Back Clinic Chiropractic Examination. An initial chiropractic examination for musculoskeletal disorders will typically have four parts: a consultation, case history, and physical examination. Laboratory analysis and X-ray examination may be performed. Our office provides additional Functional and Integrative Wellness Assessments in order to bring greater insight into a patient’s physiological presentations.
Consultation:
The patient will meet the chiropractor which will assess and question a brief synopsis of his or her lower back pain, such as:
Duration and frequency of symptoms
Description of the symptoms (e.g. burning, throbbing)
Areas of pain
What makes the pain feel better (e.g. sitting, stretching)
What makes the pain feel worse (e.g. standing, lifting).
Case history. The chiropractor identifies the area(s) of complaint and the nature of the back pain by asking questions and learning more about different areas of the patient’s history, including:
Family history
Dietary habits
Past history of other treatments (chiropractic, osteopathic, medical and other)
Occupational history
Psychosocial history
Other areas to probe, often based on responses to the above questions.
Physical examination: We will utilize a variety of methods to determine the spinal segments that require chiropractic treatments, including but not limited to static and motion palpation techniques determining spinal segments that are hypo mobile (restricted in their movement) or fixated. Depending on the results of the above examination, a chiropractor may use additional diagnostic tests, such as:
X-ray to locate subluxations (the altered position of the vertebra)
A device that detects the temperature of the skin in the paraspinal region to identify spinal areas with a significant temperature variance that requires manipulation.
Laboratory Diagnostics: If needed we also use a variety of lab diagnostic protocols in order to determine a complete clinical picture of the patient. We have teamed up with the top labs in the city in order to give our patients the optimal clinical picture and appropriate treatments.
Most of us will experience it at some point — but how does it influence on athletic performance? Chiropractic injury specialist, Dr. Alexander Jimenez investigates.
Research postulates that 80 percent of the populace will undergo an acute onset of back pain at least once in their lifetimes. This adds a considerable financial burden not just on the medical system (physician consultations, prescribed drugs, physiotherapy) but also the financing of the workforce in lost employee hours and loss in productivity.
The types of lower back pain that an individual may experience include (but are not limited to):
1. Lumbar spine disc herniation with/ without sciatica
8. Inflammatory arthritis such as rheumatoid and anklyosing spondylitis
9. Facet joint sprains
10. Bone injuries such as stress fractures, pars defects and spondylolisthesis.
The focus for this paper will be on the previous group — that the bone injuries. This may be simply postural (slow onset repetitive trauma) or related to sports; for instance, gymnastics.
The two demographic groups that tend to endure the most extension-related low back pain are:
1. People who endure all day, for instance, retailers, army, security guards etc.. Prolonged position will obviously force the pelvis to start to migrate to an anterior tilt management. This may begin to place compressive pressure on the facet joints of the spinal column as they also change towards an expansion position since they accompany the pelvic tilt.
2. Extension sports such as gymnastics, tennis, swimming, diving, football codes, volleyball, basketball, track and field, cricket fast bowlers. This is more pronounced in sports that involve extension/rotation.
Pathomechanics
With normal extension of the lumbar spine (or backward bending), the facet joints begin to approximate each other and compress.�The articular processes of this facet above will abut the articular process of the facet below. This is a normal biomechanical movement. However, if the extension ranges are excessive, the procedures will impinge quite aggressively and damage to the cartilage surfaces within the facet joint can result. Sports such as gymnastics, functioning in tennis, and handling in American Soccer may all involve uncontrolled and excessive extension.
It would be unlikely that a bone stress response or even a stress fracture could be brought on by an isolated expansion injury. It would be more likely that a sudden forced extension injury may damage an already pre-existing bone strain reaction.
Similarly, if an individual stands daily and the pelvis migrates into lateral tilt, then the aspects will be placed under low load compression but for extensive intervals.
With ongoing uncontrolled loading, stress is then transferred from the facet joint to the bone below (pars interarticularis). This originally will manifest as a pressure reaction on the bone. This bone strain may advance to a stress fracture throughout the pars if uncorrected. This fracture is also referred to as a “pars flaw”, or spondylolysis.
It was initially considered that stress fractures of the pars was a congenital defect that introduced itself at the teenage years. However, it is now agreed that it is probably obtained through years of overuse into extension positions, especially in young sportspeople involved with expansion sports. What’s more, one-sided pars defects often occur more commonly in sport which also included a rotational component such as tennis serving or fast bowling in cricket.
The stress fracture can then advance to impact the opposite side, causing a bilateral strain fracture, with anxiety subsequently being transferred to the disk in between both levels.
Spondylolisthesis features bilateral pars defects which could possibly be a result of repetitive stress into the bilateral pars in extension athletics, but more likely it is an independent pathology that manifests in the early growing stages (9-14) as this pathology is often viewed in this age category. If they become symptomatic in later years because of involvement in expansion sports, it is exceedingly likely that the defects were there by a young age but presented asymptomatically. As a result of rapid growth spurts in teenage years and the high-volume training experienced by teenaged athletes, it is possible that these dormant spondylolisthesis then pose as ‘acute onset’ back pain in teenage years.
In summary, the progression of this bone stress reactions tends to follow the following continuum:
1. Facet joint irritation
2. Pars interarticularis stress response
3. Stress fracture to the pars
4. Pars defect (or spondylolysis)
5. Spondylolisthesis due to activity or more likely congenital and found later in teenage years due to participation in�extension sports.
The landmark publication related to spondylolysis and spondylolisthesis was presented by Wiltse et al (1976) and they classified these injuries as follows:
1. Type I: dysplastic � congenital abnormalities of L5 or the upper sacrum allow anterior displacement of L5 on the sacrum.
2. Type II: isthmic � a lesion in the pars interarticularis occurs. This is subclassified as
a. lytic, representing a fatigue fracture of the pars,
b. elongated but intact pars, and c. acute fracture.
3. Type III: degenerative � secondary to long-standing intersegmental instability with associated remodeling of the articular processes.
4. Type IV: traumatic � acute fractures in vertebral arch other than the pars.
5. Type V: pathological � due to generalized or focal bone disease affecting the vertebral arch.
The vast majority of spondylolysis and sponylolisthesis accidents are Type II — the isthmic variety.
For the purposes of this paper, we will refer to the above stages as the posterior arch bone stress injuries (PABSI).
Epidemiology
It is a lot more widespread at the L5 level (85-90 percent). It’s a high asymptomatic prevalence in the general population and is often found unintentionally on x ray imaging. Nonetheless, in athletes, particularly young athletes, it is a common reason for persistent low back pain. From the young athlete, the problem is often referred to as ‘active spondylolysis’.
Active spondylolysis is normal in virtually every gamenevertheless, sports such as gymnastics and diving and cricket pose a much greater danger due to the extension and turning character of the sport. The progression from an active spondylolysis into a non-union type spondylolisthesis has been associated with a greater prevalence of spinal disk degeneration.
Early detection through screening and imaging, therefore, will highlight those early at the bone stress phase and if caught early enough and managed, the progression to the larger and more complicated pathologies are avoided as a result of therapeutic capacity of the pars interarticularis in the early stages.
It is more common to find teens and young adults afflicted by PABSI. This will highlight the rapid growth of the spine through growth spurts that is also characterized by a delay in the motor control of the muscle system during this period. Furthermore, it’s thought that the neural arch actually gets stronger in the fourth decade hence possibly explaining the low incidence of bone stress reactions in mid ages.
The incidence of spondylolysis has been reported to be around 4-6% in the Caucasian population (Friedrikson et al 1984). The rates seem to be lower in females and also in African-American males. It has also been suggested that a link exists between pars defects and spina bifida occulta.
The incidence of spondylolysis seems to be higher in the young athletic population than in the general population. Studies in gymnasts, tennis, weightlifting, divers and wrestlers all show disproportionately high incidence of spondylolysis compared with the general population of age-matched subjects.
Tennis
The tennis serve generates excessive extension and rotation force. In addition, the forehand shot may also produce elevated levels of spinning/ extension. The more traditional forehand shot demanded a great deal of weight shift through the legs to the torso and arms. However, a more favorite forehand shot is to currently face the ball and also generate the force of this shot utilizing hip rotation and lumbar spine extension. This action does increase ball speed but also puts more extension and compressive loads on the spine potentially resulting in a greater degree of stress on the bone components.
Golf
The most likely skill component involved in golf that may cause a PABSI are the tee shot with a 1 wood when forcing for distance. The follow-through of this shot entails a significant quantity of spine rotation with maybe a level of spine expansion.
Cricket
Fast bowlers in cricket are the most susceptible to PABSI. This will occur on the opposite side to the bowling arm. As the front foot engages on plant stage, the pelvis abruptly stops moving but the spine and chest continue to proceed. With the wind-up of this bowling action (rotation), when coupled with expansion this can place large forces on the anterior arch of the thoracic. More than 50% of fast bowlers will create a pars stress fracture. Young players (up to 25) are most vulnerable. Cricket governments have implemented training and competition guidelines to avoid such injuries by restricting the number of meals in training/games.
Field Events
The more common field events to cause a PABSI would be high leap followed by javelin. Both these sports create enormous ranges of backbone extension and under significant load.
Contact Sports
Sports like NFL, rugby and AFL all require skill components that need backbone expansion under load.
Gymnastics/Dancers
It goes without saying that gymnastics and dancing involves a substantial amount of repetitive spine expansion, particularly backflips and arabesques. It has been suggested that nearly all Olympic degree gymnasts could have suffered from a pars defect. Many organizing bodies now put limits on the number of hours young gymnasts can instruct to prevent the repetitive loading on the spine.
Diving
Spine extension injuries occur mostly off the spring board and on water entrance.
Diagnosis Of PABSI In Athletes
Clinical investigation
These can pose as preventable injuries. Research shows that the incidence was emphasized from the general population that have nil indicators of back pain. But, individuals will typically complain of back ache that is deep and generally unilateral (one side). This may radiate into the buttock area. The most offending movements tend to be described as expansion moves or backward bending movements. This may be a slow progression of pain or might be initiated by one acute episode of back pain in a competitive extension motion.
On clinical examination:
1. Pain may be elicited with a one-leg extension/rotation test (standing on the leg on the affected side) � stork test.
2. Tenderness over the site of the fracture.
3. Postural faults such as excessive anterior tilt and/or pelvic asymmetry.
The one-legged hyperextension test (stork test) was suggested to be pathognomonic for busy spondylolysis. A negative evaluation was stated to effectively exclude the diagnosis of a bone stress-type injury, thus creating radiological investigations unnecessary.
But, Masci et al (2006) examined the connection between the one-legged hyperextension test and gold standard bone scintigraphy and MRI. They discovered that the one-legged hyperextension test was neither sensitive nor specific for active spondylolysis. Moreover, its negative predictive value was so poor. Thus, a negative test can’t exclude energetic spondylolysis as a possible cause.
Masci et al (2006) go on to indicate that the bad relationship between imaging and the one-legged test may be because of a number of factors. The extension test would be expected to move a significant extension force on to the lower back spine. In addition to putting substantial strain on the pars interarticularis, it might also stress different regions of the spinal column like facet joints as well as posterior lumbar disks, and this may subsequently induce pain in the existence of other pathology such as facet joint arthropathy and spinal disc disease. This will explain the poor specificity of the test. Conversely, the inadequate sensitivity of the test may be related to the subjective reporting of pain by issues performing the maneuvre, which may vary based on individual pain tolerance. Additionally, this evaluation can preferentially load the fifth cervical vertebra, and so bone stress located in the upper lumbar spine may not test positive.
Grade 1 spondylolisthesis are normally asymptomatic; nonetheless, grade 2+ lesions often present with leg pain, either with or without leg pain. On examination, a palpable slip could be evident.
Imaging
Clinical assessment of active spondylolysis and the more severe pars defects and spondylolisthesis can be notoriously non-specific; this is, not all patients suffering PABSI will present with favorable abstract features or positive signs on analyzing. Thus, radiological visualization is important for diagnosis. The imaging methods available in the diagnosis of bone stress injury are:
1. Conventional radiology. This test is not very sensitive but is highly unique. Its limits are partially because of the cognitive orientation of the pars defect. The oblique 45-degree films may show the timeless ‘Scotty Dog’ appearance. Spondylolisthesis can be looked at simply on a lateral movie x-ray.
2. Planar bone scintigraphy (PBS) and single photon emission computed tomography (SPECT). SPECT enhances sensitivity in addition to specificity of PBS than straightforward radiographic study. Comparative research between PBS and conventional radiology have shown that scintigraphy is more sensitive. Patients with positive SPECT scan must then undergo a reverse gantry CT scan to assess whether the lesion is active or old.
3. Computed tomography (CT). The CT scan is considered to be more sensitive than conventional radiology and with higher specificity than SPECT. Regardless of the type of cross-sectional image utilized, the CT scan provides information on the state of the flaw (intense fracture, unconsolidated flaw with geodes and sclerosis, pars in procedure for consolidation or repair). The “inverse gantry” perspective can evaluate this condition better. Repeat CT scan can be used to track progress and recovery of the pars defect.
4. Magnetic resonance imaging (MRI). This technique shows pronounced changes in the signal in the amount of the pars. This is recognized as “stress response” and can be classified into five different degrees of action. MRI can be helpful for evaluating elements that stabilize isthmic lesions, for example intervertebral disc, common anterior ligament, and related lesions. The MRI isn’t as specific or sensitive as SPECT and CT combination.
Therefore, the current gold standards of investigation for athletes with low back pain are:
1. bone scintigraphy with single photon emission computed tomography (SPECT); if positive then
MRI has many advantages over bone scintigraphy, for instance, noninvasive nature of the imaging along with the absence of ionizing radiation. MRI changes in active spondylolysis include bone marrow edema, visualized as increased signal in the pars interarticularis on edema-sensitive sequences, and fracture, visualized as reduced signal in the pars interarticularis on T1 and T2 weighted sequences.
However, there is greater difficulty in detecting the changes of busy spondylolysis from MRI. Detecting pathology from MRI relies on the interpretation of distinct contrasts of signals compared with normal tissue. Unlike stress fractures in different parts of the body, the little region of the pars interarticularis may make detection of those changes harder.
However, unlike MRI, computed tomography has the capability to differentiate between acute and chronic fractures, and this differentiation might be an important determinant of fracture healing. Accordingly, in areas using pars interarticularis fractures discovered by MRI, it might nonetheless be necessary to execute thin computed tomography slices to determine whether or not a fracture is severe or chronic — an important factor in fracture resolution.
A herniated disc can lead to pain as well as disrupt your daily activities, as you likely know. That is probably what brings you to the office of the doctor: You have back pain or neck pain, and you’d love to understand why.
Your doctor will ask you questions and execute a few exams. This is to try to find the origin of your pain and also to find out which intervertebral disks are herniated. An accurate diagnosis will help your doctor develop a treatment plan method to help you recover and to handle your herniated disc pain and other spine symptoms.
Physical Exam: Herniated Disc Diagnosis
As part of the physical exam, your doctor will ask about your current symptoms and remedies you have already tried for your pain. Some average herniated disc diagnostic questions include:
When did the pain begin? Where’s the pain (cervical, thoracic or mid-back, or lumbar or lower back)?
What activities did you lately do?
What do you do for your herniated disc pain?
Can the disc herniation pain radiate or travel to other parts of your body?
Does anything reduce the disk pain or make it even worse?
Your doctor may also observe your position, range of movement, and physical condition both lying down and standing up. Movement that causes pain will be noticed. A Las�gue evaluation, also referred to as the Straight-Leg Raising evaluation, may be accomplished. You’ll be asked to lie down and extend your knee with your hip bent. If it produces pain or makes your pain worse, this may indicate a herniated disc.
With a herniated disc (or a bulging or ruptured disc), you might feel stiff and may have lost your normal spinal curvature because of muscle strain. Your physician may also feel for tightness and note the spine’s curvature and alignment.
Neurological Exam: Herniated Disc Diagnosis
Your spine specialist will also run a neurological exam, which tests your reflexes, muscle strength, other nerve changes, and pain disperse. Radicular pain (pain that travels away from the source of the pain) can increase when stress is applied directly to the affected area. You might, for instance, have sciatica; this is radicular pain that might be caused by the herniated disk. Since the disc is compressing a nerve, you might experience pain and symptoms in other areas of the body, although the origin of the pain is on your spine.
Imaging Tests for Herniated Discs
Your spine specialist may order imaging tests to help diagnose your injury or condition; you might have to see an imaging facility for those evaluations.
An X-ray may demonstrate a secondhand disk space, fracture, bone spur, or arthritis, which might rule out disk herniation. A computerized axial tomography scan (a CT or CAT scan) or a magnetic resonance imaging test (an MRI) equally can show soft tissue of a bulging disk or herniateddisc. So that you may get treatment these tests will demonstrate location and the stage of the herniated discs.
Other Tests to Diagnose�a Herniated Disc
To obtain the most accurate identification, your spine specialist may order additional tests, for example:
Electromyography (EMG): He or she may order an examination known as an electromyography to measure your nerves respond, if your spine pro suspects you’ve got nerve damage.
Discogram or discography: A sterile procedure where dye is injected into one of your vertebral disc and seen under special conditions (fluoroscopy). The goal is to pinpoint which disk(s) might be causing your pain.
Bone scan: This technique generates film or computer images of bones. A very small number of radioactive substance is injected into a blood vessel throughout the blood flow. It collects on your bones and can be detected by a scanner. This procedure helps doctors detect spinal problems such as disease, a fracture, tumor, or arthritis.
Laboratory evaluations: Typically blood is attracted (venipuncture) and tested to determine if the blood cells are normal or abnormal. A metabolic disease which might be contributing to a back pain may be indicated by Chemical changes in the blood.
The scope of our information is limited to chiropractic and spinal injuries and conditions. To discuss options on the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .�
By Dr. Alex Jimenez
Additional Topics: Sciatica
Lower back pain is one of the most commonly reported symptoms among the general population. Sciatica, is well-known group of symptoms, including lower back pain, numbness and tingling sensations, which often describe the source of an individual’s lumbar spine issues. Sciatica can be due to a variety of injuries and/or conditions, such as spinal misalignment, or subluxation, disc herniation and even spinal degeneration.
There are a number of important factors to take into consideration, such as the timing of when an MRI scan must be performed and limitations with interpretation of findings, to get an MRI scan for herniated discs.
To begin with, the difficulty with the results of an MRI scan, as with a number of other diagnostic studies, is that the abnormality may not always be the source of an individual’s back pain or other symptoms. Numerous studies have shown that approximately 30 percent of people in their twenties and forties have a lumbar disc herniation in their MRI scan, even though they don’t have any pain.
An MRI scan cannot be interpreted on its own. Everything Has to Be well-correlated into the individual patient’s condition, for example:
Symptoms (such as the duration, location, and severity of pain)
Any deficits in their examination
Another concern with MRI scans is the time of when the scan is done. When a patient has experienced the following symptoms would be the only time that an MRI scan is needed immediately:
Bowel or bladder incontinence
Progressive weakness due to nerve damage in the legs.
Herniated Disc Analysis with MRI
Obtaining an MRI (magnetic resonance imaging) can be an important step in correctly assessing a herniated disc in the spine. Unlike an X-ray, MRI uses a magnetic field and a computer to create and record detailed pictures of the internal workings of your entire body. This technology can also be capable of producing cross-sectional views in identifying a disc of the body, which greatly help doctors. MRI scans are based on new technology, but they have become essential in diagnosing a number of back and neck issues, such as spinal stenosis, herniated discs and bone spurs.
An MRI scan has a number of benefits that greatly help a herniated disc patient. The advantages of an MRI can be:
Unobtrusive
Painless and free of radiation
Can focus on a particular part of the entire body
Extremely accurate
Diagnosing Disc Herniation
Should you believe you have a herniated disc in the neck or back, the very first step would be to visit a physician. Your physician will have the ability to supply you with a complete evaluation and inspection of your medical history to create a identification. Following that, you may be referred to execute an MRI stabilize and to confirm the herniated disc.
At the imaging center you’ll be put to the tubular MRI machine to get a body scan. You may remain enclosed in the MRI device for up to an hour while the comprehensive scan of place where the herniated disc along the spine is completed. The MRI can reveal the exact condition of the herniated disc and surrounding arrangements. This allows your doctor to produce the treatment plan that is right for you and to understand the origin of the disc damage and pain.
Herniated Disc Follow-Up Treatment
Most patients are able to successfully treat herniated disc pain using nonsurgical standard treatments prescribed by their physician. These include relaxation, compression treatment and mild exercise. Surgery can then be explored when months or weeks of treatment do not bring a return to previous action.
If you’re researching surgical options and have become concerned by a number of the risks and unsuccessful results of traditional open back operation, contact a specialist. Spine surgery specialists perform minimally invasive spine surgery, including invasive stabilization surgeries and minimally invasive decompression, which can treat a number of the very acute herniated discs. They may review your MRI to determine if you are a candidate for minimally invasive spine surgery, which may help you get your life back.
The scope of our information is limited to chiropractic and spinal injuries and conditions. To discuss options on the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .�
By Dr. Alex Jimenez
Additional Topics: Sciatica
Lower back pain is one of the most commonly reported symptoms among the general population. Sciatica, is well-known group of symptoms, including lower back pain, numbness and tingling sensations, which often describe the source of an individual’s lumbar spine issues. Sciatica can be due to a variety of injuries and/or conditions, such as spinal misalignment, or subluxation, disc herniation and even spinal degeneration.
A healthcare professional’s clinical diagnosis focuses on finding out the source of a patient’s pain. For this reason, the clinical identification of pain in the herniated disc relies on more than only the findings from a diagnostic evaluation, like CT scan or an MRI scan.
The spine care professional arrives at a clinical diagnosis of the cause of the patient’s pain by means of a combination of findings by a comprehensive medical history, conducting a complete physical exam, and, if appropriate, running one or more diagnostic tests:
Medical history: The physician will choose the patient’s medical history, such as a description of if sciatica, the back pain or other symptoms occur, a description of how the pain feels, what remedies, positions or activities make the pain feel better and more.
Physical examination: The physicians will conduct a physical exam of the individual, such as muscle power and analyzing neural function in parts of the leg or arm, analyzing for pain in positions and much more. Ordinarily, this series of physical tests will give a good idea of the type of back issue the individual has to the spine professional.
Diagnostic tests: After the physician has a fantastic idea of the origin of the patient’s pain, a diagnostic evaluation, such as a CT scan or a MRI scan, is often ordered to confirm the presence of an anatomical lesion at the backbone. The evaluations can give a picture of the location of nerve roots and the disc.
It’s important to emphasize that MRI scans and other diagnostic tests aren’t utilized to diagnose the patient’s pain; rather, they are only utilized to confirm the existence of an anatomical problem that was suspected or identified throughout the medical history and physical examination. Because of this, while the radiographic findings on an MRI scan or other tests are significant, they aren’t as important in diagnosing the reason for the patient’s pain (that the clinical investigation demonstrated) as are the findings from the medical history and physical examination. Many times, an MRI scan or other kind of evaluation will be used for the purpose of treatment, so the healthcare specialist can determine the way it’s currently impinging on the nerve root and precisely where the herniated disc is.
When MRI is Used to Diagnose Herniated Discs
When patients have predominantly experienced leg pain along with a lumbar disc herniation, MRI scans are usually recommended early in a patient’s path of pain.
Therefore, physicians often recommend waiting 3 to 6 months (following the onset of lower back pain) prior to having an MRI scan done as a way to see whether the pain will get better with conservative (nonsurgical) remedies. As a very general guideline, if the results of the MRI scan aren’t likely to affect a patient’s further back pain therapy, and �the patient will continue with non-surgical treatments such as chiropractic treatments, physical therapy and drugs, waiting to acquire an MRI scan, as well as other imaging scans, in most situations is a fair option.
What Happens When a Disc Herniates
Though the spinal discs are made to withstand significant amounts of force, injury and other issues with the disc can happen. After the disc ages or is injured, the outer portion (annulus fibrosus) of a disk may be torn as well as the disc’s inner substance (nucleus pulposus) can herniate or extrude out of the disk. Nerves, and the inner portion of the disc surround each spinal disc that leaks out comprises proteins, therefore when this material comes in contact with a nerve wracking pain that may travel down the length of the nerve can be caused by it. Even a tiny disk herniation which enables a small quantity of the inner disc material to touch the nerve may cause pain.
Pain from a Herniated Disc vs. Degenerative Disc Disease
A herniated disc will generally create another type of pain than degenerative disk disease (another common disc problem).
When a patient has a symptomatic degenerated disc (one which causes pain or other symptoms), it’s the disc space itself which is debilitating and is the origin of pain. This type of pain is called axial pain.
When a patient has a symptomatic herniated disc, it is not the disk space itself that hurts, but rather the disc difficulty is causing pain in a nerve in the spine. This kind of pain is typically called radicular pain (nerve root pain, or tingling from a lumbar herniated disk).
In conclusion, when an individual begins to experience painful symptoms along their lower back, or lumbar spine, although they may sometimes not experience any symptoms, it a herniated disc is suspected, its recommended to seek immediate medical attention and to consider having an MRI, CT scan or other imaging tests to properly diagnose the presence of a herniated disc or other injury and/or condition before following with treatment.
The scope of our information is limited to chiropractic and spinal injuries and conditions. To discuss options on the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .�
By Dr. Alex Jimenez
Additional Topics: Sciatica
Lower back pain is one of the most commonly reported symptoms among the general population. Sciatica, is well-known group of symptoms, including lower back pain, numbness and tingling sensations, which often describe the source of an individual’s lumbar spine issues. Sciatica can be due to a variety of injuries and/or conditions, such as spinal misalignment, or subluxation, disc herniation and even spinal degeneration.
Thomas M Kosloff1*�, David Elton1�, Jiang Tao2� and Wade M Bannister2�
CHIROPRACTIC & MANUAL THERAPIES
Abstract
Background: There is controversy surrounding the risk of manipulation, which is often used by chiropractors, with respect to its association with vertebrobasilar artery system (VBA) stroke. The objective of this study was to compare the associations between chiropractic care and VBA stroke with recent primary care physician (PCP) care and VBA stroke.
Methods: The study design was a case�control study of commercially insured and Medicare Advantage (MA) health plan members in the U.S. population between January 1, 2011 and December 31, 2013. Administrative data were used to identify exposures to chiropractic and PCP care. Separate analyses using conditional logistic regression were conducted for the commercially insured and the MA populations. The analysis of the commercial population was further stratified by age (<45 years; ?45 years). Odds ratios were calculated to measure associations for different hazard periods. A secondary descriptive analysis was conducted to determine the relevance of using chiropractic visits as a proxy for exposure to manipulative treatment.
Results: There were a total of 1,829 VBA stroke cases (1,159 � commercial; 670 � MA). The findings showed no significant association between chiropractic visits and VBA stroke for either population or for samples stratified by age. In both commercial and MA populations, there was a significant association between PCP visits and VBA stroke incidence regardless of length of hazard period. The results were similar for age-stratified samples. The findings of the secondary analysis showed that chiropractic visits did not report the inclusion of manipulation in almost one third of stroke cases in the commercial population and in only 1 of 2 cases of the MA cohort.
Conclusions: We found no significant association between exposure to chiropractic care and the risk of VBA stroke. We conclude that manipulation is an unlikely cause of VBA stroke. The positive association between PCP visits and VBA stroke is most likely due to patient decisions to seek care for the symptoms (headache and neck pain) of arterial dissection. We further conclude that using chiropractic visits as a measure of exposure to manipulation may result in unreliable estimates of the strength of association with the occurrence of VBA stroke.
Keywords: Chiropractic, Primary care, Cervical manipulation, Vertebrobasilar stroke, Adverse events
Background
The burden of neck pain and headache or migraine among adults in the United States is significant. Survey data indicate 13% of adults reported neck pain in the past 3 months [1]. In any given year, neck pain affects 30% to 50% of adults in the general population [2]. Prevalence rates were reportedly greater in more eco- nomically advantaged countries, such as the USA, with a higher incidence of neck pain noted in office and com- puter workers [3]. Similar to neck pain, the prevalence of headache is substantial. During any 3-month time- frame, severe headaches or migraines reportedly affect one in eight adults [1].
Neck pain is a very common reason for seeking health care services. �In 2004, 16.4 million patient visits or 1.5% of all health care visits to hospitals and physician offices, were for neck pain� [4]. Eighty percent (80%) of visits occurred as outpatient care in a physician�s office [4]. The utilization of health care resources for the treatment of headache is also significant. �In 2006, adults made nearly 11 million physician visits with a headache diagno- sis, over 1 million outpatient hospital visits, 3.3 million emergency department visits, and 445 thousand inpatient hospitalizations� [1].
In the United States, chiropractic care is frequently utilized by individuals with neck and/or headache com- plaints. A national survey of chiropractors in 2003 re- ported that neck conditions and headache/facial pain accounted respectively for 18.7% and 12% of the patient chief complaints [5]. Chiropractors routinely employ spinal manipulative treatment (SMT) in the management of patients presenting with neck and/or headache [6], either alone or combined with other treatment approaches [7-10].
While evidence syntheses suggest the benefits of SMT for neck pain [7-9,11-13] and various types of headaches [10,12,14-16], the potential for rare but serious adverse events (AE) following cervical SMT is a concern for researchers [17,18], practitioners [19,20], professional organizations [21-23], policymakers [24,25] and the public [26,27]. In particular, the occurrence of stroke affecting the vertebrobasilar artery system (VBA stroke) has been associated with cervical manipulation. A recent publication [28] assessing the safety of chiropractic care reported, �…the frequency of serious adverse events varied between 5 strokes/ 100,000 manipulations to 1.46 serious adverse events/ 10,000,000 manipulations and 2.68 deaths/10,000,000 manipulations�. These estimates were, however, derived from retrospective anecdotal reports and liability claims data, and do not permit confident conclusions about the actual frequency of neurological complications following spinal manipulation.
Several systematic reviews investigating the association between stroke and chiropractic cervical manipulation�have reported the data are insufficient to produce definitive conclusions about its safety [28-31]. Two case�control studies [32,33] used visits to a chiropractor as a proxy for SMT in their analyses of standardized health system databases for the population of Ontario (Canada). The more recent of these studies [32] also included a case-crossover methodology, which reduced the risk of bias from confounding variables. Both case�control studies reported an increased risk of VBA stroke in association with chiropractic visits for the population under age 45 years old. Cassidy, et al. [32] found, how- ever, the association was similar to visits to a primary care physician (PCP). Consequently, the results of this study suggested the association between chiropractic care and stroke was non-causal. In contrast to these studies, which found a significant association between chiropractic visits and VBA stroke in younger patients (<45 yrs.), the analysis of a population-based case-series suggested that VBA stroke patients who consulted a chiropractor the year before their stroke were older (mean age 57.6 yrs.) than previously documented [34].
The work by Cassidy, et al. [32] has been qualitatively appraised as one of the most robustly designed investigations of the association between chiropractic manipulative treatment and VBA stroke [31]. To the best of our knowledge, this work has not been reproduced in the U.S. population. Thus, the main purpose of this study is to replicate the case�control epidemiological design published by Cassidy, et al. [32] to investigate the association between chiropractic care and VBA stroke; and compare it to the association between recent PCP care and VBA stroke in samples of the U.S. commercial and Medicare Advantage (MA) populations. A secondary aim of this study is to assess the utility of employing chiropractic visits as a proxy measure for exposure to spinal manipulation.
Methods
Study design and population
We developed a case�control study based on the experience of commercially insured and MA health plan members between January 1, 2011 and December 31, 2013. General criteria for membership in a commercial or MA health plan included either residing or working in a region where health care coverage was offered by the in- surer. Individuals must have Medicare Part A and Part B to join a MA plan. The data set included health plan members located in 49 of 50 states. North Dakota was the only State not represented.
Both case and control data were extracted from the same source population, which encompassed national health plan data for 35,726,224 unique commercial and 3,188,825 unique MA members. Since members might be enrolled for more than one year, the average�annual commercial membership was 14.7 million members and the average annual MA membership was 1.4 million members over the three year study period, which is comparable to ~5% of the total US population based on the data available from US Census Bureau [35]. Administrative claims data were used to identify cases, as well as patient characteristics and health service utilization.
The stroke cases included all patients admitted to an acute care hospital with vertebrobasilar (VBA) occlusion and stenosis strokes as defined by ICD-9 codes of 433.0, 433.01, 433.20, and 433.21 during the study period. Pa- tients with more than one admission for a VBA stroke were excluded from the study. For each stroke case, four age and gender matched controls were randomly se- lected from sampled qualified members. Both cases and controls were randomly sorted prior to the matching using a greedy matching algorithm [36].
Exposures
The index date was defined as the date of admission for the VBA stroke. Any encounters with a chiropractor or a primary care physician (PCP) prior to the index date were considered as exposures. To evaluate the impact of chiropractic and PCP treatment, the designated hazard period in this study was zero to 30 days prior to the index date. For the PCP analysis, the index date was excluded from the hazard period since patients might consult PCPs after having a stroke. The standard health plan coverage included a limit of 20 chiropractic visits. In rare circumstances a small employer may have selected a 12-visit limit. An internal analysis (data not shown) revealed that 5% of the combined (commercial and MA) populations reached their chiropractic visit limits. Instances of an employer not covering chiropractic care were estimated to be so rare that it would have had no measurable impact on the analysis. There were no limits on the number of reimbursed PCP visits per year.
Analyses
Two sets of similar analyses were performed, one for the commercially insured population and one for the MA population. In each set of analyses, conditional logistic regression models were used to examine the association between the exposures and VBA strokes. To measure the association, we estimated the odds ratio of having the VBA stroke and the effect of total number of chiropractic visits and PCP visits within the hazard period. The analyses were applied to different hazard periods, including one day, three days, seven days, 14 days and 30 days for both chiropractic and PCP visits. The results of the chiropractic and PCP visit analyses were then compared to find evidence of excess risk of having stroke for patients with chiropractic visits during the
hazard period. Previous research has indicated that most patients who experience a vertebral artery dissection are under the age of 45. Therefore, in order to investigate the impact of exposure on the population at different ages, separate analyses were performed on patients stratified by age (under 45 years and 45 years and up) for the study of the commercial population. The number of visits within the hazard period was entered as a con- tinuous variable in the logistic model. The chi square test was used to analyze the proportion of co-morbidities in cases as compared to controls.
A secondary analysis was performed to evaluate the relevance of using chiropractic visits as a proxy for spinal manipulation. The commercial and MA databases were queried to identify the proportions of cases of VBA stroke and matched controls for which at least one chiropractic spinal manipulative treatment procedural code (CPT 98940 � 98942) was or was not recorded. The analysis also calculated the use of another manual therapy code (CPT 97140), which may be employed by chiropractors as an alternative means of reporting spinal manipulation.
Ethics
The New England Institutional Review Board (NEIRB) determined that this study was exempt from ethics review.
Results
The commercial study sample included 1,159 VBA stroke cases over the three year period and 4,633 age and gender matched controls. The average age of the patients was 65.1 years and 64.8% of the patients were male (Table 1). The prevalence rate of VBA stroke in the commercial population was 0.0032%.
There were a total of 670 stroke cases and 2,680 matched controls included in the MA study. The aver- age patient age was 76.1 years and 58.6% of the patients were male (Table 2). For the MA population, the prevalence rate of VBA stroke was 0.021%.
Claims during a one year period prior to the index date were extracted to identify comorbid disorders. Both the commercial and MA cases had a high percentage of comorbidities, with 71.5% of cases in the commercial study and 88.5% of the cases in the MA study reporting at least one of the comorbid conditions (Table 3). Six comorbid conditions of particular interest were identified, including hypertensive disease (ICD-9 401�404), ischemic�heart disease (ICD-9 410�414), disease of pulmonary circulation (ICD-9 415�417), other forms of heart disease (ICD-9 420�429), pure hypercholesterolemia (ICD-9 272.0) and diseases of other endocrine glands (ICD-9 249�250). There were statistically significant differences (p = <0.05) between groups for most comorbidities. Greater proportions of comorbid disorders (p = <0.0001) were reported in the commercial and MA cases for hyper- tensive disease, heart disease and endocrine disorders (Table 3). The commercial cases also showed a larger proportion of diseases of pulmonary circulation, which was statistically significant (p = 0.0008). There were no significance differences in pure hypercholesterolemia for either the commercial or MA populations. Overall, cases in both the commercial and MA populations were more likely (p = <0.0001) to have at least one co- morbid condition.
Among the commercially insured, 1.6% of stroke cases had visited chiropractors within 30 days of being admit- ted to the hospital, as compared to 1.3% of controls visit- ing chiropractors within 30 days prior to their index date. Of the stroke cases, 18.9% had visited a PCP within 30 days prior to their index date, while only 6.8% of controls had visited a PCP (Table 4). The proportion of exposures for chiropractic visits was lower in the MA sample within the 30-day hazard period (cases = 0.3%; controls = 0.9%). However, the proportion of exposures for PCP visits was higher, with 21.3% of cases having PCP visits as compared to12.9% for controls (Table 5).
The results from the analyses of both the commercial population and the MA population were similar (Tables 6, 7 and 8). There was no association between chiropractic visits and VBA stroke found for the�overall sample, or for samples stratified by age. No estimated odds ratio was significant at the 95% confidence level. MA data were insufficient to calculate statistical measures of association for hazard periods less than 0�14 days for chiropractic visits. When stratified by age, the data were too sparse to calculate measures of association for hazard periods less than 0�30 days in the commercial population. The data were too few to analyze associative risk by headache and/or neck pain diagnoses (data not shown).
These results showed there is an association existing between PCP visits and VBA stroke incidence regardless of age or length of hazard period. A strong association was found for those visits close to the index date (OR 11.56; 95% CI 6.32-21.21) for all patients with a PCP visit within 0�1 day hazard period in the commercial sample. There was an increased risk of VBA stroke associated with each PCP visit within 30-days prior to the index date for MA patients (OR 1.51; 95% CI 1.32-1.73) and commercial patients (OR 2.01; 95% CI 1.77-2.29).
The findings of the secondary analysis showed � that of 1159 stroke cases from commercial population � there were a total of 19 stroke cases associated with chiropractic visits for which 13 (68%) had claims documentation indicating chiropractic SMT was performed. For the control group of the commercial cohort, 62 of 4633 controls had claims of any kind of chiropractic visits and 47 of 4633 controls had claims of SMT. In the commercial control group, 47 of 62 DC visits (76%) included SMT in the claims data. Only 1 of 2 stroke cases in the MA population included SMT in the claims data. For the MA cohort, 21 of 24 control chiropractic visits (88%) included SMT in the claims data (Table 9).
None of the stroke cases in either population included CPT 97140 as a substitute for the more conventionally re- ported chiropractic manipulative treatment procedural codes (98940 � 98942). For the control groups, there were three instances where CPT 97140 was reported without CPT 98940 � 98942 in the commercial population. The CPT code 97140 was not reported in MA control cohort.
Discussion
The primary aim of the present study was to investigate the association between chiropractic manipulative treatment and VBA stroke in a sample of the U.S. population. This study was modeled after a case�control design previously conducted for a Canadian population [32]. Administrative data for enrollees in a large national health care insurer were analyzed to explore the occurrence of VBA stroke across different time periods of exposure to chiropractic care in comparison with PCP care.
Unlike Cassidy et al. [32] and most other case�control studies [33,37,38], our results showed there was no significant association between VBA stroke and chiropractic visits. This was the case for both the commercial and MA populations. In contrast to two earlier case�control studies [32,33], this lack of association was found to be irrespective of age. Although, our results (Table 8) did lend credence to previous reports that VBA stroke occurs more frequently in patients under the age of 45 years. Additionally, the results from the present study did not identify a relevant temporal impact. There was no significant association, when the data were sufficient to calculate estimates, between chiropractic visits and stroke regardless of the hazard period (timing of most recent visit to a chiropractor and the occurrence of stroke).
There are several possible reasons for the variation in results with previous similar case�control studies. The younger (<45 yrs.) commercial cohort that received chiropractic care in our study had noticeably fewer cases. The 0�30 days hazard period included only 2 VBA stroke cases. There were no stroke cases for other hazard periods in this population. In contrast, earlier studies reported sufficient cases to calculate risk estimates for most hazard periods [32,33].
Another factor that potentially influenced the difference in results concerns the accuracy of hospital claims data in the U.S. vs. Ontario, Canada. The source population in the Province of Ontario was identified, in part, from the Discharge Abstract Database (DAD). The DAD includes hospital discharge and emergency visit diagnoses that have undergone a standardized assessment by a medical records coder [39]. To the best of our know- ledge, similar quality management practices were not routinely applied to hospital claims data used in sourcing the population for our study.
An additional reason for the disparity in results may be due to differences in the proportions of chiropractic visits where SMT was reportedly performed. Our study showed that SMT was not reported by chiropractors in more than 30% of commercial cases. It is plausible that a number of the cases in earlier studies also did not�include SMT as an intervention. Differences between studies in the proportion of cases reporting SMT may have affected the calculation of risk estimates.
Also, there were an insufficient number of cases having cervical and/or headache diagnoses in our study. Therefore, our sample population may have included proportionally less cases where cervical manipulation was performed.
Our results were consistent with previous findings [32,33] in showing a significant association between PCP visits and VBA stroke. The odds ratios for any PCP visit increase dramatically from 1�30 days to 1�1 day (Tables 6 and 7). This finding is consistent with the hypothesis that patients are more likely to see a PCP for symptoms related to vertebral artery dissection closer to the index date of their actual stroke. Since it is unlikely that the services provided by PCPs cause VBA strokes, the association�between recent PCP visits and VBA stroke is more likely attributable to the background risk related to the natural history of the condition [32].
A secondary goal of our study was to assess the utility of employing chiropractic visits as a surrogate for SMT. Our findings indicate there is a high risk of bias associated with using this approach, which likely overestimated the strength of association. Less than 70% of stroke cases (commercial and MA) associated with chiropractic care included SMT. A somewhat higher proportion of chiropractic visits included SMT for the control groups (commercial = 76%; MA = 88%).
There are plausible reasons that support these findings. Internal analyses of claims data (not shown) consistently demonstrate that one visit is the most common number associated with a chiropractic episode of care. The single visit may consist of an evaluation without treatment such as SMT. Further; SMT may have been viewed as contraindicated due to signs and symptoms of vertebral artery dissection (VAD) and/or stroke. This might explain the greater proportion of SMT provided to control groups in both the commercial and MA populations.
Overall, our results increase confidence in the findings of a previous study [32], which concluded there was no excess risk of VBA stroke associated chiropractic care compared to primary care. Further, our results indicate there is no significant risk of VBA stroke associated with chiropractic care. Additionally, our findings highlight the potential flaws in using a surrogate variable (chiropractic visits) to estimate the risk of VBA stroke in association with a specific intervention (manipulation).
Our study had a number of strengths and limitations. Both case and control data were extracted from the same source population, which encompassed national health plan data for approximately 36 million�commercial and 3 million MA members. A total of 1,829 cases were identified, making this the largest case� control study to investigate the association between chiropractic manipulation and VBA stroke. Due to the nationwide setting and large sample size, our study likely reduced the risk of bias related to geographic factors. However, there was a risk of selection bias � owing to the data set being from a single health insurer � including income status, workforce participation, and links to health care providers and hospitals.
Our study closely followed a methodological approach that had previously been described [32], thus allowing for more confident comparisons.
The current investigation analyzed data for a number of comorbid conditions that have been identified as potentially modifiable risk factors for a first ischemic stroke [40]. The differences between groups were statistically significant for most comorbidities. Information was not obtainable about behavioral comorbid factors e.g., smoking and body mass. With the exception of hypertensive disease, there are reasons to question the clinical significance of these conditions in the occurrence of ischemic stroke due to vertebral artery dissection. A large multinational case-referent study investigated the association between vascular risk factors (history of vascular disease, hypertension, smoking, hypercholesterolemia, diabetes mellitus, and obesity/overweight) for ischemic stroke and the occurrence of cervical artery dissection [41]. Only hypertension had a positive association (odds ratio 1.67; 95% confidence interval, 1.32 to 2.1; P <0.0001) with cervical artery dissection.
While the effect of other unmeasured confounders cannot be discounted, there is reason to suspect the absence of these data was not deleterious to the results. Cassidy, et al. found no significant differences in the results their case-crossover design, which affords better control of unknown confounding variables, and the findings of their case�control study [32].
Our results highlight just how unusual VBA stroke is in the MA cohort (prevalence = 0.021%) and � even more so � for the commercial population (prevalence = 0.0032%). As a result, some limitations of this study re- lated to the rarity of reporting VBA stroke events. Despite the larger number of cases, data were insufficient to calculate estimates and confidence intervals for seven measures of exposure (4 commercial and 3 MA) for chiropractic visits. Additionally, we were not able to compute estimates specifically for headache and neck pain diagnoses due to small numbers. Confidence intervals associated with estimates tended to be wide making the results imprecise [42].
There were limitations related to the use of administrative claims data. �Disadvantages of using secondary data for research purposes include: variations in coding from hospital to hospital or from department to department, errors in coding and incomplete coding, for example in the presence of comorbidities. Random errors in coding and registration of discharge diagnoses may dilute and attenuate estimates of statistical association� [43]. The recordings of unvalidated hospital discharge diagnostic codes for stroke have been shown to be less precise when compared to chart review [44,45] and validated patient registries�[43,46]. Cassidy, et al. [32] conducted a sensitivity analysis to determine the effect of diagnostic misclassification bias. Their conclusions did not change when the effects of misclassification were assumed to be similarly distributed between chiropractic and PCP cases.
A particular limitation in using administrative claims data is the paucity of contextual information surround- ing the clinical encounters between chiropractors/PCPs and their patients. Historical elements describing the occurrence/absence of recent trauma or activities reported in case studies [47-51] as potential risk factors for VBA stroke were not available in claims data. Confidence was low concerning the ability of claims data to provide accurate and complete reporting of other health disorders, which have been described in case�control designs as being associated with the occurrence of VBA stroke e.g., migraine [52] or recent infection [53]. Symptoms and physical examination findings that would have permitted further stratification of cases were not reported in the claims data.
The reporting of clinical procedures using current pro- cedural terminology (CPT) codes presented additional shortcomings concerning the accuracy and interpretation of administrative data. One inherent constraint was the lack of anatomic specificity associated with the use of standardized procedural codes in claims data. Chiropractic manipulative treatment codes (CPT 98940 � 98942) have been formatted to describe the number of spinal regions receiving manipulation. They do not identify the particular spinal regions manipulated.
Also, treatment information describing the type(s) of manipulation was not available. When SMT was re- ported, claims data could not discriminate among the range of techniques including thrust or rotational manipulation, various non-thrust interventions e.g., mechanical instruments, soft tissue mobilizations, muscle energy techniques, manual cervical traction, etc. Many of these techniques do not incorporate the same bio- mechanical stressors associated with the type of manipulation (high velocity low amplitude) that has been investigated as a putative risk factor for VBA stroke [54-56]. It seems plausible that the utility of future VBA stroke research would benefit from explicit descriptions of the particular type of manipulation performed.
Moreover, patient responses to care � including any adverse events suggestive of vertebral artery dissection or stroke-like symptoms � were not obtainable in the data set used for the current study.
In the absence of performing comprehensive clinical chart audits, it is not possible to know from claims data what actually transpired in the clinical encounter. Further, chart notes may themselves be incomplete or otherwise fail to precisely describe the nature of interventions [57]. Therefore, manipulation codes represent surrogate
measures, albeit more direct surrogate measures, than simply using the exposure to chiropractic visits.
Our study was also limited to replication of the case� control design described by Cassidy, et al. [32]. For pragmatic reasons, we did not attempt to conduct a case-crossover design. While the addition of a case- crossover design would have provided better control of confounding variables, Cassidy, et al. [32] showed the results were similar for both the case control and case crossover studies.
The findings of this case�control study and previous retrospective research underscore the need to rethink how to better conduct future investigations. Researchers should seek to avoid the use of surrogate measures or use the least indirect measures available. Instead, the focus should be on capturing data about the types of services and not the type of health care provider.
In alignment with this approach, it is also important for investigators to access contextual data (e.g., from electronic health records), which can be enabled by qualitative data analysis computer programs [58]. The acquisition of the elements of clinical encounters � including history, diagnosis, intervention, and adverse events � can provide the infrastructure for more action- able research. Because of the rarity of VBA stroke, large data sets (e.g., registries) containing these elements will be necessary to achieve adequate statistical power for making confident conclusions.
Until research efforts produce more definitive results, health care policy and clinical practice judgments are best informed by the evidence about the effectiveness of manipulation, plausible treatment options (including non-thrust manual techniques) and individual patient values [20].
Conclusions
Our findings should be viewed in the context of the body of knowledge concerning the risk of VBA stroke. In contrast to several other case�control studies, we found no significant association between exposure to chiropractic care and the risk of VBA stroke. Our secondary analysis clearly showed that manipulation may or may not have been reported at every chiropractic visit. Therefore, the use of chiropractic visits as a proxy for manipulation may not be reliable. Our results add weight to the view that chiropractic care is an unlikely cause of VBA strokes. However, the current study does not exclude cervical manipulation as a possible cause or contributory factor in the occurrence of VBA stroke.
Authors’ Contributions
DE conceived of the study, and participated in its design and coordination. JT participated in the design of the study, performed the statistical analysis and helped to draft the manuscript. TMK participated in the design and coordination of the study, and wrote the initial draft and revisions of the manuscript. WMB participated in the coordination of the study and the statistical analysis, and helped to draft the manuscript. All authors contributed to the interpretation of the data. All authors read and approved the final manuscript.
Author Details
1Optum Health � Clinical Programs at United Health Group, 11000 Optum Circle, Eden Prairie MN 55344, USA. 2Optum Health � Clinical Analytics at United Health Group, 11000 Optum Circle, Eden Prairie MN 55344, USA.
Received: 14 October 2014 Accepted: 28 April 2015
Published Online: 16 June 2015
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Case Report: The Assessment of Traumatic Cervical Spine Injury and Utilization of Advanced Imaging in a Chiropractic Office.
Abstract: the objective is to explore the standard of care regarding the assessment of cervical spine injuries in a setting of a chiropractic office. Diagnostic studies include physical examination, range of motion studies, orthopedic testing and cervical spine. MRI.
Introduction: On January 30, 2017 a 49 year old female presented in my office to a second opinion examination at the request of her attorney. She had been involved in a rear-end collision on 12/12/2015. (2) She was transported to a local hospital and arrived with complaints of headaches, disorientation, right-sided neck pain and right arm pain. At the hospital emergency department CAT scan was taken of her brain, which proved to be negative. She received prescriptions of muscle relaxers and pain relievers and instructed to visit her primary care physician if her symptoms persisted.
Initial Examination
She consulted a local Chiropractor on December 15, 2015. The initial examination included the following from my review of the doctor�s notes: Presenting complaints were right-sided neck pain that radiates to the right arm. The doctor�s records show a positive cervical compression test and a positive maximum cervical compression test. Both produced pain bilaterally worse on the right. Facet provocation tests were positive for facet disease. Right side radicular pain pattern includes the trapezius and deltoid. No x-ray studies were included in the doctor�s orders. The patient received 23 chiropractic treatments from 12/15/2015 through 4/5/2016 for a diagnosis of cervical sprain/strain. The treatments consisted of spinal manipulation and a variety of soft tissue therapies.
Around January 15, 2017 I received a phone call from a local attorney regarding this patient and asking if I would do a second opinion examination on her due to persistent neck pain and right upper extremity pain. The patient presented on January 30, 2017 for my evaluation. My clinical findings are as follows:
Vitals: Age 49, weight 170 lbs. height 5� 8�, B.P 126/82, pulse 64, Resp. 16/min.
Appearance: in pain
Orthopedic/Range of motion: All cervical compression tests produced pain with radiation bilaterally worse on the right. Range of motion studies revealed: 40 degrees of left rotation and 32 degrees of right rotation with radiating pain produced by both motions.
Palpation: cervical spine palpation produced centralized spine pain that radiates to the right shoulder with numbness in the right arm and hand.
The patient informed me during the examination that her pain made it difficult to sleep through the night. If she was on her right side her right arm and hand would go numb immediately. A big part of this patient�s life was riding and caring for her horse and she could not do either because it resulted in severe neck and arm pain.
My recommendation to her and her attorney was to obtain a cervical spine MRI with a 1.5 Tesla machine due to the high quality images it can produce. MRI is a highly sensitive tool to evaluation of neurologic tissue including the spinal cord and nerve roots. (1) I bypassed the x-ray at this time due to the clinical presentation and 12% of spinal cord with injuries having no radiographic abnormality. (3)
Imaging
Figure 1: T2 Sagittal Cervical Spine MRI
Fig 2: T2 Axial Cervical Spine with Scout line through C3/4.
Radiology Report: The report and the images demonstrated a right paracentral disc extrusion measuring 9 mm and extending 8 mm cranial/caudal causing abutment of the spinal cord. (Fig 1)(2) Additionally the diameter of the central canal was reduced to 8.1mm and projected into the right lateral recess resulting in severe stenosis of the right neural canal. (Fig 2) Additional findings not pictured: C4/5 demonstrated a 2.5 mm bulging disc with facet hypertrophy with moderate stenosis of the left neural canal and severe stenosis of the right neural canal. C5/6 demonstrated a 1.5 mm posterior subluxation narrowing the central canal to 9.1 mm with unconvertebral joint hypertrophy resulting in moderate right and severe left neural canal stenosis. C6/7 revealed a broad based disc herniation worse on the left measuring 3.6 mm resulting in severe neural canal stenosis bilaterally complicated by unconvertebral joint hypertrophy. The MRI findings correlate with the patient�s clinical presentation. (4)
Discussion: When the patient returned to a consultation on the MRI findings my recommendation was to consult a neurosurgeon. (3) Her attorney asked me if the treating doctor acted incompetently. My only response was that I would have ordered the MRI immediately before treating the patient with manual manipulation. The case is likely to go to trial and there is a good chance that I will be called in as an expert witness. It is almost a guarantee that the defense attorney will ask me if I would have treated the patient for such a long period of time without an MRI or whether the treating doctor could have made the problem worse. The failure to accurately determine a diagnosis may result in malpractice action or a board hearing or both for this treating doctor and I would have ordered the MRI immediately considering the radicular findings and symptoms. After any myelopathic or significant radiculopathic symptoms a referral of advanced imaging needs to be performed in order to conclude and accurate diagnosis, prognosis and treatment plan prior to rendering care. Diagnostic appropriateness in the case of traumatic injury or with any etiology with neurologic symptoms or findings necessitates following triage protocols. In this case, an immediate 2-3mm MRI of the cervical spine is clinically indicated and proved integral to the safe care of this patient.
The scope of our information is limited to chiropractic and spinal injuries and conditions. To discuss options on the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
References:
Haris, A.M., Vasu, C., Kanthila, M., Ravichandra, G., Acharya, K. D., & Hussain, M. M. 2016. Assessment of MRI as a modality for evaluation of soft tissue injuries of the spine as compared to intraoperative assessment. Journal of Clinical and Diagnostic Research, 10(3), TC01-TC05
Schneider RC, Cherry G, Pantek H. The syndrome of acute central cervical spinal cord injury, with special reference to the mechanisms involved in hyperextension injuries of cervical spine. J Neurosurg 1954; 11: 546�577.
Tewari MK, Gifti DS, Singh P, Khosla VK, Mathuriya SN, Gupta SK et al. Diagnosis and prognostication of adult spinal cord injury without radiographic abnormality using magnetic resonance imaging: analysis of 40 patients. Surg Neurol 2005; 63: 204�209.
Miyanji F, Furian J, Aarabi B, Arnold PM, Fehlings MG. Acute cervical traumatic spinal cord injury: MR imaging Findings correlated with neurologic outcome-prospective study with 100 consecutive patients. Radiology 2007; 243: 820�827.
Additional Topics: Recovering from Auto Injuries
After being involved in an automobile accident, many victims frequently report neck or back pain due to damage, injury or aggravated conditions resulting from the incident. There’s a variety of treatments available to treat some of the most common auto injuries, including alternative treatment options. Conservative care, for instance, is a treatment approach which doesn’t involve surgical interventions. Chiropractic care is a safe and effective treatment options which focuses on naturally restoring the original dignity of the spine after an individual suffered an automobile accident injury.
Title: Conservative care and axial distraction therapy for the management of cervical and lumbar disc herniations and ligament laxity post motor vehicle collision.
Dr. Alex Jimenez, doctor of chiropractic, focuses on the diagnosis, treatment and prevention of a variety of injuries and conditions associated with the musculoskeletal and nervous systems, utilizing several chiropractic methods and techniques. The following procedures may be similar to his own but can differ according to the specific issue and complications by which the individual is diagnosed.
Abstract: This middle-aged female was injured in a vehicle collision causing her to sustain disc and additional ligament injuries in the cervical and lumbar spine. Diagnostic studies included physical examination, orthopedic and neurological testing, lumbar MRI, multiple cervical MRI�s, CRMA with motion cervical radiographs and EMG studies. Typically, conservative care is initiated prior to interventional procedures, and this case study seeks to explore the usage of passive therapy for mechanical spine pain and noted anatomic disc lesions after failure of interventional procedures. She reported both short term and long term success regarding pain reduction along with improvement in her activities of daily living after initiating conservative care, and continued to report further reductions in pain with periodic pain management using conservative care.
Introduction: The 49-year-old married female (Spanish speaking patient) reported that on March 4th, 2014 she was the seat-belted driver of a truck that was struck by a much larger fuel truck changing lines, hitting her vehicle at the front passenger side (far side, side impact). The force of the impact caused her truck to be lifted up and the right wheel popped off. Her head hit the window after impact and the spinal pain and complaints started approximately 24 hours later. Two days after the crash she went to the emergency department. Occupant pictures were taken describing an out of position occupant injury. She did not report any additional significant trauma after the collision.
Initial Diagnosis and Treatment for Disc Herniations
Prior to her evaluation at our clinic, she utilized multiple providers for diagnosis and treatment over the course of 11 months. She went to the emergency department, utilized 3 pain management medical doctors, neuropsychologist and a cognitive rehabilitation therapist. Imaging included radiographs and MRI of the right shoulder revealing rotator cuff tear; radiographs of the lumbar and thoracic spine, and left hand; CT of the head and cervical spine were performed; MRI cervical (3) and lumbar spine. Medications prescribed included Fentanyl, Percocet, Naprosyn, Cyclobenzaprine, Norco, Hydrocodone-acetaminophen, Soma, and Carisoprodol. Physical therapy was provided for spinal injuries and she did not respond to treatment. The neurosurgeon recommended epidural steroid injections and facet blocks. Cervical nerve blocks and cervical trigger point injections, cervical and lumbar epidural steroid injections (ESI), lateral epicondyle steroid injections were performed, none of which were palliative. Post-concussion disorder and PTSD with major depressive disorder were diagnosed.
On February 12th, 2015, she presented to our office with neck pain (average 6/10 VAS) that affected her vision, with paresthesia�s in both upper extremities radiating to the hands with numbness. She had low back pain (average 6/10 VAS), and she additionally reported paresthesia at the plantar surface of feet bilaterally. She had left elbow pain, right shoulder pain, knee pain, headaches and �anxiety� along with anterior sternal pain.
Her injuries were causing significant problems with her activities of daily living. Summarily she had increased pain with lifting, increased pain and restricted movement with bending, walking and carrying. She had been unable to perform any significant physical activity from the time of the crash in March 2014 until March 2015. Her right hand was always hurting and her forearms. She was not able to clean windows or do laundry, difficulty using stairs, problems with mopping, ironing and cleaning. She had to limit her walking and jogging primarily due to neck pain and right arm pain. She was not able to sit for long periods of time and sleeping was disrupted due to numbness in her hands. She was only able to walk on a treadmill for 10 minutes before having to stop due to pain, prior to the crash she would exercise for an hour.
Prior History: No significant prior musculoskeletal or contributory medical history was reported.
Research Study Conclusions
Clinical Findings (2/12/15): She had a height of 5�2�, measured weight of 127 lbs.
Visual analysis of the cervical spine revealed pain in multiple ranges of motion including flexion, extension, bilateral rotation and bilateral side bending. On extension pain was noted in the upper back, on rotation pain was noted in the posterior neck, and on lateral flexion pain was noted contralaterally.
Visual analysis of the lumbar spine revealed pain in the low back on all active ranges of motion, including flexion, extension and side bending, pain primarily at L5/S1.
Dual inclinometer testing was ordered based on visual active range of motion limitations with pain.
Sensory testing was performed of the extremities, C5-T1 and L4-S1. No neurological deficits other than right sided C5 hypoesthesia.
Foraminal compression test produced pain in the cervical spine. Foraminal distraction test caused an increase in pain in the neck. Jackson�s test on the right produced pain bilaterally in the neck. Straight leg raise bilaterally produced low back pain, double Straight leg raise produce pain at L5/S1 at 30 degrees.
Muscle testing of the upper extremities was tested at a 5/5 with the exception of deltoid bilaterally tested at a 4/5. The patient�s deep tendon reflexes of the upper and lower extremities were tested including Triceps, Biceps, Brachioradialis, Patella, Achilles: all were tested at 2+ bilaterally, equal and reactive. No evidence of clonus of the feet and Hoffman�s test was unremarkable.
C3-C5 right sided segmental dysfunction was noted on palpation. T5-T12 spinous process tenderness on palpation. Low back pain on palpation, particularly L5/S1.
Imaging Results
MRI Studies:
I reviewed the cervical MRI images taken May 2014 with the following conclusions (images attached):
Dramatic reversal of the normal cervical curvature, apex C5/6.
C5/6 herniation, indentation of the spinal cord anteriorly. High signal posterior on STIR.
Due to the angular kyphosis of the cervical spine and axial slices performed, C6/7 slices did not render a pure diagnostic image for disc disruption.
Fig. 1 (A) T2 Axial C5/6, 2 months post injury Fig. 1 (B) Sag T2 C5/6
I reviewed cervical MRI images taken September 17th, 2014 approximately 6-months post injury, and rendered the following conclusions:
Reversal of the normal cervical lordosis.
C5/C6 herniation (extrusion type) with indentation of spinal cord, appropriate CSF noted posteriorly.
I reviewed the cervical MRI dated October 24th, 2015 (images attached):
C4/5 herniation, extrusion type, left oriented into the lateral recess and neural canal causing moderate neural canal stenosis
Fig. 2 (A) 3D Axial C4/5, 19 months post injury Fig. 2 (B) Sag T2 C4/5
IMPRESSIONS: C4/5 herniation noted on 10/24/15 was not noted on prior images. The patient reported no additional injury or symptoms between MRI studies, so it is postulated that initial slices revealed a false negative; or due to the severity of abnormal cervical biomechanics, it is possible that the C4/5 disc herniated between the pre/post MRI�s with no significant increase in symptomatology. There was improvement at C5/6 related to disc abnormality and cord involvement (see below).
Fig. 3 (A) 3D Axial C5/6, 19 months post injuryFig. 3 (B) Sag T2 C5/6, 19 months post injury
The cervical flexion/extension images were digitized February 2016 and interpreted by myself and Robert Peyster MD, CAQ Neuroradiology, revealing a loss of Angular Motion Segment Integrity at intersegment C6/C7 measured at 19.7 degrees (maximum allowed 11 degrees), indicating a 25% whole person impairment according to the AMA Evaluation of Permanent Impairment Guidelines 5th edition1. CRMA provided from Spine Metrics, independent analysis.
Evidence of significant ligament injury causing functional subfailure was measured at C3/4 at 10.4 degrees and at C4/5 measuring 10.9 degrees regarding angular motion. Abnormal paradoxical translation motion measured at C6/7 and C7/T1.
Functional Testing:
EMG of the upper extremity revealed bilateral C6 radiculopathy, December 16th, 2015.
Range of Motion Cervical Dual Inclinometry:
Initial Max 4 months later % Improvement
Cervical Extension 44 42 -5%
Flexion 40 62 55%
Cervical Left 25 41 64%
Lateral flexion Right 12 26 117%
Cervical Left 46 59 28%
Rotation Right 43 73 70%
Conservative treatment rendered: A neurosurgical referral was made for assessment and surgical options. Conservative care was initiated despite failure of other medical procedures since there is �further evidence that chiropractic is an effective treatment for chronic whiplash symptoms�2-3. The patient was placed on an initial care plan of 2-3x/week for 5 months, with a gap in passive care for 1 month.
23 chiropractic visits. Instrument adjusting cervical spine was utilized with Arthrostim. Non-rotatory HVLA (high velocity low amplitude) spinal adjustments were performed thoracic and lumbar spine, applied A-P. No HVLA spinal adjustments to the cervical spine.
Prior to being placed at maximum medical improvement she had persistent low back symptoms, continued tingling in the fingertips and occasional neck pain at a 4/10, with her upper extremity paresthesia�s improved 50%. She continued with pain management chiropractic care after MMI, approximately 1 visit every 3-4 weeks with axial distraction to the cervical and lumbar spine, chiropractic adjustments as needed (PRN). 2 years/9 months post collision, and 1 year/9 months after initiating conservative care at our clinic, she reports only slight (1-2/10 VAS) spinal complaints with her primary concern being a torn rotator cuff injury from the crash that still requires surgical intervention. After initiating care at our clinic, no other interventional procedures were performed, although medication usage persisted. Due to improvement in symptoms and functional status, spinal surgery was not considered. She still utilizes Aleve PRN, 1-2 tablets. No significant active spinal rehabilitation was utilized. The patient was given at home active care consisting only of cervical and lumbar stretches, walking, and ice to affected areas.
Conclusion:While chiropractic care is safe even in the presence of herniations and radicular symptoms, �the likelihood of injury due to manipulation may be elevated in pathologically weakened tissues�4. Due to cord involvement, the provider decided to utilize low force procedures although HVLA spinal adjustments to the cervical spine could be considered safe due to lack of cord compression. HVLA spinal adjustments A-P were utilized in the lumbar and thoracic spine not only for short term pain relief but also as part of managing the chronic low back pain secondary to ligament/disc damage. While previously theorized to be only episodic, low back pain can be a lifelong condition requiring patients to seek ongoing care5. This care can be active, passive, pharmaceutical, interventional, or conservative in nature, but ongoing pain management therapy is often required for permanent ligament conditions. There is clear benefit to the patient population to be able to avoid surgical intervention due to risks, costs, ongoing prescription medication usage and adjacent level degeneration in the future6. Avoiding opioid usage is also a high priority in today�s environment.
Long term conservative care utilizing instrument spinal adjusting and targeted axial distraction therapy significantly reduced subjective reporting of pain, increased activities of daily living, and allowed the patient to avoid further spinal injections or surgical intervention. Considering that various interventional procedures failed prior to conservative care, it is important that providers work in an interdisciplinary environment such that the safest, and in this case the most effective, therapies are utilized first to reduce risk to the patient and maximize benefit and reduce costs.
In this case study, the patient utilized multiple pain management physicians, cervical nerve blocks and epidural steroid injections, and was not directed to conservative care for 11 months post injury. Utilizing chiropractic as conservative care would have enabled this patient to regain function and decrease pain while reducing costs and risks that are associated with medications and interventional procedures.
Competing Interest: There are no competing interests in the writing of this case report.
De-Identification: All of the patient�s data has been removed from this case.
The scope of our information is limited to chiropractic and spinal injuries and conditions. To discuss options on the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
Cocchiarella L., Anderson G. Guides to the Evaluation of Permanent Impairment, 5th Edition, Chicago IL, 2001 AMA Press.
Khan S, Cook J, Gargan M, Bannister G. A symptomatic classification of whiplash injury and the implications for treatment. Journal of Orthopaedic Medicine 1999; 21(1):22-25.
Whedon J, Mackenzie T, Phillips R, Lurie J. Risk of traumatic injury associated with chiropractic spinal manipulation in Medicare Part B beneficiaries aged 66-99 years. Spine, 2015; 40:264�270.
Hestbaek L, Munck A, Hartvigsen L, Jarbol DE, Sondergaard J, Kongsted A: Low back pain in primary care: a description of 1250 patients with low back pain in Danish general and chiropractic practices. Int J Family Med, 2014.
Faldini C., Leonetti D., Nanni M. et al: Cervical disc herniation and cervical spondylosis surgically treated by Cloward procedure: a 10-year-minimum follow-up study. Journal of Orthopaedics and Traumatology, June 2010.Volume 11, Issue 2,pp 99-103.
Additional Topics: Recovering from Auto Injuries
After being involved in an automobile accident, many victims frequently report neck or back pain due to damage, injury or aggravated conditions resulting from the incident. There’s a variety of treatments available to treat some of the most common auto injuries, including alternative treatment options. Conservative care, for instance, is a treatment approach which doesn’t involve surgical interventions. Chiropractic care is a safe and effective treatment options which focuses on naturally restoring the original dignity of the spine after an individual suffered an automobile accident injury.
IFM's Find A Practitioner tool is the largest referral network in Functional Medicine, created to help patients locate Functional Medicine practitioners anywhere in the world. IFM Certified Practitioners are listed first in the search results, given their extensive education in Functional Medicine
Among the commercially insured, 1.6% of stroke cases had visited chiropractors within 30 days of being admit- ted to the hospital, as compared to 1.3% of controls visit- ing chiropractors within 30 days prior to their index date. Of the stroke cases, 18.9% had visited a PCP within 30 days prior to their index date, while only 6.8% of controls had visited a PCP (Table 4). The proportion of exposures for chiropractic visits was lower in the MA sample within the 30-day hazard period (cases = 0.3%; controls = 0.9%). However, the proportion of exposures for PCP visits was higher, with 21.3% of cases having PCP visits as compared to12.9% for controls (Table 5).
The results from the analyses of both the commercial population and the MA population were similar (Tables 6, 7 and 8). There was no association between chiropractic visits and VBA stroke found for the�
