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.
Chiropractic as the Solution for Mechanical Spine Failure and Failed Back Surgery.
By: William J. Owens DC, DAAMLP
Mark Studin DC, FASBE(C), DAAPM, DAAMLP
A report on the scientific literature.
The latest CDC statistics show that in 2012, 54 out of 100 people had self-reported musculoskeletal conditions. By way of comparison, that is six times more than self-reported cases of cancer, double that of respiratory disease and one-third more than circulatory disorders. If we extrapolate that to a more current population in the United States of 321 million, that equates to 173 million people reporting musculoskeletal problems in 2012. Many of these are spine patients who suffer long-term without any type of biomechanical assessment or functional case management.
In 2013, Itz, Geurts, van Kleef, and Nelemans reported, “Non-specific low back pain [LBP] is a relatively common and recurrent condition with major medical and economic implications for which today there is no effective cure” (p. 5). The idea that spinal pain has a “natural history” resulting in a true resolution of symptoms is a myth and the concept that spine pain should only be treated in the acute phase for a few visits has no support in the literature. We don’t address cardiovascular disease in this manner, i.e. wait until you have a heart attack to treat, we don’t follow this procedure with dentistry, i.e. wait until you need a root canal to treat, and we certainly don’t handle metabolic disorders such as diabetes in this way, i.e. wait until you have diabetic ulcers or advanced vascular disease to treat. Why does healthcare fall short with spinal conditions in spite of the compelling literature that states the opposite in treatment outcomes?
The front lines of medical care for spine-related pain is typically the prescription of pain medication, particularly at the emergency care level, and then if that doesn’t work, a referral is made to physical therapy. If physical therapy is unsuccessful, the final referral is to a surgeon. If the surgeon does not intervene with surgery, then the diagnosis becomes “non-specific back pain” and the patient is given stronger medication since there is nothing the surgeon can do. In those surgical interventions that result in persistent pain, a commonly reported problem, there is an ICD-10 diagnosis for failed spine surgery, M96.1
A recent article Ordia and Vaisman (2011) described this syndrome a bit further stating the following, “We propose that these terms [post laminectomy syndrome or failed back syndrome] should be replaced with Post-surgical Spine Syndrome (PSSS)” (p. 132). They continued by reporting, “The incidence of PSSS may be reduced by a meticulous neurological examination and careful patient selection. The facet and sacroiliac joints should always be examined, particularly when the pain is predominantly in the lower back, or when it radiates only to the thigh or groin and not below the knee” (Orida & Vaisman, 2011, p. 132). The authors finally stated, “Adherence to these simple guidelines can result in a significant reduction in the pain and suffering, as also the enormous financial cost of PSSS” (Orida & Vaisman, 2011, p. 132). What they are referring to is a careful distinction between an “anatomical” versus a “biomechanical” cause of the spine pain.
According to Mulholland (2008), “[Surgery] Spinal fusion became what has been termed the “gold standard” for the treatment of mechanical low back pain, yet there was no scientific basis for this” (p. 619). He continued, “However whilst that fusion [surgery] may be very effective in stopping movement, it was deficient in relation to load transfer” (Mulholland, 2008, p. 623). He concluded, “The concept of instability as a cause of back pain is a myth. The clinical results of any procedure that allows abnormal disc loading to continue are unpredictable” (Mulholland, 2008, p. 624). Simply put, surgery does not correct the underlying biomechanical failure or the cause of the pain.
When a biomechanical assessment is lacking, the patient’s pain persists and allopathic medicine is focused on “managing the pain” vs. correcting the underlying biomechanical lesion/pathology/imbalance, the medication of choice at this point in care has been opioid analgesics. Back in 2011, the CDC reported, “Sales of OPR quadrupled between 1999 and 2010. Enough OPR were prescribed last year  to medicate every American adult with a standard pain treatment dose of 5 mg of hydrocodone (Vicodin and others) taken every 4 hours for a month” (p. 1489). That was 6 years ago, which was when people began to feel that treating musculoskeletal pain with narcotics was trending in the wrong direction. Now, in 2016, we can see there is a problem of epidemic proportions to the point that MDs are changing how they refer spine patients for diagnosis and treatment.
Dowell, Haegerich, and Chou (2016), along with the CDC, published updated guidelines relating to the prescription of opioid medication:
Opioid pain medication use presents serious risks, including overdose and opioid use disorder. From 1999 to 2014, more than 165,000 persons died from overdose related to opioid pain medication in the United States. In the past decade, while the death rates for the top leading causes of death such as heart disease and cancer have decreased substantially, the death rate associated with opioid pain medication has increased markedly.
…a recent study of patients aged 15–64 years receiving opioids for chronic noncancer pain and followed for up to 13 years revealed that one in 550 patients died from opioid-related overdose at a median of 2.6 years from their first opioid prescription, and one in 32 patients who escalated to opioid dosages >200 morphine milligram equivalents (MME) died from opioid-related overdose. (p. 2)
Clearly, there needs to be a nationwide standard for the process by which patients with spine pain are handled, including academic and clinical leadership on spinal biomechanics. The only profession that is poised to accomplish such a task is chiropractic.
In a recent study by Houweling et al. (2015), the authors reported, “The purpose of this study was to identify differences in outcomes, patient satisfaction, and related health care costs in spinal, hip, and shoulder pain patients who initiated care with medical doctors (MDs) vs those who initiated care with doctors of chiropractic (DCs) in Switzerland” (p. 477). This is an important study which continually demonstrates maintaining access to chiropractic care, for both acute and chronic pain is critical. We can also see from current utilization statistics that chiropractic care is underutilized on a major scale. The authors also state, “Although patients may be comanaged with other medical colleagues or paramedical providers (eg, physiotherapists), treatment for the same complaint may vary according to the type of first-contact provider. For instance, MDs tend to use medication, including analgesics, muscle relaxants, and anti-inflammatory agents, for the treatment of acute nonspecific spinal pain, whereas DCs favor spinal manipulative therapy as the primary treatment for this condition” (Houweling et al., 2015, p. 478). The continue by stating “This study showed that spinal, hip, and shoulder pain patients had modestly higher pain relief and satisfaction with care at lower overall cost if they initiated care with DCs, when compared with those who initiated care with MDs” (Houweling et al., 2015, p. 480). Overall, when taking cost into consideration, “Mean total spinal, hip, and shoulder pain-related health care costs per patient during the 4-month study period were approximately 40% lower in patients initially consulting DCs compared with those initially consulting MDs” (Houweling et al., 2015, p. 481). The authors concluded, “The findings of this study support first-contact care provided by DCs as an alternative to first-contact care provided by MDs for a select number of musculoskeletal conditions” (Houweling et al., 2015, p. 481).
Bases on the literature and outcome studies, backed up with 121 years of doctors of chiropractic and their patients’ testimonies, the time has never been better for the chiropractic profession to move into treating the 93% of the population that is not under care. Chiropractic must be moved from the accepted standard of biomechanical processes in the laboratory to the standard of care for spine beyond fracture, tumor or infection across all professions, inclusive of physical therapy. The outcomes overwhelmingly support that anything less perpetuates the epidemic of failed back treatments.
1. Centers for Disease Control and Prevention. (2015). National hospital discharge survey. Retrieved from: http://www.cdc.gov/nchs/nhds.htm
2. United States Census Bureau. (n.d.). Quick facts, United States. Retrieved from https://www.census.gov/quickfacts/
3. Itz, C. J., Geurts, J. W., van Kleef, M., & Nelemans, P. (2013). Clinical course of non‐specific low back pain: A systematic review of prospective cohort studies set in primary care. European Journal of Pain, 17(1), 5-15.
4. Ordia, J., & Julien Vaisman. (2011). Post-surgical spine syndrome. Surgical Neurology International, 2, 132.
5. Mulholland, R. C. (2008). The myth of lumbar instability: The importance of abnormal loading as a cause of low back pain. European Spine Journal, 17(5), 619-625.
6. Centers for Disease Control and Prevention. (2011). Vital signs: Overdoses of prescription opioid pain relievers - United States, 1999--2008. Morbidity and Mortality Weekly Report, 60(43), 1487-1492.
7. Dowell, D., Haegerich, T. M., & Chou, R. (2016). CDC guideline for prescribing opioids for chronic pain - United States, 2016. JAMA, 315(15), 1624-1645.
8. Houweling, T. A., Braga, A. V., Hausheer, T., Vogelsang, M., Peterson, C., & Humphreys, B. K. (2015). First-contact care with a medical vs chiropractic provider after consultation with a swiss telemedicine provider: Comparison of outcomes, patient satisfaction, and health care costs in spinal, hip, and shoulder pain patients. Journal of Manipulative and Physiological Therapeutics, 38(7), 477-483.