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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:
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:
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:
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
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:
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. Ultrasound studies Musculoskeletal diagnostic ultrasound is a test used to visualize soft tissue structures and identify signs of inflammation and scar tissue (adhesions) around joints, nerve roots, tendons, ligaments and muscle. This test is important because it confirms the presence of adhesions and medical need for maniuplation under anesthesia. Manipulative Techniques 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. 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. 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. 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:
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