo-sciatica
Sciatica where disc bulges are contained less than 5 mm
Failed back surgery
Chronic occipital or tension headaches
Conditions where narcotic pain relievers are of little benefit
Traumatic torticollis
RSD

Contraindications
Contraindication to anesthesia as determined by current medical literature and is the responsibility of the licensed medical co-manager (anesthesiologist).

Contraindications to manual manipulation of high velocity, low velocity or soft tissue techniques as established by current literature relative to technique specific for articular derangements, bone weakening and destruction disorders, circulatory and cardiovascular disorders, or neurological disorders.

Specific contraindications to manipulation of the spine under anesthesia include:

Malignancy with metastasis to bone
Tuberculosis of the bone
Fractures
Acute arthritis
Acute gout
Uncontrolled diabetic neuropathy
Syphilitic articular or periarticular lesions
Gonorrheal spinal arthritis
Excessive spinal osteoporosis
Evidence of cord or caudal compression by tumor, ankylosis and malacia bone disease.

Evaluation of the Patient

Candidates are selected for manipulation under anesthesia after obtaining an adequate history, thorough physical examination, and the appropriate diagnostic imaging and laboratory procedures necessary for an accurate diagnosis of the underlying condition.

History and physical
The burden of proof for medical necessity rests with the treating doctor. It should be substantially documented in the patient’s history and physical, with specific emphasis on: the failure to respond to conservative means in the history; indication of fibrosis and/or myofibrosis in the physical examination; and any supportive diagnostic testing as indicated and warranted by medical necessity of the patient’s condition.

A complete physical examination is performed paying special attention to motion palpation of the spine and a visual inspection and palpation of the skin (manifestation of sympathetic nervous system changes including edema, tissue texture, increase or decrease of moisture, temperature changes, etc). Additionally, digital palpation identifies increased or decreased changes in muscle and fascia tone which lead to altered biomechanics.

Laboratory exam
Laboratory examinations should be performed to further evaluate patient health. They not only contribute to differential diagnosis, but they also help the medical saff assess patient health prior to going under anesthesia. Females of child bearing years should be evaluated for pregnancy.

Females of child bearing years should be evaluated for pregnancy. A male past 40 years of age should also have the following test done: serum alkaline and acid phosphatase. After completion of the preliminary work, other laboratory procedures may be indicated.

Radiographic examination
Anterior-posterior (front/back) and lateral (side) radiographs of the joints involved should be taken. Additionally, extension and lateral bending views may be of benefit in visualizing loss of function. Many times one may want a detailed view of the joints which are to be manipulated under anesthesia. Motion studies on fluoroscopy may be helpful.

Studies should be repeated after serial manipulation under anesthesia to see what changes have been affected by the procedure. When warranted, CT Scan and/or MRI scan of the spine should be employed to rule out or confirm suspected pathology.

Electrodiagnostic tests
Electrodiagnostic studies of the appropriate spinal outflows should be performed to rule out specific neurological dysfunction. These tests confirm or differentiate diagnosis of neuropathy, radiculopathy or plexopathy. They show the presence or lack of nerve compression and localize and assess the degree of injury along the course of a nerve.

Techniques under anesthesia may vary from patient to patient as medical necessity indicates by the involved tissues and existing relative contraindications and/or possible complications that may exist. Some of the techniques include:

Soft tissue procedures - lateral stretching, linear stretching, deep pressure, traction and/or separation of muscle origin and insertion.

Tissue:	periarticular
Goals:	decrease muscle spasm and increase tissue mobility

Articulatory procedures (mobilization without impulse, low velocity techniques) - placing articulation through full anatomic range of motion. A passive serial repetitive oscillatory rhythmic springing force in the direction of restriction.

Tissue:	periarticular and articular
Goals:	increase quantity of motion - gradual movement of restrictive barrier to restore range of motion increase quality of motion - smooth range of movement with normal elastic and feel

Specific joint mobilization procedure - mobilization with impulse, high velocity technique. Extrinsic operator applied thrust overcoming restrictive articular movement. Engagement of the restrictive barrier and thrust through the barrier to achieve normal joint movement.

Tissue:	articular and intra articular
Goals:	increase joint range of motion reduce joint restrictions reduction of hyper tonicity stretch shortened fibrosed connective tissues of the articulation

under anesthesia.

Post Operative Care

The patient should experience an immediate increase in range of motion, even though there is usually some temporarily added muscle soreness similar to feeling of having completed an aggressive exercise session. In cases involving symptoms caused by disturbance from adhesions and shortened tissues, there should be a significant change, either immediately or within a short period following the procedures.

In effort to minimize the re-formation of adhesions, passive manipulation and active exercises are prescribed. Some use of additional therapies may also be prescribed, such as:

· Electrical muscle stimulation

· Ultrasound

· Hot moist packs

· Massage

The most important post operative care is an active rehabilitation program, starting within one to two weeks after the manipulation under anesthesia procedure and lasting for a minimum of four to six weeks.

Supporting Studies

There are several research studies about the effectiveness of manipulation under anesthesia, including:

1. 83% of 600 patients with EMG verified radiculopathies reported significant improvement - Robert Mensor, MD

2. Patients that had back pain for a minimum of 10 years reported an 87% recovery rate after MUA - 1987 with Ongly et al

3. 51% of patients with unrelieved symptoms after conservative care had been exhausted reported good to excellent results three years post MUA - Donald Chrisman, MD

4. 71% of 723 MUA patients had good results (return to normal activity relatively symptom free) and 25.3% had fair results (return to normal activity with slight residuals) and that flexibility, elasticity and range of motion can be restored following MUA - Bradford and Siehl

5. 83% of 517 patients treated with MUA responded well - Paul Kuo, MD professor of Orthopedic Surgery

6. Krumhansi and Nowacek reported on an MUA study done on 171 patients who experienced constant intractable pain for several months to 18 years. All of the patients of the study failed other conservative intervention. The results of the study showed that 25% of the patients had no pain, 50% were much improved with pain markedly decreased, 20% were better and could tolerate their pain but it interfered with work and recreation. Failures comprised 5% where there was minimal or no pain relief periods.

The medical literature demonstrates that for over forty years chronic neuromuscular skeletal conditions that have failed the conservative protocol may respond well to manipulation under anesthesia.

The overall effectiveness of spinal manipulation under anesthesia has been reported by researchers with success rates varying according to case selection criteria.

Diagnosis of herniated disc reported excellent to good results in:

60% - PC Colonna and ZB Friendenberg: 1949
64% - Merrill C Mensor, MD: 1949
60% - Donald Sielh, DC: 1963

Diagnosis of myofibrositis reported excellent to good results in:

96.3% - Donald Siehl, OD: 1963
75% - BR Krumhansi and CJ Nowacek: 1988

By: Richard Reid, MD,
Rosie Desimone, D.C.,
Ben Eubank, D.C.
October 23, 2002

References

1. Greenman, PE: Manipulation with the patient under anesthesia. J. Amer. Osteopathic Assoc., 92(9):1159 -1167, Sept. 1992.

2. West, D.C., C.C.R.D., Mathews, M.D., Miller, PA-C, Kent, M.D. "Effect of Management of Spinal Pain in 200 Patients Evaluated for Manipulation Under Anesthesia." J. Neurol Oethop Med Surg. (1998) 18: pp. 31-42.

3. Guidelines for Chiropractic Quality Assurance and Practice Parameters: Proceedings of the Mercy Center Consensus Conference, Burlingame, CA, January 25 - 30, 1992. S Haldeman et al (eds.), Gaithersburg, MD: Aspen Publishers, Inc. 1993.

4. Dreyfuss P, et al. MUJA: Manipulation under joint anesthesia/analgesia: A treatment approach for recalcitrant low back pain of synovial joint origin. J Manipulative Physiol Ther. 1995;18:537-546.

5. Davis CG. Chronic cervical spine pain treated with manipulation under anesthesia. J Neuromusculoskeletal Syst. 1996;4:102-115.

6. Francis R. Spinal manipulation under general anesthesia: A chiropractic approach in a hospital setting. J Am Chiro Assoc. 1989; Dec:39-41.

7. Alexander GK. Manipulation under anesthesia of lumbar post-laminectomy syndrome patients with epidural fibrosis and recurrent HNP. J Am Chiro Assoc. 1993;June:79-81.

8. Dan NG, Saccasan PA. Serious complications of lumbar spinal manipulation. Med J Aust. 1983;2(12):672-673.

9. Hughes BL.Management of cervical disk syndrome utilizing manipulation under anesthesia. J Manipulative Physiol Ther. 1993;16:174-181.

10. Aspegren DD, et al. Manipulation under epidural anesthesia with corticosteroid injection: Two case reports.J Manipulative Physiol Ther. 1997;20(9):618-621.