Aurora, IL Chiropractic - Dr. Robert W. Boer, DC - Fox Valley Physician Services

Manipulation Under Anesthesia

WHAT IS MANIPULATION UNDER ANESTHESIA?

 

Manipulation under anesthesia (MUA) is the use of manual manipulation of the spine combined with the use of general anesthetic. The addition of anesthetic allows for the benefits of manipulation to be shared with those patients who cannot tolerate manual techniques because of pain response, spasm, muscle contractures, and guarding. MUA uses a combination of specific short-level arm manipulations, passive stretches, and specific articular and postural kinesthetic integrations to obtain a desired outcome.

 

IS MUA NEW OR EXPERIMENTAL?

 

Spinal manipulation under anesthesia (MUA) has been used to treat a wide variety of musculoskeletal disorders dating as far back as the 1930s and 1940s. Most of the forms of MUA discussed in the literature have been performed and documented by the medical and osteopathic professions. It would also appear that most of this research has dealt primarily with MUA as an approach to treating certain types of mechanical lumbar and cervical spine dysfunction. The generally accepted rationale for how MUA works is based on solid scientific data relating to muscle and joint physiology. Authors and researchers such as Guyton, Fung, Crowe, and Hill have all helped to establish the unique physiologic properties that synovial joints and muscles have and how those properties act when subjected to traction and stretching forces. MUA in the clinical setting is based on the hypothesis that fibrous adhesions in the joint capsules and surrounding supportive tissues can be altered by the use of specific manipulative and stretching techniques. The result of altering adhesions is increased mobility of the motor unit caused by an increase in flexibility of the supportive tissue. Siehl and Claybourne have documented the validity of MUA as a procedure useful in treating musculoskeletal disorders when restrictition of the joint, joint capsule, and surrounding musculature has taken place as a result of the formation of fibrous adhesions.

 

WHO CAN BENEFIT FROM MUA AND WHY DOES MUA WORK?

 

The goals in treatment of mechanical spine pain is to correct the aberrant spinal motion of the involved segments, thereby improving function and decreasing pain. This is achieved via a variety of techniques, most of which can be simplified into two types of forces : (1) high-velocity, short-duration and (2) low velocity, long-duration.


These two applications of force will affect different aspects of the subluxation components. The former affects the osseous disrelationship or misalignment. The latter addresses the "tough soft tissue" component. These applications are used in an isolated or combined fashion, depending on the nature of the lesion. Office based SMT (spinal manipulative technique) is rendered via specific short-lever arm-adjustive forces tipically combined with traditional physiotherapeutic modalities such as ultrasound, hydrocollator, interferential, cryotherapy, traction, and passive/active rehabilitation
A percentage of these patients ultimately will not respond to conscious SMT on the basis of one or more of the following criteria:

  1. Chronicity of the case because of joint or soft tissue fibrosis, which has inhibited restoration of appropriate joint mechanics
  2. Acute myofascial rigidity and painful inhibition, which disallows conscious SMT
  3. Severe joint dysfunction and subluxation such that correction of evident spinal biomechanical misalignment is not achievable through conscious SMT
  4. Contained disc herniation (buldge) of less than 5mm that has become refractory to conscious SMT
  5. Multiple recurrences during the active-resistive phase of joint rehabilitation


WHAT IS THE MUA PROCEDURE LIKE?


Before the day of the procedure, the patient is instructed regarding their nothing-by-mouth status and medications. The patient must be accompanied by a friend or family member to drive the patient home after the procedure. No patient will be allowed to drive home after this procedure. The patient then signs an informed consent affidavit and right after placed on the procedure table and hemodynamic monitoring is instituted, including electrocardiography, blood pressure, and pulse oximetry. Supplemental oxygen is given via nasal cannula. The patient is initially sedated mildly with Versed (Midazolam) and asked to provide input regarding drug activity.

The MUA procedure generally takes between 15 and 20 minutes. The patient is continually monitored by the anesthesia provider. Blood pressures are obtained at least every 5 minutes, and a complete anesthesia record is maintained. The patient is yaken to the recovery room at the termination of the procedure, provided the vital signs are stable. He or she will then be continually monitored in the recovery room, with supplemental oxygen administered on the basis of the facility protocol, which includes stable vital signs, no nausea or vomiting, and return of coordinated motor function.

 

The following are indications for manipulative procedures under anesthesia, when manipulation is the therapy of choice:

     

  1. The patient has responded favorably to conservative, non invasive chiropractic and medical treatments, but continues to experience intractable pain and /or biomechanical dysfunction.  Sufficient care has been rendered prior to recommending MUA (standard is 2-6 weeks).  Manipulative procedures have been utilized in the clinical setting during the 2-6 week period prior to recommending MUA.  The patient's level of reproduced pain interferes with lifestyle. (Sleep, daily functional activities, work habits, etc.)
  2. Chronic or recurring pain.
  3. Pain so severe that narcotic analgesics are of little benefit.
  4. Chronic Myositis; peripheral muscular fibrotic adhesion formation (adhesions and scar tissues will begin to develop 6 - 12 hours after an initial injury).
  5. Chronic Fibrositis; peripheral, can be muscular of articular: related to fibrotic adhesion buildup over short or long periods of time (i.e. facet joint encapsulation or encapsulitis with associated restriction of motion).
  6. Nerve entrapment; peripheral (i.e. syndrome or inflammation or disc pathology).
  7. Disc Pathology; Disc protrusions, bulging discs, of herniations less than 3 millimeters in the cervical spine and 5 millimeters in the lumbar spine (spontaneous or from traumatic origin) documented by CT, MRI or Myelography.
  8. Traumatically induced restriction of range of motion can be peripheral of radicular (i.e. Torticollis).
  9. Chronic production arthritis; spondylosis, spondyloarthritis, and spondyloathrosis.
  10. Lumbarization associated with acute/chronic pain; peripheral in nature, causing muscle splinting, fibrotic adhesions and/or chronic spasm.
  11. Sacralization associated with acute/chronic pain; peripheral causing chronic muscle splinting contracture, spasm fibrotic adhesion formation (relating to degenerative changes).
  12. Chronic disc changes; associated with fibrotic adhesions due to degenerative changes.
  13. Traumatic Torticollis; peripheral in nature, causing severe muscle splinting and / or contracture, vertebral subluxation due to trauma (intractable pain from hyper flexion/hyperextension injury).
  14. Failed spinal surgery.
  15. Headaches; non-organic origin.