Upper Cervical Spine Biedermann (21), a manual medicine practitioner, studied biomechanical problems (i.e., subluxation) of the upper cervical spine in newborns. Approximately 135 babies who were available for follow-up were reviewed in the report. The babies were referred to the author because of asymmetrical posture, and the case histories included the following disturbances:

The symptoms described by the patients’ parents could be caused by a variety of pathologic conditions. Biedermann (21) states that if motor asymmetries, sleeping alterations, or facial scoliosis are present, then the suboccipital articulations should be evaluated for blockages (i.e., fixation dysfunction). He also advocates the use of plain film radiographs for determining malalignment of the suboccipital region and for determining the appropriate vector of force during the adjustment. In addition, the radiograph is used for the detection of malformations. Biedermann (21) states that basing treatment on information not taken from the radiograph is why his colleagues probably do not have as favorable results. A high proportion of the newborns in this study experienced prolonged labor times during delivery when compared with normal babies. Most patients only required one to three adjustments before remission of symptoms occurred. However, no long-term follow-up of these patients was reported. These findings parallel the clinical observations of many practicing chiropractors and indicate that chiropractic care for newborns is promising. Further research on suboccipital subluxation, including prospective controlled studies, should be undertaken to control for the natural history of these disorders.

Lumbar Retrolisthesis Plaugher et al. (56), in a retrospective consecutive case analysis of pretreatment and comparative radiographs from 49 adult outpatients attending a chiropractic clinic, found that retrolisthesis of the L5 or L4 vertebra was reduced about 34% after an average of eight adjustments directed at the level of displacement. No statistically significant change was detected in a retrospective control group. The doctor whose records were scrutinized usually performed comparative evaluations just before the 10th visit and the patients usually continued care on an individual basis after this comparative analysis. Twenty-five patients who entered the clinic between January 1, 1986, and March 1, 1986, had their records added to those of another 25 patients who entered the clinic between April 1, 1986, and June 1, 1986. Because of poor quality radiographs in one case, a total of 49 patients were analyzed. There were 31 women (63%) and 18 men (37%). The mean age was 44 years (SD, 20 years). The most common complaint at entrance was low back pain, which occurred in 79% of the population. Fifty-three percent of the patients had mid-back or neck symptoms. Sixty-four percent of the patients had referred pain to either shoulder or upper and/or lower extremity. Fortyseven percent of the patients had viscerosomatic or somatovisceral symptoms. Patient complaints included headache, constipation, dysmenorrhea, shortness of breath, and nervousness.

Sacral Base and Lumbar Lordosis Angles In the aforementioned study (56), measurements were also made of the sacral base angle and the lumbar lordosis angle in the adult patients. No statistically significant changes were observed before or after treatment. The length of time between analyses was about 1 month and occurred before the 10th office visit. The use of these radiologic parameters as outcome measurements in short-term trials (i.e., <1 month) of chiropractic adjustments is questionable.

Banks (57) has shown that reduction of the hyperextension component of the lower lumbar motion segments is readily attainable in adults with side posture manipulation. A statistically significant decrease in the average disc angle at the involved level was detected in his sample of 13 patients, with clinical diagnoses of facet syndrome (i.e., hyperextension of the lower lumbar and lumbosacral disc spaces with concomitant facet jamming).

Cervical Lordosis Plaugher et al. (56) observed no significant change in the cervical lordosis after examination of the initial and comparative radiographs. On average, six and a half cervical and upper thoracic adjustments
delivered between the initial and comparative radiographs. All patients who reported for care were analyzed, regardless of the level of adjustment.

These findings contrast with the results of Leach (58), who showed significant improvement in the cervical lordosis after treatment, in the magnitude of 2 to 5 degrees. Because Leach’s study did not evaluate the reliability and examiner measurement error of his analysis, these results can be questioned.

Giesen et al. (59) evaluated radiographic findings in children with hyperactivity disorder as part of a smallscale time-series study of seven patients. A moderate level of correlation was found between radiographic findings before treatment and baseline skin conductance levels. In four of the seven subjects, the number of positive x-ray findings reduced after specific adjustive treatment.

A case report has been presented by Thornton (60) of a 13-year-old patient with a cervical kyphosis. Three specific adjustments to the atlas subluxation was followed by a complete return of the normal cervical lordosis.

Harrison et al. (61), in a preliminary study of adult patients, evaluated the efficacy of cervical extensioncompression traction in the restoration of the cervical lordosis. Treatment was approximately 3 to 4 months. Their pilot study demonstrated a positive effect of this treatment on the lordosis. The addition of supine-positioned diversified spinal manipulation, including lateral flexion and rotational forces combined with prone drop-table adjustments, did not enhance the effect demonstrated with extension-compression traction treatment alone. The results of this study should provide the impetus for a large-scale, controlled clinical trial. Research should also focus on the type and duration of treatment that is most effective in restoring the cervical lordosis. Comparison clinical trials of different techniques should be a high priority for the chiropractic profession.

Coronal Plane Spinal Posture Grostic and DeBoer (62), using a retrospective design, compared atlas laterality (±θZ) after specific adjustments. The data, from a sample of 523 case files, tended to show a reduction in this type of displacement after chiropractic care. Plaugher et al. (56) detected no changes in the posture of the shoulder girdle (42 patients) or scoliosis magnitude (18 patients) in their retrospective consecutive case analysis. These patients were primarily adults with scoliosis. Each patient received an average of eight adjustments between examinations. Although there are several case studies describing the role of chiropractic care in the patient with scoliosis (see Chapter 14), more formal prospective trials are needed to adequately address the plethora of issues facing the attending clinician, especially in the case of mild curvatures (i.e., <20 degrees).

Transverse Plane Posture Grostic and DeBoer (62), in a retrospective study of case files, found that Y-axis rotational subluxation of the atlas reduced after specific adjustments.

Leg Length Inequality In the pediatric patient, the clinical assessment of leg length is irrelevant for a newborn, someone who is nonambulatory, or in an active toddler who never stops moving. Most of the clinical application of leg length inequality evaluation pertains to the juvenile or adolescent.

Should leg length inequality be detected below the level of palpatory findings of injury, then radiographic assessment of the more caudad areas is often indicated (15). This is because pelvic unleveling can cause compensational changes (i.e., scoliosis) in the spine above. Plain film usage must always answer the question of whether the information obtained is of clinical benefit. The findings from the radiographic examination are likely to alter the therapeutic course by providing alignment information.

The issue of whether leg lengths should be equal at a certain stage in a child’s life, considering the fact that leg length growth may be far from even, deserves discussion. Asymmetrical growth that evens out later should be balanced with the appropriate clinical goal of avoiding asymmetrical loading on the endplates during skeletal maturation, resulting in slight wedging of the vertebrae (i.e., Heuter-Volkmann Law) (34). If orthotic inserts are prescribed, then follow-up with low-exposure radiographic investigation with the appliances worn needs to be performed to assess periodic and final leg length. All appliances, from heel lifts to orthotic inserts, must be continually posturally evaluated (iliac crest height) at each chiropractic visit during a child’s growth (63). An appliance, if incorrectly applied, can cause permanent vertebral deformation through bone remodeling and asymmetrical epiphyseal plate growth (34). The high prevalence of leg length inequality in adults (64,65,66) should alert the clinician to the potential for this type of asymmetry in children.

Osteochondroma This tumor is simply an exostosis. It is the most common benign tumor of bone, although only 2% occur in the spine. Seventy-five percent of osteochondromas occur in patients younger than age 20, and men are more frequently affected than women (174). Spinal osteochondromas rarely cause symptoms (175). Osteochondromas arise from metaphyseal sites in other bones, with 50% being found in the shoulder and knee. Radiographic findings in extraspinal lesions include a pedunculated mass presenting with a “coat hanger” or “cauliflower” appearance. This finding is characteristic in the knee, hip, and ankle.

Osteoid Osteoma About 1% of spine tumors are osteoid osteomas; these are seen more frequently in men than women and usually appears between the ages of 10 and 25 years. The posterior elements are involved more frequently than the vertebral body. The lumbar spine is more frequently affected than the cervical or thoracic region. Common extraspinal sites include the femur and tibia. Radiologically, osteoid osteoma presents with a lucent nidus surrounded by reactive sclerosis (Fig. 4-17). Localized pain, worse at night and relieved by aspirin, is characteristic of the disease (176). Osteoid osteoma is one of the most frequent causes of a painful scoliosis (177).

Osteoblastoma Approximately 40% of these lesions occur in the spine (178). Most patients are younger than 30 years of age, and the posterior elements are involved more frequently than the vertebral bodies. Radiologically, an expansive lesion with a thin, clearly defined rim is characteristic (179). Like osteoid osteoma, pain is usually the presenting symptom. Unlike osteoid osteoma, however, the pain is not worse at night (180).

Aneurysmal Bone Cyst Although these tumors account for only 1% of primary bone tumors, 11% to 22% occur in the spine. The lesion is usually painful. Neurologic deficit may result from the expansile nature of the tumor (181,182) (Fig. 4-18). Most aneurysmal bone cysts are found in the 5- to 20-year-old age group, and females account for about 60% of cases (183). Extraspinal sites most commonly affected are the femur and tibia. A “blown out” appearance is characteristic. According to Yochum and Rowe (1), the aneurysmal bone cyst is the only benign bone tumor known to cross the epiphyseal plate.

Eosinophilic Granuloma This lesion occurs in the second or third decade of life and may not be a true neoplasm. The clinical presentation is often that of an adolescent with back pain. Vertebra plana often occurs, but neurologic deficit is rare. In the absence of neurologic deficit, the condition is self limiting, and reconstitution of height is the rule. This condition was previously reported as Calve’s disease, incorrectly believed to be a form of juvenile ischemic necrosis (1,184).

Simple Unicameral Bone Cyst Simple bone cysts are very rare in the spine. Two cases have been reported
in the literature (185,186). Most unicameral bone cysts occur in the humerus or femur. These cysts are most prevalent in the 2- to 20-year-old age group, and men are affected more frequently than women. These lesions are characterized radiologically by a geographic lucency. The lesion is asymptomatic unless a pathological fracture occurs, which is common. A “fallen fragment” of cortex freely floating within the cyst is considered pathognomonic, but does not occur in all cases (187).

Astrocytoma Astrocytomas were formerly graded on a scale of 1 through 4, with a grade 1 being benign and a grade 4 denoting malignancy. This system has been supplanted by the terms astrocytoma, anaplastic astrocytoma, and glioblastoma.

Shafrir and Kaufman (188) presented a case report of a 4-month-old boy who had torticollis since birth. The chiropractor did not take radiographs of the patient. Roentgenograms obtained after presentation as a tetraplegic after a chiropractic adjustment demonstrated widening of the pedicle widths, indicative of a spaceoccupying lesion. An infant presenting with a persistent congenital torticollis should undergo radiographic examination for a potential skeletal anomaly (i.e., Klippel-Feil) or a widened interpedicular distance suggestive of spinal cord tumor.

Multiple Myeloma The most common primary malignant tumor in bone, multiple myeloma, usually occurs in patients older than age 50, but rarely is seen in young patients. Multiple lytic lesions and altered serum proteins are characteristic (172). The vertebrae, ribs, pelvis, and skull are the sites most frequently affected.

Ewing’s Sarcoma This tumor rarely involves the spine, but when it does, localized pain is usually present. The 5- to 20-year-old age group is most often affected. Metastasis can occur. This is an aggressive and potentially fatal tumor (1,172). Long bones frequently affected include the femur, tibia, and pelvis. An “onion skin” periosteal reaction in long bones is classic, accompanied by underlying intramedullary destruction (187).

Malignant Lymphoma Osseous lesions are seen in about 15% of persons with lymphoma. An “ivory vertebra” appearance in a patient with Hodgkin’s disease is characteristic (187). This condition may be seen in young adults. Metastasis can occur. Lymphoma is a potentially fatal tumor (189).

Osteosarcoma Primary involvement of the spine is rare, and spinal osteosarcoma is usually caused by metastasis. Less than 2% originate in the spine. The condition is most commonly seen during the second decade of life. Spinal involvement may be difficult to treat, and the condition is potentially fatal (190,191). Osteosarcoma typically affects the 10- to 25-year-old age group and is more common in men. Most cases involve the knee, particularly the distal femur. A “sunray” periosteal reaction with Codman’s triangles is often present. Osseous lesions may be sclerotic, lytic, or mixed (1,187).

Chondrosarcoma, fibrosarcoma, and chordoma rarely occur in children or adolescents. Metastasis to the spine in children is most frequently from neuroblastoma and leukemia (172). Neuroblastomas are tumors of infancy and childhood. The peak incidence is at 2 to 3 years, and neuroblastomas are uncommon after age 7 to 8 years. They arise in sympathetic nervous tissue, most frequently in the abdomen, and an adrenal gland is often involved. The presenting finding is usually an abdominal mass (192). When metastasis to the spine occurs, destruction of a pedicle may be the earliest radiographic sign. Larger lesions may be lytic, mixed, or sclerotic (172).

Pediatric Spine Infections Infections in the pediatric and adolescent spine are uncommon in the United States. When infections do occur, the route is usually hematogenous. There are four main categories of pediatric spinal infections (193,194).

Discitis This condition usually follows a benign course. Low-grade fever, irritability, back rigidity, muscle spasm, and tenderness may present clinically. Treatment consists primarily of immobilization and rest. Antibiotics are sometimes used, although this treatment is controversial (195). Radiographically the condition demonstrates collapse of the affected disc, narrowing of the disc space, and marginal destruction with sclerosis of the end plates (Fig. 4-19). Usually the condition is localized to one site (192). CT scans may be helpful in the differential diagnosis of discitis, especially in early and atypical clinical presentations or in the case of a nonspecific plain film examination (196).