Academy of Chiropractic
Quickie Podcast 1289
Clinical Information 296 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
Triaging Neuropathies vs Radiculopathies
Dr. Studin: So, what's your clinical setting?
Guest Dr: So, I have a patient and she has severe diabetes with healthy legs, female age about 65. So we were addressing other parts of the spine and shoulder first, but she had slight increase in low back pain, which has already chronic. And we're going to do this properly. She presented with chronic low back.
Dr. Studin: Is it localized or is it radiating?
Guest Dr: There was minor radiation. Okay. And comorbidities the neuropathy in the legs with a history of amputation, um, and all five digits on the left.
Dr. Studin: What type of neuropathy?
Guest Dr: Diabetic. So she has a diabetic neuropathy, which is advanced and patient. I didn't order MRI in the beginning with her because the low back seemed only minorly increased and we were focused on other areas but as time went on, she was experiencing weakness in her legs and some symptoms that she hadn't had before. Um, so I sent her out for an EMG to determine an EMG, easier adjustment EMG NCV to determine if we had some signs that the muscle weakness may have been from the spine and the neurologist, and I'm not fully familiar with how much information we can glean on that when there's advanced diabetic neuropathy, you really can
Dr. Studin: have you taken the EMG course yet?
Guest Dr: I have. Okay. So we, we you're able to put the amplitude of the, of the, um, uh, the snaps, the mode, uh, by my brain is mush right now.
Dr. Studin: You look at the amplitude of the motor sensory tests, and that'll tell you, the number of nerves involved are dying and I'll let you know the chronicity of, of the diabetes, uh, and, and how much it's affecting the nerve. So you really can tell if it's advanced than the, and it's moving down, especially if there had been a previous one. And if she's had that, uh, amputation, et cetera, I guarantee you she's had NCVs before. So with respect to this, was there a deck? Yes or no?
Guest Dr: The, um, neurologist wrote in the report that he believes it is, um, likely that there's a radiating component from the spine. So the answer's yes. Yeah, it was ridiculous.
Dr. Studin: Okay. So your next step is an MRI now.
Guest Dr: Um, she has a chronic Spani and she says she does not want surgery. And that has nothing to do with this conversation. So you need to know what you're treating, right? Well, she's, she's essentially towards the end of care now. Yeah. But she's not gotten better. Right. So you're, you're, you've been treating a woman that's getting progressively worse and not knowing why.
Dr. Studin: Yes. Okay. So you need to tell this woman you're getting progressively worse and I don't know why we've done a conservative course of care. Now it's time for an MRI. What if she has a quarter, uh, Quantis syndrome? What if she has a tumor in there? You're flying blindly right now. So she needs to get an MRI and you need to tell her, I'm not suggesting the MRI will lead towards surgery, but I am telling you is there is something else going on that I still don't know. And I'm not going to leave that to guesswork.
Guest Dr: So that will follow up with neurosurgeon.
Dr. Studin: Okay. So why don't you see, don't use the word neurosurgeon with her up front, because you'll scare the heck out of her and she might get the MRI. How long have you been treating her?
Guest Dr: Um, she stopped in return. So over the whole span, it's been about 10 months.
Dr. Studin: Okay. The protocol for an MRI, just so that you're clear and I'm sure you are, but people are listening. So I'm going to say it for everyone. Say if there's radiating pain, if there's motor weakness, if there's sensory aberration, um, any type of radicular stuff that immediate MRI is indicated in the absence of that. After about six weeks of conservative care, if the pain is persistent, then an MRI is also clinically indicated to help you determine, uh, what the cause of that persistent pain is, because what you're doing is it working it's real. It's really that simple. So you really don't want to deviate that because what can be said, God forbid she has a tumor, is that you delayed necessary care. And you're the reason the tumor, um, metastasized. You are the reason she died. You're the reason, blah, blah, blah. Okay. So I have fought that fight personally, um, back in the 1980s, whenever I wasn't in it, without going into a long, long story. Um, but you don't want to ever have to defend yourself at that level, which is the secondary reason to do this. The primary reason is to ensure the patients properly diagnosed and triaged accordingly. Anything else on this?
Guest: No. Thank you.