Chiropractic Co-Management of Pre & Post-Spine Surgical Cases
By: Matt Erickson DC, FSBT
Mark Studin DC, FASBE(C), DAAPM, DAAMLP
Ashraf Ragab, MD, Orthopedic Spine Surgeon
Reference: Erickson M., Studin M., Ragag A. (2019) Chiropractic Co-Management of Pre and Post-Surgical Cases, American Chiropractor 41(9), 34, 36,38-40
A report on the scientific literature
When a patient presents in a chiropractic office and has clinical signs of either radiculopathy (nerve root compression) at the neural canal or central canal regions or any myelopathic findings (cord compression with ensuing neurological deficit distal to the level of the lesion), immediate referral for an MRI should be considered. Based upon your clinical findings, triage then ensues as a result of creating a clinically driven diagnosis, prognosis and treatment plan. In a smaller percentage of cases, it will be discovered that the patient has a condition that requires a referral to a spine surgeon or a pain management provider. Regardless of where the patient is directed, having the patient fully worked up (examination, x-rays and advanced imaging) before the referral takes place is an important aspect of what the Doctor of Chiropractic can and should do and is within the lawful scope of practice within all 50 states and the United States territories.
Among those patients referred to the spine surgeon, some will not require or be a candidate for surgery. This is an area where a Doctor of Chiropractic especially with post-graduate training in Primary Spine Care and spinal biomechanical engineering, can be a big help to the surgeon by ensuring that a higher portion of the referred patients presents with the condition that likely requires the surgeon’s services. By triaging those patients who more likely needs the spine surgeon or pain management doctor’s services, it allows the specialist to save time on screening patients in the clinic who do not need their services and instead, it allows them to spend more time performing medically necessary spine-related procedures which allows patients to be taken care of more efficiently.
In the event a patient does not require surgery, unless there is a contraindication to correcting a patient’s neuro-musculo-biomechanical failure leading to structural imbalance, the Doctor of Chiropractic can co-manage the patient with the pain management provider. For the pain management provider, they may recommend various pain management procedures like a spinal epidural injection, a medial branch block or a facet injection. And given that pain management providers don’t focus on spinal biomechanics, but the Doctor of Chiropractic does, for most patients, this collaborative approach is ideal for better patient outcomes.
In patients who do require surgery, the treatment plan can be as simple as the referral to the spine surgeon. This however brings the question, “What is the Doctor of Chiropractic’s role in managing patients before and after surgery?”
In some cases, immediate surgery may be required. This would be the case where the patient has a spinal cord injury like myelomalacia-which is regarded as softening of the spinal cord due to damaged neural tissue that fills in with a glial scar. A glial scar, according to Silver and Miller (2004, February) “consists predominately of reactive astrocytes [star-shaped glial cells-cells without neurons, in the brain or spinal cord] and proteoglycans [molecules made of sugar and proteins]” (p. 146). Further, myelomalacia forms with pressure on the spinal cord which may be due to biomechanical failure and ensuing cord pressure in post-trauma cases. Immediate surgery may also be required with a disc extrusion (a type of disc herniation) which presents with myelopathic findings (ensuing neurological deficit distal to the site of the spinal cord lesion following trauma) and in patients with an advanced nerve root compression leading to pain, numbness, tingling and weakness into the upper or lower extremity at the level the nerve root has been compressed.
In other patients however, while surgery may be indicated, the Doctor of Chiropractic can work to improve the patient’s biomechanical balance before surgical intervention. This is another area a Primary Spine Care trained Doctor of Chiropractic has the additional post-graduate training to co-manage this type of case. Regardless, these considerations must be coordinated with the spine surgeon if surgery is required. Sagittally balancing the spine for better patient surgical outcomesas reported by Makhni, Shillingfor, Latatta Hyun and Kim (2018), “Adult spinal deformity with sagittal imbalance is associated with significant pain, disability, as well as directly and negatively influence health-related quality of life scores. The spine surgeon has to understand the whole global and regional alignment changes after sagittal imbalance to address the multiplanar deformity. Restoration of global alignment and minimization of complications through various surgical options can successfully improve the pain and function of spinal deformity patients” (pp. 176-177).
Importance of Sagittal Balance
Sagittally balancing the lumbar spine is further supported in an article published on Helia.com related to lectures on the outcomes of lumbar spine surgery about sagittal balance, Hu (2016, para 3) reported, “Surgical outcomes for spine surgery are improved when spinal, pelvic and hip alignment is considered in both degenerate and deformity cases, and how we better understand these will help us better improve outcomes for our patients” (https://www.healio.com/spine-surgery/lumbar/news/print/spine-surgery-today/%7B54ac5ca2-7939-407d-96a5-31fa9c0fc904%7D/proper-sagittal-balance-may-correlate-with-better-surgical-outcomes).
Hu (2016) also reported, “Sagittal imbalance in a patient can negatively affect the outcomes of a surgical procedure. But, how extensive the surgery required is to correct the imbalance must be carefully considered for the individual patient” (para. 4). r. LeHuec (2016) added, “Sagittal balance is an active phenomenon for patients. “The best course of action is to strive to achieve sagittal balance in patients” (para. 8).
In a study by
Finally, in an article by Yeh, Lee, Chen, Yu, Liu, Peng, Wang, and Wu, (2018) they concluded, “The results of this study support previous findings that functional outcomes are closely associated with sagittal radiographic parameters in the patients with the degenerative thoracolumbar spinal disease who received long-segment fusion. The achievement of global and regional sagittal alignment balance is a crucial factor for improved postoperative functional outcomes” (p. 1361).
According to a publication titled “A Detailed Guide to Your Surgery and The Recovery Process” by the Johns Hopkins Spine Service (n.d., p. 16), “Walking is the best activity you can do for the first 6 weeks after surgery. Further, there will be “restrictions for the first 6 weeks after surgery,” the patient should “avoid twisting and bending” and avoid lifting, pushing or pulling objects greater than 5 lbs” (https://www.hopkinsmedicine.org/orthopaedic-surgery/_documents/patient-information/patient-forms-guides/JHULumbSpineSurgeryGuide.pdf).
From the Johns Hopkins publication (n.d.), patients are advised to call the surgeon’s office to make a 6-week follow-up appointment. At that appointment, x-rays will be performed to evaluate how the surgical area is healing. If everything checks out, “patients may be given a handout of lower back exercises to begin at home.” Patients may also be provided a prescription for outpatient physical therapy, but that is dependent upon the patient’s recovery (p. 24).
When physical therapy begins, the goal is to gradually improve strength, flexibility and endurance. The patient may also receive help with activities of daily living like gate training (learning how to walk properly again). However, while beneficial, physical therapy is limited in that a physical therapist does not focus diagnosing and correcting the spinal biomechanics. Further, a physical therapist is not licensed to manage the patients on a physician level. This is where the Doctor of Chiropractic is needed as part of the long-term recovery solution.
Following the initial 6-week evaluation, according to Hayeri and Tehranzadeh (2009, para. 21), “Evaluation of the postoperative spine usually begins with conventional radiographs in AP and lateral projections. It usually takes 6 to 9 months for a solid bone fusion to be established radiographically.” Hayeri and Tehranzadeh (2009, para. 20) also reported, “Postoperative imaging plays an important role in the assessment of fusion and bone formation. It is also helpful to detect instrument failure and other suspected complications. It is necessary to compare current images with previous studies to identify any subtle changes and disease progression” (https://appliedradiology.com/articles/diagnostic-imaging-of-spinal-fusion-and-complications).
Hayeri and Tehranzadeh (2009) added, Currently, computed tomography (CT) with multiplanar reconstruction (MPR) is considered the modality of choice for imaging bony details and assessing osseous formation and hardware position despite artifact formation.” (para. 22).
It is important to understand, patients don’t need to wait 6-9 months to start treatment with the Doctor of Chiropractic. About 6 weeks following surgery, if the patient is healed enough to begin physical therapy, the patient should be able to tolerate gentle mechanical corrections above and below the level of the surgical fusion. However, the patient will need to first be cleared to do so by the surgeon. Doing this can help in the patient’s recovery process and prepare the patients spine for a more comprehensive correction process once the patient is cleared. It can also help to shorten the time needed for correction.
The Doctor of Chiropractic (trained in Primary Spine Care) therefore, can take on a critical and important role in the management of patients before and after spine surgery. Further, unlike the physical therapist, the Doctor of Chiropractic having physician class status, is licensed to fully diagnose, manage and treat biomechanical pathology of the spine when indicated.
Primary Spine Care
Despite this, not all Chiropractic Doctors have additional post-graduate training or experience to manage complex spine cases. This is no different than a Medical Doctor having just completed medical school not being able to function in the capacity of a specialist short of residency and/or a fellowship program.
One solution that provides the Doctor of Chiropractic with the additional training and experience to manage complex spine cases is an extensive post-graduate training program in Primary Spine Care as previously discussed. Currently, there is a growing body of Chiropractic Doctors through an extensive post-graduate program offered through the Academy of Chiropractic, that are becoming qualified in Primary Spine Care that is well prepared to take on the role in managing patients with complex spine related issues (https://www.academyofchiropractic.com/component/content/article.html?id=1224).
The concept of the Doctor of Chiropractic taking on the role of a Primary Spine Care provider was discussed in an article by Erwin, Korpela and Jones (2013). The stated, “Chiropractors have the potential to address a substantial portion of spinal disorders; however the utilization rate of chiropractic services has remained low and largely unchanged for decades. Other health care professions such as podiatry/chiropody, physiotherapy and naturopathy have successfully gained public and professional trust, increases in the scope of practice and distinct niche positions within mainstream health care. Due to the overwhelming burden of spine care upon the health care system, the establishment of a ‘primary spine care provider’ may be a worthwhile niche position to create for society’s needs. Chiropractors could fulfill this role, but not without first reviewing and improving its approach to the management of spinal disorders” (p. 285).
In conclusion, the Doctor of Chiropractic has the foundational training to diagnose, manage and treat patients when indicated both before and after spinal surgery. However, with additional post-graduate training in Primary Spine Care, the Doctor of Chiropractic can obtain the necessary skills to manage more complex spine conditions which include coordinating care with the spine surgeon, pain management doctors and even a patient’s primary care doctor. With the current opioid crisis in the United States, there is a need for a front-line provider to lead in the management of non-surgical spine care and the Doctor of Chiropractic as a licensed physician is positioned to take on that role especially with additional training in Primary Spine Care.