What is the emphasis of the COX technique?
The non-surgical reduction or elimination of neuro-compressive disc and non-discal lesions of the spine.
What happened to one of Dr. Cox's 1st patients/
She had signs of a disc problem, he took an x-ray, got the listing, and attempted side posture. Patient had to be carried out of his office and had surgery the next day.
Who invented the flexion distraction table and developed the basic technique?
Dr. John McManis, DO
In what year was the 1st COX table made?
1972
Where did Dr. Cox's wife develop a cervical herniation?
C6
What are the 4 main effects of Cox Flexion Distraction?
1) Increase in IVD space height and reduce annular distortion
2) Low Intradiscal Pressure (up to 192mm/Hg). Allows the NP to assume a more central position within the annulus.
3) Increase Foraminal Area up to 28%
4) Restore Facet Joint Physiologic ROM
A Cox study showed that EMG activity _______ with Flexion / Distraction.
INCEASES
How many joints are present in the intervertebral joint complex?
THREE (3)
2 Facet Joints (Synovial, greatest movement)
1 Cartilaginous Disc (amphiarthroses, least movement)
Name the passive structures of the Vertebral Support System.
Discs, Ligaments, and Joint Capsule's (job is the check or restrain movement)
Name the active structures of the Vertebral Support System.
Musculature (Produce Movvement)
Pain produces in the posterior column is referred to as
Dorsal Rami Pain
Pain produced in the Anterior Column is referred to as
Discogenic Pain
What are the 4 components of the lumbar intervertebral disc?
1. The Annulus Fibrosus
2. The Nucleus Pulposus
3. The Cartilaginous End Plate
4. Water
What do the NP, AF, and CEP all contain?
1. Proteoglycans
2. Collagen
3. Cells
4. Water
What disc structure has a high concentration of proteoglycans?
The Nucleus Polposus
Proteoglycans
--Are found in connective tissue and are made up of proteins and carbohydrates.
-- They provide structural support for the body
-- PG are negatively charged and attract Na+ and K+, which in term attract water via osmosis.
Proteoglycan breakdowns in the NP is associated with
Decreased disc fluid and tissue breakdown leading to DDD.
What is preferred to help disc health, Glucosamine or Chondroitin Sulfate
Chondrotin Sulfate
Good Quality Joint and Disc repair formulas will have.
Chondroitin Sulfate and Perna-Canaliculus
What is the difference between Type I and Type II Collagen
Type 1 -- Ropelike molecule, tough and strong. Gives AF ability to withstand tensile forces
Type 2 -- Weaker then Type 1, gives NP the ability to resit compression forces
What are the cells role in the disc?
They manufacture the PGs and the Collagen.
What part of the disc contains the highest concentration of cells?
The Cartilaginous End Plate
The greater the internal hydrostatic pressure, the _____ ability the disc has to resit compression
Greater
IVD are responsible for ____% of the length of the vertebral column.
25
In any given quadrant of the annulus, upwards of ___% of the lamellae are incomplete?
40
What happens when the Nucleus loses its proteoglycan content?
-- It can no longer hold water to properly brace the annulus.
-- It can no longer resist compressive or tensile loads, which leads to DDD
The dry weight of the nucleus is ____ % of its wet weight.
15
How tall is each lumbar IVD approximately
10-12mm
What causes water to squeeze out of the disc and lose height?
ADLS
What restores disc height
Recumbent rest
The Cartilaginous End Plate
Is a thin horizontal layer of hayaline cartilage, usually less then 1mm thick
Elastin
Is a protein in connective tissue that allows the tissue to resume its shape after stretching or contracting. 5x more flexible than a rubber band.
What segment levels have the most flexion and extension?
L5/S1
Etiology of the HNP
Congenital/Developmental
Repetitive Microtrauma
Accumulated Macrotrauma
Poor Nutrition
Poor Health Habits
Biomechanical Factors
Autoimmune Factors
Biochemical Factors
What is considered a repetitive microtrauma?
Cumulative Flexion/ Rotational/ Compressive injuries
or
Sedentary Lifestyle
A normal disc can withstand an average of ___ degrees of torsion before failure, while a degenerative disc can withstand ____ degrees.
23, 14
During lateral flexion, which way does the annulus bulge or move towards?
The Concave side
In lateral flexion, the NP of healthy discs displace _______ the side of lateral flexion.
Away From
Contained Disc Lesion
The annulus is partially torn, but still restraining the nucleus.
Noncontained Disc Lesion
The Annulus is fully toen and has allowed nuclear material to leak, extrude, sequester, or free fragment.
Name the four types of annular tears
Concentric, Radial, Rim Lesion, and Transverse
Concentric Tears
Circumferential
Rim Lesion
AKA Transverse Tears
Are Grade 1 fissures associated with pain?
No
What % of Grade 3 fissures are associated with pain.
70%
Grade 1 fissure
Reach the inner 1/3
Grade 2 Fissure
Reach into the 2nd or middle 3rd of annulus
Grade 3 Fissure
Extend into the outer 1/3 of the Annulus
Bulge
Expansion of disc material beyond its normal boarders without tearing or renting of the annular fibers
Protrusion
Localized bulge of displaced nuclear material that has torn through at least the inner layers of the annulus.
Extrusion
NP that has torn through all layers of the annulus, but remains attached in the disc.
Sequestration
A free nuclear fragment
What failures more according to research, Endplate Junction Failure or Annulur Fiber failure?
Endplate Junction (65%)
What segments have the most LDHs?
L4-L5 (49%)
How long does healing typically take in disc injuries?
90 days. Protrusions reduce between 6 months and 1 year.
What way does a patient lean towards for relief in a lateral disc herniation?
Away (Lat Away)
What way does a patient lean towards for relief in a medial disc herniation?
Towards (Me To)
L3 Disc, effects the ___ Nerve
L4
L5 Disc will have pain where?
S1 Dermatone (Back of leg, Heel, lateral side of foot)