Academy of Chiropractic
Quickie Consult 1244
Clinical Information 280 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
Managing a one-year case and EMG-NVC
Guest Dr: So I have a patient that was referred to me by her primary care physician about a year post motor vehicle crash. Nothing has worked. Patient had low back pain and radiating leg pain, negative MRIs, and she's had probably about two or three MRIs. So I get her.
Dr Studin: did you get her from the beginning, or you just have her now?
Guest Dr: No, I said I got her about a year after she'd already exhausted. mechanism of injury was, head on collision and she had her right foot jammed and extended onto the brake. locked. So I did a X rays and she's got a compensatory scoliosis. So the fluxion extension views, I really couldn't see if there was angular motion or translation. So I sent them out and had them digitized and it came back that she has alteration of motion segment integrity in angular motion, which is rotation at L2.
Dr Studin: Angular motion is not rotation. Angular deviation is different than then rotation, from a the P it tilts in the X axis. give me a number.
Guest Dr: So in translation at L1, it's 2.47 degrees.
Dr Studin: No, it’s 2.47 millimeters.
Guest Dr: L2, there's angular motion of 11.68 degrees.
Dr Studin: So you missed threshold.
Guest Dr: L2. There's translation of 5.68 millimeters. So there's angular motion and translation. Angular motion at L3 2.44 degrees, at L4 for translations, 3.57 millimeters at L5 She's also a mess. She's got angular motion at 20.88 degrees along with translation at 2.52 millimeters.
Dr Studin: Did you say the last one was L5 S1 or just L5?
Guest Dr: L5 on this one. So she meets the AMA rate-able criteria at L2, but basically she's got sloppy joints throughout her.
Dr Studin: I'm not really interested in rating right now, that's for insure. Let me ask you now about MRIs. What did the MRI show?
Guest Dr: A small tiny disc herniation at L5 S1.
Dr Studin: When you scroll down through the canals, did you see anything?
Guest Dr: Nope.
Dr Studin: Were they stenotic?
Guest Dr: Nope.
Dr Studin: Does she have radiating pain down her legs?
Guest Dr: down the right leg
Dr Studin: Bowel or bladder dysfunction?
Guest Dr: No, no, none of that.
Dr Studin: any tingling, numbness, motor weakness Sensory weakness?
Guest Dr: tons of sensory weakness. And she's got signs of central nervous system, changes like she's got hypersensitivity every time Myself or any of the providers she sees touches her back, especially at L2, her back goes into spasm and she has to sit down and she can't stand up Right She's not faking it. It's happened to consistently.
Dr Studin: does she have a tethered cord where the court extends beyond?
Guest Dr: No
Dr Studin: did you look in the thoracics, is there any model Malaysia going on in the lower thoracics that you picked up in the lumbar?
Guest Dr: No
Dr Studin: you might need to do a brain MRI or cervical MRI cause I agree with you. this seems central in innovation or in causation. And you're going to have to rule out that first. Now a local surgeon, there's nothing for them to do, but…
Guest Dr: She's already been to two neurologists. They've looked at the thoracic spine, they've looked at the brain.
Dr Studin: Did they do a brain MRI?
Guest Dr: That one I don't know about, she doesn't have any complaints. she doesn't have any cognitive complaints whatsoever. And by the way, the symptom of when you touch her back and she falls over, that's been something that's developed gradually and progressively as her pain has been persistence. So that's been a development. So when I say central nervous system, that's not central nervous system injury. That's central nervous system hypersensitivity that's divided up the time.
Dr Studin: it's not a question of a local neurosurgery because I don't believe she's A candidate number one, even with the vertebra in two planes being biomechanically failed, I don't think plates and screws in that area would answer that question. let's go from simple to complex. Were you ever trained in Logan basic technique?
Guest Dr: No
Dr Studin: SOP blocking?
Guest Dr: I think early on I learned how to do that before I was afraid to adjust.
Dr Studin: Why don't you play around with a category one SOP block and just look it up in the books. Place in wedges and if you don't have blocks, just get a pair of blocks. normally I put a patient on initially for 10 minutes, maybe 15, put her on only for five the first time. Then have her come back later the same day and probe the area and see if she has the same result. And if she does, then put the blocks on for 15, then let her hang out for 15, 20 minutes. Probe the area, see if you get any change. I'm trying to see if there's any direct correlation between spinal position. Even reset the pelvis. The lumbar is a let go to see if it makes any changes, if it makes any changes, you know what's related to lumbosacral. If it doesn't make any changes, then it's above. You understand what I'm saying? even if it changes a temporary, but as long as you're making change because it's that change that will show us what's going on And if you get some change down below, she might need to be plated in and screwed. If you don't get changed down below, then what's going to happen is I'm going to have you have a conversation with Dr. Edwards, the nurse surgeon, and in Utah, maybe dr shabby also, but I'm also going to have you work with or maybe Dr. Perkins the a vascular surgeon. I don't think of a neurologist
Guest Dr: I've got a neurologist that I have in our cases and MD-PhD, Harvard trained. He's really good. Yeah.
Dr Studin: he's not a vascular neurologist. Different And I want you to have a vascular neurologist, so we're going to do a lot of first you guys do a little bit of probing. And by the way, if you block her and you've got only a temporary correction that you might have to go to the surgeon to be plated and screwed, maybe, I don't know.
Guest Dr: So for example, looking at her thoracic MRI, she's got one right sided paracentral annular fissure at PA9 and that's it there's never the core. So basically, I wanted a surgeon that understands multilevel instability and just to take a look at this and see where and if, what, if anything needs to be stabilized.
Dr Studin: So listen, we could look at a surgeon to do that, but the issue is that with multiple level instability, Edwards understand spinal biomechanics better than anyone, you're right A local neurosurgeon's, not even dr Shadi doesn't have the depth of understanding, Dr. Edwards has a better on the state of spinal biomechanics. Why don't you take the first step We've got a lot of resources to pull from, but I also want to make sure that you don't have something else that, you could have ms going on in there, you could have the beginning of Parkinson's, I don't think ALS is a consideration, but you've got all of those things going on and we got to figure it out. So it's going to be one step at a time, inch by inch. And just to make sure this lady does not do anything physically, she's not lifting, carrying, bending, no trampoline work, but none of that stuff because anything can really set her off.
Guest Dr: I'm not going to let her go and start kicking footballs for the New York giants.
Dr Studin: also just document this conversation that you communicated with me and then what the plan is. So this way, you know, God forbid she sneezes, they don't blame you for delaying necessary care, but get her in and then call me back as soon as you have that, even if she's in your office. Okay?
Guest Dr: she's had like 10 MRIs. You've seen multiple surgeons, multiple neurologists.
Dr Studin: we're going down to the box right now, let's start there. we'll start with the set blocks. And so that makes it simple, just to rule that out.