Vertebral Subluxation Complex
By Mark Studin DC, FASBE(c), DAAPM
Eric Kaplan DC, FIAMA
Reference: Studin M., Kaplan E. (2022) Vertebral Subluxation Complex vs. Patho-Neuro-Biomechanical Lesion, American Chiropractor, 41 (9) Pgs. 18, 20 , 22, 24
Is Chiropractic a philosophy, an art, and a science? Or is it a science, utilizing an art, that recognizes a philosophy? Are you purely a “subluxation-based” practitioner, or only functioning in the pain model and anti-subluxation, or a combination of both? Are you at a chiropractic school that has banned the word subluxation, or a school that mandates the use of that concept? As I pose those questions to chiropractic practitioners, it is too often confusing for them to answer. Imagine the confusion of an unknowing public, or politicians trying to figure out if their support is prudent. Our profession is a “niche’” industry and these disparate beliefs hurt us all no matter your practice model.
Subluxation is not a word that our profession should shy away from. It has been used since the inception of our profession and we have used that to “brand” chiropractic. However, as we have evolved with continual new evidence in the scientific community, we should progress and embrace the changes that will be the core of expanding utilization beyond our (approximate) 9% of the population.
When we look carefully at the vertebral subluxation complex [VSC], Leonard Faye (1966) helped developed that concept. However, there were many others who contributed, and all were considered “theorists” during their time because science had not caught up to those theories. What makes Faye, DD and BJ Palmer and so many others so remarkable are that it was so close to what we know now to be factual, yet it was derived in the absence of today’s technology that has afforded us so many answers.
“Faye’s model was congruent with those from previous theorists that chiropractic vertebral subluxation (CVS) may lead to pathophysiology and then pathology. He hypothesized that normal physiological processes would be restored, and the “life forces” would be unblocked by correcting the CVS. He proposed that the objective was to develop an examination rationale to look at the locomotor system as a whole with the spine as “part of a closed kinematic system. The rationale for adjusting included finding the fixation, mobilizing the fixation, and rechecking to confirm improvement. Faye in conservation discussed creating the concept of CVS as “a complex clinical entity” in 1963 as comprising pathophysiological changes associated with “one or more of the following: Neuropathophysiology Kinesiopathology, Myopathology, Histopathology, and Biochemical Pathology.
If it wasn’t for Faye and others, who piggybacked and expanded on DD and BJ’s “vitalistic” theories, where would science have looked? Most scientific breakthroughs were founded on theory, then tested to figure out why in the validation process in the proverbial “laboratory.” Chiropractic was and is no different. Here, in part is what science has explained about chiropractic, subluxation, and biomechanics.
Evans (2002) reported “…on flexion of the lumbar spine, the inferior articular process of zygapophyseal joint moves upward, taking a meniscoid with it. On attempted extension, the inferior articular process returns toward its neutral position, but instead of re-entering the joint cavity, the meniscoid impacts against the edge of the articular cartilage and buckles, forming a space-occupying "lesion" under the capsule: a meniscoid entrapment. A large number of type III and type IV nerve fibers (nociceptors) have been observed within capsules of zygapophyseal joints. Pain occurs as distension of the joint capsule provides a sufficient stimulus for these nociceptors to depolarize. Muscle spasm would then occur to prevent the impaction of the meniscoid. The patient would tend to be more comfortable with the spine maintained in a flexed position because this will disengage the meniscoid. Extension would therefore tend to be inhibited. This condition has also been termed a "joint lock" or "facet-lock" the latter of which indicates the involvement of the zygapophyseal joint.” P. 252-253
NOTE: The Evans article has been cited 265 times, as recently as numerous times in 2022. It has been reported that anything over 25 times is considered impactful in the scientometric indicator.
The dislodged meniscoid renders biomechanical pathology or aberrant loading of the spinal column. Panwar and Hamza (2022) reported spinal inability to carry spinal loads…includes the clinical consequences of neurological deficits and/or pain.” P. 53
Panjabi (2006) described the negative sequella of pathobiomechanics in a stabilization-destabilization scenario involving corrupted neurological transducers. As Evans reported on the meniscoid entrapment, the process includes distention and firing of the joint capsule. The joint capsule as reported by Solomonow (2009) is comprised of ligaments for both mechanical and sensory functions. Dougherty (2020) reported Pacinian (crimp receptors) and Ruffini (stretch receptors) Corpuscles, Golgi ligament organs, and free nerve endings (nociceptors) in the joint capsule. These provide proprioception and mechanoreception afferently and are all considered somatosensory receptors.
As a result of the biomechanical instability, as reported by Solomonow (2009) there is a compensatory ligamento-muscular reflex thatmay be inhibitory or excitatory, as may be fit to preserve joint stability; inhibiting muscles that destabilize the joint or increased antagonist co-activation to stabilize the joint. Panjabi (2006) then reported “The corrupted muscle response pattern leads to corrupted feedback to the control unit via tendon organs of muscles and injured mechanoreceptors [and nociceptors], further corrupting the muscle response pattern. (p. 669)
Sampath et. Al (2017) reported “A key causative mechanism responsible for the perception of pain is nociception that occurs at the site of tissue injury… These biochemical markers include various neuropeptides such as neurotensin, oxytocin, substance-P (SP), and orexin-A… These chemicals are primarily released at the injury site, they also result in the initiation of an inflammatory process which further results in the production of numerous pro-inflammatory and immuno-regulatory cytokines and neurotransmitters.” p. 120
The meniscoid entrapment as described by Evans (2002) and the type III and IV nociceptor reaction at the zygapophyseal joints explain where there is bone on the nerve and aberrant neurological sequella. Cramer et. Al (2002) reported that a chiropractic high velocity, low amplitude adjustment creates joint gapping and normalizing of spinal biomechanics. These are topics discussed in other papers but underscore that biomechanics can be pathological and create negative neurological sequelae.
The result of biomechanical failure is remodeling, based upon Wolff’s Law. Wang et. Al (2019) reported “According to Wolff’s law, bones in the living body will adapt to mechanical loads under which they are placed. If loads on a particular bone increase, the bone will remodel to become thicker and stronger to resist the loads. The inverse is also true; if loads on a bone decrease, the bone will become thinner and weaker. Then, does the morphology of human bones continue to change under long-term strains after skeletal maturity? The answer is also YES. Based on clinical observations and a series of scientific studies, the dynamic deformation of human bones continues under long-term strains even after skeletal maturity.” P. 2636 The same responses occur in connective tissues according to Davis Law which is a corollary of Wolf's Law.
The above articles represent 20 years of evidence in the literature and is rending answers to past theories. Faye’s theory of the 5 components of the VSC also validates DD and BJ’s theory of bone on the nerve but now allows for an accurate anatomical location of what bone on what nerve(s). Now that we have an evidence-based affirmation, how do we best position our communication, bill with carriers, and argue in the medical-legal-insurance communities from a legally defensible posture? The answer must be devoid of philosophy, prejudice, and dogma from within the chiropractic profession to prevent furthering the chasm based upon the dichotomy of beliefs.
Although it would be most appropriate to use the term Patho-Neuro-Biomechanical Lesion based on contemporary literature, it would create more confusion with a new description of what chiropractic treats and does not solve the medical-legal-insurance-internal philosophical challenges. Although ICD-10 has added vertebral subluxation complex, it is not directed at chiropractic. Gwilliam (2012) reported, “According to General Equivalency Mapping (GEMs), the commonly used ICD-9-CM code of 739.1 (non-allopathic lesions; cervical region cervicothoracic region) may be replaced with M99.01, which is “segmental and somatic dysfunction of the cervical region.” This differs little from ICD-9-CM and still does not use the word “subluxation.” However, nearby we find the code M99.11, which is defined as “subluxation complex (vertebral) of the cervical region.” This sounds just like the verbiage most chiropractors use, but GEMs point to this code back to 839.00, not 739.1 in ICD-9-CM. This is the code for “closed dislocation, cervical vertebra, unspecified,” which implies that the definition is still not geared towards the chiropractic model.”
The answer has been revealed in the ICD-10 code in the M99.8X code set:
Once you establish a biomechanical lesion, you can further define the pathological sequella in your patient with additional diagnostic codes ranging from muscular and neurological to systemic or any other clinically valid findings you conclude on your patient. The M99.8X diagnostic codes best reflect the evidence in the literature giving a causative foundation for the 5 components of the VSC and offering a pathway to position the chiropractic profession as leaders in the diagnosis and treatment of mechanical spine pathology. It is evidence-based and consistent with the medical, legal, and insurance industries.
All our schools need to teach the 5 components of the VSC, and the evidence to support the conclusion as that will help define who we are. All our political organizations need to put aside philosophical differences, take blinders off, and evolve in accordance with the evidence in the literature. However, all academic and political entities should rally around the diagnostic conclusion of biomechanical lesions as that is consistent with the evidence in the literature and the insurance industry. It allows us to mainstream our conclusions and avoid confusion in the healthcare industry. It is the common bond for every DC and allows each practitioner to further define care based upon additional diagnosis, how they choose to practice within their lawful scope.