Academy of Chiropractic Personal Injury & Primary Spine Care Program
Quickie Consult 1146
Clinical Information 272 CI
Preamble: Many of the issues I bring to you are very small, yet each issue is just that, an issue. If you take care of the small issues, then you will be able to build and more importantly, focus on the bigger issues...a larger practice and more family time. -Mark Studin 2006
"Diagnosing Radiculopathy and Hypoesthesia"
Dr Studin: what's going on? Start from the beginning so that people who are listening to this understand the set up. So you have a patient who's in a car accident
Guest Doctor: I had a patient that was in a rear end, a car collision, she had significant, injuries to her neck and lower back.
Dr Studin: How old was she?
Guest Doctor: 32 years old.
Dr Studin: 32-year-old female in a rear end collision, Was the car stopped or moving?
Guest Doctor: No, she was stopped at a red light. And my question to you is that, after reviewing the studies and formulating a diagnosis, I have a problem with putting in a cervical and Lumbar radicular apathy.
Dr Studin: This should have nothing to do with the MRI results. So we're thinking of Lacasse as a clinical finding. So what did you find in your clinical examination prior to the MRI?
Guest Doctor: Prior to the MRI she had a radiculopathy symptom, going the left upper and lower extremity, through the multiple progress exams, this continued to be a significant factor. Her original, upper right extremity and lower extremity exhibited weakness and hypoesthesia at several dermatome levels. My question to you is when I'm formulating the diagnosis in trying to associate her injuries with her functional lost.
Dr Studin: when you say injuries of functional loss, function meaning ADL or the meaning a motor or sensory?
Guest Doctor: I'm talking about physical motor dysfunction. Weakness. Actually, functional deficits of our normal daily functional activities. My question is, do I put in my diagnosed clinical cervical radicular opposite the right cervical radicular apathy, clinical.
Dr Studin: the word clinical comes out, Diagnosis is radiculopathy, and the ICD 10, there's no word clinical in there. The clinical is where you'd determine those things are occurring. So, when you find motor or sensory loss, that's just, it's a hypoesthesia, weakness, all that stuff. That's a diagnostic entity. So the question is, do you put all of that in your diagnoses?
Guest Doctor: That's my question to you.
Dr Studin: it's not a straightforward answer, the short answer is yes, but there's more to it than that. So originally you diagnosed A radiculopathy empathy, you really can't do an EMG anymore. You've taken that off the table, if the purpose of doing an EMG and CV really is to determine a radiculopathy opposite. And if you've already diagnosed, why are you going to do a test after for something you've already diagnosed.
Guest Doctor: well an EMG and NCV are objective studies that firmly a detailed a diagnosis of a apathy.
Dr Studin: That's a counter argument, but I have to tell you in audit or in defense, in court, it's a poor argument because in your clinical evaluation, you've already diagnosed that because you know what muscle is weak. You already know what dermatome is lost. So you already have those, there's no more diagnostic dilemma. If you're doing it to confirm what you've already diagnosed, you're already diagnosed it. What do you need to confirm it? That's an argument. So therefore I would strongly suggest you change your initial diagnosis from radiculopathy Kathy to injury to nerve root cause the exact same thing. However, you still leave the door open to do the EMGs. You need to conclude or radiculopathy apathy or a D myelinating neuropathy to determine if there's a systemic issue there, to make you bulletproof, I would start with injured and nerve root. Now hypoesthesia I would always diagnose from the beginning, motor weakness, I would always diagnose what is there and remember there's no such thing as a working diagnosis. I want to rule out a herniated disc. So I have a working diagnosis of a herniated disc that was done, when we were growing up, that was considered appropriate, but that has been years ago. I'm talking back in the seventh, late seventies and 1980s, but that was taken off the table. You only diagnose what is. So therefore, every eval and re-eval, it really should be updating your diagnosis. And perhaps you could even choose to update your diagnosis in yourself most in between the evals and the re-evals that gives you an opportunity to, to really stay current with what's going on, but then there's another issue, you have the MRI now in the beginning if I had a from a triage perspective, if I have radicular symptomatology and the cervical and lumbar distribution with motor ends or sensory weakness and the media the MRI should be done prior to even touching the patient. Cause you don't know what's going on there. I wouldn't adjust them, I wouldn't touch them. I would just palliative work, heat, ice therapy may be blocking them. All these palliative things.
Guest Doctor: Nobody does SLT anymore. I do.
Dr Studin: They tell you SLT was my right. Any acute lower back problem. There is not a better technique in the world than SLT simple. It works every single time. But I don't want to give it to treatment. That's a whole different conversation. But I would treat them palliatively. I get the MRI immediately, even in New Jersey where there's a legal obstacle to get MRIs pulled care path, which is roadblock that the carriers put up there. There's not a chiropractor that I've trained in the state of New Jersey that cannot get past that nonsensical roadblocks and get the MRI proves immediately. You do the immediate MRI, you keep your diagnosis of what I would do of injured in their route Hypoesthesia, the litany of diagnosis, it's not inappropriate to have 10, 15, 20 diagnoses because your diagnoses tell the story and that should be altered as your care continues. So as your diagnoses changed, the story changes, you get to control the narrative of what's going on with the patient as they're progressing from the acute to the subacute to the chronic stage, and show up as a residual through your diagnoses, and I like to call it the diagnoses symphony because it's that symphony of various different players that you get to tell an entire story.
Guest Doctor: In my initial report, I always put probable cervical radiculopathy apathy in my initial report.
Dr Studin: No, you can only report what is, now in your discussion you can say that I am ordering an MRI because, I need to determine if there is or is not a herniated disc. Even though I've diagnosed injury to nerve root, I suspect a radiculopathy, and this is in discussion, not in diagnosis and discussion, I suspect that there's a radiculopathy empathy, based upon a space occupying lesion such as herniated disk. Therefore, I'm going to be ordering an MRI and EMG and CV to determine if it's a radiculopathy apathy or d myelinating neuropathy and what's going on, So discussions and reports give you the latitude to say what you want to say, but you only diagnosed what you've concluded. And that's really important. You don't diagnose what you think might be there or what you want to rule out, as far as report writing goes and narrative writing goes, I don't know if you use doctor Schoenfeld.
Guest Doctor: I do use him. I've sent one term I want to send actually Laura Miller's one to him because it's really extensive.
Dr Studin: don't use names. He's just wonderful, he charges $150 bucks to do it, look at it this way. How much time does it take you to write a narrative? your time is usually about three hours per person. Sometimes four, from beginning to end, that's like paying $35 an hour to do it. You make more than $35 an hour. I'd rather see you in production rather than sit in front of the computer typing out.