Case Report: Establishing the Efficacy for Trauma Trained Chiropractors as Primary Spine Care Physicians
Donald A. Capoferri, D.C., DAAMLP
Abstract: The objective of this case report is to explore the use of chiropractic and chiropractors as a primary spine care specialty and the efficacy of early referral to a properly trained and credentialed chiropractor. Diagnostic studies included physical examination, radiographic examinations, cervical, thoracic, and lumbar spine MRI studies and brain MRI study. Treatments included non-surgical axial decompression and low-level laser treatments. Once a clinical examination and diagnosis was formed, a favorable prognosis was expected. With appropriate chiropractic management, the outcome proved excellent in pain reduction and had minimal effect on the numbness and weakness of the patient’s left upper and lower extremities.
Key Words: Disc herniation, syringomyelia, multiple sclerosis, disc bulge, demyelination.
Introduction: On 8/23/2017, a 49-year-old female presented for examination and treatment of chronic left sided lumbar spine pain that began on 8/1/1983 after a slip and fall incident. The pain was described as sharp, burning, and deep with radiation into the back of the left leg with an 8 out of 10 on the VAS (visual analog scale) scale, worsening since its onset.
Other Presenting Concerns: The patient also presented with sub-acute chest pain with radiation into the left upper arm. She described the pain as 8 out of 10 and has stayed the same since 7/1/2017 and is of unknown origin. The patient also reported numbness and tingling of the left lower extremity since 7/1/2017 of unknown origin. The final reported complaint was numbness and tingling of the left lower arm since 7/1/2017 that seems to start in the left upper back and shoulder and travels to the left lower arm rated at 8/10 on the VAS scale. The reported symptoms have made sleeping and staying asleep, bending over, using a computer, and concentrating very difficult.
Prior Treatments: Medical care including orthopedic specialist, neurology with prescription medications, chiropractic care, and physical therapy.
Past Medical History: The patient’s past history includes use of prescription and over the counter medications. Surgical history includes tonsils and adenoids in 2008, wisdom tooth extraction in 1990, partial hysterectomy in 2002 and C-section in 1998. The family health history includes Alzheimer’s disease, anemia, arthritis, diabetes, heart disease, and high blood pressure.
Clinical Findings: The patient presents as a 49-year-old female of average build, clean and neat and well groomed. The vitals are: Height: 61 inches, Weight: 168 lbs, Pulse: 74 bpm, BP: 168/117 mm/Hg in left arm. The patient’s appearance is visibly uncomfortable and restless.
Physical Findings: Palpation of the paraspinal musculature revealed moderate to severe spasms on the left neck, upper thoracic, and lumbosacral regions. Orthopedic testing produced pain and dizziness with foraminal compression. Upper thoracic pain with Soto Hall’s test and Sternal compression produced pain on the left anterior chest. Percussion test produced pain in the upper thoracic spine.
Neurologic Testing: Diminished right patella reflex and 3/5 weakness of the left deltoid muscle group and left hamstring muscle group with hypersensitivity to light touch along the C6, C8, T1, L3, L4 and L5 dermatomes were the only positive neurologic findings. All other tests are within normal limits. Digital muscle testing was ordered following up on the initial manual findings of muscle weakness. The results were profound left sided deficits in the upper and lower extremities; deltoids 35% weaker than right side, left biceps 68% weaker than right, left triceps 26% weaker than right, wrist extensors 47% weaker than right. The left hamstring group was 25% weaker than right, left quadriceps 40% weaker than right, left anterior tibialis 44% weaker than right.
Radiographic Findings: I personally reviewed cervical spine and thoracic spine x-rays taken on 8/14/17 and found the following: A severe loss of the cervical lordosis, translation of C3 on C4, C4 on C5 in extension. T3 is laterally flexed on T4 with body rotations to the left of T3, T4, and T5. A bifid spinous is noted of C6. Mild posterior osteophyte is noted on C3 and C4. Lumbar x-rays taken on 8/23/2017 revealed pelvic unleveling with right inferiority, anteriority of L5 on S1, an inferior Schmoral’s node on L5 and mild demineralization, disc degeneration and joint degeneration of the lumbar spine. Moderate to severe foraminal encroachment of L4/L5, L5/S1 is noted.
MRI findings by radiologist:
Cervical spine: MRI taken at 2.5 mm slice thickness, with gradient echo and STIR studies revealed C4-C5 right paracentral herniated disc measuring 2 x 3 mm not indenting the cord. A small syrinx of the cord is noted at level of C6-C7 interspace and extending above and below for a total of 15mm in length and 2mm in width. (Fig. 1A) (3)
Thoracic Spine: MRI taken at 3.0 mm slice thickness, angled to the disc with STIR and T2 axial views revealed a T4-T5 central protrusion measuring 2 x 4 mm in size in the midline.
Lumbar Spine: MRI taken at 3.0 mm slice thickness, angled to the disc with STIR and T2 Axial views. L5/S1 demonstrates a central disc herniation with annular tear measuring 3x 6 mm indenting the epidural space and very mildly touching the thecal sac.
I personally reviewed the MRI studies and my impression is as follows:
Cervical spine also demonstrated a C3-C4 disc bulge compressing the thecal sac and deforming the normal shape of the cord by altered CSF pressure. (Fig. 1B) (1). C5-C6 demonstrates a central protrusion with annular tear compressing the ventral cord in the midline by altered CSF pressure.
In addition to the radiologist findings, the thoracic study demonstrated significant facet arthritis at the level of T10 that indents the thecal sac and compresses the left posterolateral aspect of the cord. (Fig. 2.) In addition to the radiologist’s findings, I reviewed the lumbar spine and reported an L4-L5 left asymmetric bulge with compression of the left aspect of the thecal sac. (1)
MRI Discussion: After review of the clinical examination findings, the patient’s subjective complaints and the X-ray and MRI imaging studies, the findings were reported to the patient. I subsequently ordered a brain MRI since I did find an adequate explanation of the left sided sensation and motor deficits. The brain MRI demonstrates a right frontal/parietal subcortical white matter demyelinating lesion in T2/FLAIR images. (Fig 3).
Fig. 1A: Shows a demyelination of the central cord assessed as a syrinx by radiologist
Fig. 1B: C3-C4 disc bulge, thecal sac compression, deforming the cord shape and apparent CSF in the central canal of the cord.
Fig. 2: T10 left facet arthritis indenting the thecal sac and compressing the left posterolateral cord.
Fig. 3: T2/FLAIR shows left frontal / parietal area of demyelination
Diagnostic Impression: When arriving at a diagnosis all objective findings along with subjective complaints should be considered. When I considered the profound left sided sensory and motor deficits, the clinical findings and the imaging findings I referred the patient to a neurologist for evaluation of late onset multiple sclerosis. (3) The patient consulted the lead Neurologist in the M.S. Department at Shepard Center in Atlanta who confirmed the diagnosis.
Therapeutic Focus and Assessment: At the report of findings it was explained to the patient that she did have spinal findings that were treatable and that did contribute to her pain. It was further explained that the care provided is not expected to affect the symptoms that are caused by the M.S. condition. An 8-week course of non-surgical axial decompression was completed, aimed at reduction of the C3-C4, C4-C5, C5-6, L4-L5 and L5-S1 disc displacements. At discharge, the patient reported a 90% reduction of spine pain and improvements of the left sided upper and lower extremity weaknesses. She was discharged into the care of her neurologist at that time.
Discussion: Properly trained chiropractors are the perfect fit to be the primary spine care provider. Our education includes extensive training in identifying biomechanical and anatomical lesions of the spine in order to arrive at an accurate diagnosis, prognosis and treatment plan. This includes proper triage to other healthcare providers.
In this case the patient presented with a biomechanical issue, disc herniation and degeneration, with facet arthritis, but also with a significant non-spinal pathology that was identified properly and referred appropriately.
Numerous other physicians and chiropractors evaluated this patient, all of whom treated the obvious without finding the underlying cause of her numbness and weakness, which may have delayed necessary care. A Doctor of Chiropractic, who is well trained and credentialed as a Primary Spine Care physician knows to look beyond the obvious, taking all findings and patient subjective complaints into consideration in order to obtain a proper diagnosis, prognosis, and appropriate plan of treatment for each patient.
1. Fardon DF, Williams AL, Dohring EJ, Murtagh FR, Gabriel Rothman SL, Sze GK. Nomenclature 2.0 for Disc Pathology, Spine J. 2014 Nov 1;14 (11):2525-45.doi: 10.1016/j.spinee.2014.04.022. Epub 2014 Apr 24.
2. Schippling S. Neurodegener Dis Manag. MRI for multiple sclerosis diagnosis and prognosis. 2017 Nov;7(6s):27-29. doi: 10.2217/nmt-2017-0038
3. Pillich D, El Refaee E, Mueller JU, Safwat A, Schroeder HWS, Baldauf J. Syringomyelia associated with cervical spondylotic myelopathy causing canal stenosis. A rare association.
Neurol Neurochir Pol. 2017 Nov - Dec; 51(6): 471-475. doi: 10.1016/j.pjnns.2017.08.002.Epub 2017 Aug 14.
Chiropractic Verified as
Primary Spine Care Providers
By Mark Studin
William J. Owens
A report on the scientific literature
Primary Spine care simply means being the first referral option for spine care in instances other than fracture, tumor or infection. Having a chiropractic degree is paramount and the first step in the process, but one must not forget that any doctoral training, no matter the specialty (i.e. medicine, dentistry, podiatry, etc.) is the start of a provider’s educational journey and what we do with that training is up to the doctor in clinical practice. Erwin, Korpela and Jones (2013) stated “The function of the PSCP (Primary Spine Care Provider) could easily be assumed by chiropractic, but this window of opportunity may be limited. If chiropractic does not seek to evolve, what role does chiropractic have left to perform.” (Pg. 289)
Although these authors agree that chiropractors in clinical practice can assume the role as PSCP’s in the healthcare system, we strongly disagree with the direction suggested by Erwin, Korpela and Jones. The solution is not to prescribe more drugs in an “already over-drugged society,” the solution is being able to manage the patient in a collaborative environment on a peer level being “expert” on common healthcare issues. The underlying tenant is that there is no drug for a mechanical problem, it is with that initial focus that allows chiropractic to assume a role that no other profession can accomplish. True PSCP management includes being able to accurately diagnose/triage patients and the ability to use and understand MRI is a prime example. Herzog, Elgart, Flanders and Moley (2017) reported a 43.6% error rate of general radiologists inaccurately reporting the morphology of the intervertebral disc. This underscores that when a doctor of chiropractic relies on the MRI report without understanding how to interpret the image and clinically correlate the findings to the patient’s symptoms, there is close to a 50% error rate in rendering an accurate diagnosis, prognosis and treatment plan. A PSCP must have a complete and independent diagnostic scope of practice in order to fill a useful and clinically significant role.
To use an example in a current and modern setting, a doctor of chiropractic in Cedar Park, Texas was granted a “brief 10-minutes” to meet with an orthopedic surgeon. During that short meeting the chiropractor, an 8-year graduate spoke solely and specifically of his MRI slice thickness protocols and his MRI interpretation training which is cross-credentialed in both chiropractic and medical academia. One hour later [the meeting continued well past the initial “10-minutes” suggested], the orthopedic surgeon said, “I respect chiropractic, but have very little respect for the level of training of chiropractors in our region.” This 8-year graduate walked out with 8 referrals instantly and now 1 year later, has been getting referrals weekly. That is very definition of Primary Spine Care, the orthopedic surgeon trusts the chiropractor’s ability to manage and diagnose patients and now is “off-loading” the non-surgical patients to someone that can effectively manage that case. It is because of this specific advanced training that the chiropractor is successful.
In a second recent example, in Utah, a chiropractor decided that his post-doctoral training should be focused on spinal trauma care and triage, including more specifically, MRI Spine Interpretation, Spinal Trauma Pathology, Spinal Biomechanical Engineering and Stroke Evaluation. As a result, a hospital system that has over 900 auto accident cases monthly in 5 local hospitals reached out to him to manage their spine cases (all of them). This was based purely on his curriculum vitae and the inherent credentials and knowledge base from his continued education training in the above courses. Since then, Brigham Young University’s Athletic Department and the PGA (Professional Golf Association) have both sought his services. Please don’t overlook the fact THEY ran after him to be their first option for spine; that is Primary Spine Care and credentials matter.
Thirdly, in Buffalo NY, 5 teaching hospitals refer exclusively to one chiropractor’s office and their emergency rooms refers close to 60 spine patients per month to him with that number growing steadily. This past week, the neurosurgical department just informed this doctor that their 23 neurosurgeons will be referring their non-surgical cases to this office and will be directing many of their referral sources to START with this doctor to screen for surgery and let him decide who to refer for surgical consultation. That is Primary Spine Care.
Although individual reporting does not make a trend in the profession, these are not isolated cases, and this is NOW THE TREND in chiropractic we are seeing nationally, there are similar stories in most states. None of the successes involve adding drugs as a tool of the chiropractic, however in every case becoming smarter in spine care was mandatory. In all cases it is a properly trained doctor of chiropractic that is leading Primary Spine Care alongside medical specialty and primary care in a collaborative environment as peers, when clinically indicated.
Most of the Primary Spine Care “equation” is verifying chiropractic care as the “best choice” for the “first referral”. That is being achieved though peer-reviewed outcome based studies and involves all phases of care starting with initial pain management to corrective spine care and finally when required, health maintenance care for cases that need non-opioid and non-surgical long-term management. Historically and all too frequently in current medicine, either medical management or physical therapy is considered for mechanical spine issues as the first treatment of choice. Cleveland Clinic, one of the better-known centers of medical excellence currently posted the following regarding the treatment of back pain; “These patients may be best served through prompt access to care from physical therapists or nurse practitioners as entry-level providers. When pain persists beyond four to six weeks, the care path defines when referral to spine or pain specialists, spine surgeons or behavioral health providers is indicated.” (https://consultqd.clevelandclinic. org/2014/11/sticking-with-proven-practices-for-low-back-pain/) The Mayo Clinic Staff (2017) also reported: “Physical therapy is the cornerstone of back pain treatment.”
When considering the best option for Primary Spine Care, we should consider “what” type of provider renders the best outcomes in population based studies and has the autonomy to manage the case independent of primary care and medical specialty. Based upon population based studies, both the Cleveland and Mayo clinics got it wrong as their opinions are not based upon contemporary literature and appear to be rooted in “age-old biases.” Their suggested care paths are similar to prior care paths that perhaps have led to the long-term mismanagement of mechanical spine pain that has in part, contributed to the opioid crisis.
Blanchette, Rivard, Dionne, Hogg-Johnson and Steenstra (2017) in a population based study of 5511 injured workers in Ontario Canada as reported by the Workplace Safety and Insurance Board, a governmental agency reported a comparison of outcomes for back pain among patients seen by three types of providers: medical physicians, chiropractors and physical therapists. The found “The type of first healthcare provider was a significant predictor of the duration of the first episode of compensation only during the first 5 months of compensation. When compared with medical doctors, chiropractors were associated with shorter durations of compensation and physiotherapists with longer ones. Physiotherapists were also associated with higher odds of a second episode of financial compensation.” (pg.392) and “These differences raise concerns regarding the use of physiotherapists as gatekeepers for the worker’s compensation system.” (pg. 382)
Blanchette, Rivard, Dionne, Hogg-Johnson and Steenstra (2017) continued, “The cohort study of American workers with back pain conducted by Turner et al. found that the first healthcare provider was one of the main predictors of work disability after a year. In accordance with our findings, workers who first sought chiropractic care were less likely to be work-disabled after 1 year compared with workers who first sought other types of medical care… We did not retrieve any study that directly compared physiotherapy care with other types of first healthcare providers in the context of occupational back pain, probably because most workers’ compensation systems still require a referral for physiotherapy. However, a study comparing primary physiotherapy care with usual emergency department care concluded that physiotherapy care leads to a prolonged time before patients return to their usual activities.” (pg. 389)
Cifuentes, Willets and Wasiak (2011) stated that chiropractic care during the health maintenance care period resulted in:
The study concluded that chiropractic care during the disability episode resulted in:
24% Decrease in disability duration of first episode compared to physical therapy
250% Decrease in disability duration of first episode compared to medical physician's care
5.9% Decrease in opioid (narcotic) use during maintenance care with physical therapy care
30.3% Decrease in opioid (narcotic) use during maintenance care with medical physician's care
32% Decrease in average weekly cost of medical expenses during disability episode compared to physical therapy care
21% Decrease in average weekly cost of medical expenses during disability episode compared to medical physician's care
Cifuentes et al. (2011) started by stating, “Given that chiropractors are proponents of health maintenance care...patients with work-related LBP [low back pain] who are treated by chiropractors would have a lower risk of recurrent disability because that specific approach would be used” (p. 396). The authors concluded by stating,“After controlling for demographic factors and multiple severity indicators, patients suffering nonspecific work-related LBP (low back pain) who received health services mostly or only from a chiropractor had a lower risk of recurrent disability than the risk of any other provider type” (pg. 404).
The above studies continue to verify chiropractic as a better “first option” for spine and that resolves the “what provider is best” question by using an Evidence Based approach. The “who is best” within that subset is what type of chiropractor is better suited to lead in Primary Spine Care is evident. As an example, although every medical doctor is licensed to do open heart surgery not all are trained and credentialed. Would you want a psychiatrist performing the procedure? The answer should be “they are licensed, but not qualified through training.” The same holds true for contemporary chiropractic and every chiropractor has the same opportunity. We are all held to a “continuing education standard” and are all required to seek post-doctoral training to maintain our licenses. There are a significant number of courses, both live and through enduring materials (online) to enable every chiropractor on the planet to attain the level of education mandated by the “referral sources” to be considered Primary Spine Care Providers.
Let’s not be Pollyannaish not to think that chiropractic can be successful in increasing utilization independent of the medical community and even the legal community for personal injury cases. As mentioned previously, the medical community DOES NOT CARE about your treatment approach, what they do care about is the “risk” of you missing a diagnosis. They need to trust you based on your training, and the do NOT care about what technique you use. What you do in your offices is up to you just like a pain management MD or a surgeon, remember, it’s how you triage and manage your patients that is the ultimate arbiter in having them consider you as the first option for spine care. Once you have responsibly secured the referral, based upon your clinical excellence, you get to independently decide the best course of care for your patient. Then it is business as usual during the treatment phase of care because results were never, and are not an issue in chiropractic.