Academy of Chiropractic Personal Injury & Primary Spine Care Program
Quickie Consult 131
“MRI Clinical Protocols & Case Study”
Disclaimer: These are my personal protocols and are intended to give you an insight into my thought process in treating patients. You must make your own clinical decisions based upon the clinical presentation of your individual patients.
Please note that although this was a real patient, I altered certain facts for educational purposes
I received a phone call yesterday inquiring about a patient who was treated for a car accident for 12 weeks and released from care. During that time, the patient had pain in her low back that radiated into her buttocks, with minor weakness into the lower extremities. All upper extremity findings were within normal limits and she had positive findings as follows:
DTR’s: Patella +1 left, Achilles +1 left
Hamstrings and quadriceps 4/5 left
Sensory diminished over the area above the knee anterior on both sides
Positive left Lasegue’s at 600
Positive Fabere Patrick bilaterally
Muscle spasticity bilaterally in the lumbar paraspinals, psoas and quadratus lumborum.
AP and lateral x-rays revealed diminished lumbar curve in the lateral view and foraminal compression at L4-5 and L5-S1. There were no other significant findings.
Treatment Plan: Chiropractic adjustments 3 times per week for 6 weeks followed by 2 times per week for 6 weeks.
At the end of 12 weeks of spinal diversified adjusting, the patient was doing much better and released from care. 3 weeks post care, the patient returned with significant pain radiating from her low back up her spine into the lower thoracic area. The lawyer is now pressuring the doctor for a narrative, as he wants to move the case and get paid, yet the patient is in pain and needs more care. The questions are twofold. What do you do with the patient and what to you do about the lawyer wanting a narrative?
There are many flaws in this case starting with the treatment plan. First, only AP & lateral x-rays were taken. Why weren’t oblique’s taken? The patient could have had a spondylolysis as a result of the accident and the DC adjusting could have created a catastrophic outcome for the patient. You cannot see the pars with only AP and lateral x-rays.
Second, there were significant clinical findings correlating to the symptoms necessitating an MRI of the lumbar spine. This doctor treated blindly “hoping” for a good outcome without knowing what was going on with the discs, the cauda equina or the integrity of the surrounding structures; more “guessing.”
The lumbar MRI should have the following protocols: 3mm, no gap with T2 STIR views, stacking views and a reading by a neuroradiologist. If you don’t understand this language, you MUST take the MRI Spine Interpretation Course. This one sentence, if explained to a lawyer, will open the doors to a steady stream of new patients. More importantly, it will ensure an accurate diagnosis. All MRI’s are not alike.
These 2 items are examples of what separates those who are truly expert from the rest. However, since an MRI was not done initially, an immediate lumbar MRI is now clinically indicated prior to rendering any further care. I would also consider an EMG/NCV based on the weakness and sensory changes that accompany the pain to pinpoint the level of radiculopathy and rule out any neuropathy. I would not touch the patient beyond palliative care until I had all of the findings and as a result, would expedite the testing for the patient. As a rule, I would have all of my test results within 24-48 hours. Either my staff or I would personally set up all of the appointments to ensure the timeliness of the testing. In addition, that level of attention is not lost on either the patient or the lawyer, who will usually get a detailed report from the patient.
Once I had received all of the results, I would then create a treatment plan and give the patient a written report of findings. Although this is a returning patient, she would get her results IN WRITING to bring home and review. Statistics clearly show this increases the compliance of patients and makes it easier for my staff to keep them on schedule.
Assuming the results showed any problem on the MRI other than disc material abutting or compressing the cord, I would commence aggressively adjusting my patient. I personally would see this patient daily for 2 weeks, followed by a re-evaluation, then drop her to 4 times a week for 2 weeks, and then 3 times a week for the 4 week period following that. It is my experience that an acute patient cannot go 3 times a week, as there is too much time in between the visits and I need to do much less each visit, but see him/her more frequently as a result. My results improved dramatically once I instituted that treatment protocol for the acute patient.
First, go back and read Consultation #14, Chronology of Symptomatology. That has been the most recommended consultation to re-read…Know it well.
Inform the lawyer that there is an underlying problem that has not yet been diagnosed and you have ordered an MRI and an EMG/NCV. Based upon those results, you will be treating the patient for another few weeks. Let the lawyer know that after the end of care, you want the patient to re-integrate back into his/her everyday repetitive routine and will render a final evaluation a few weeks after care has ended and deliver a report to the lawyer. At this time, also inform the lawyer that you have or will have by the next day, the MRI report and would like to sit with him/her to go over the results of the whole case. It is at this time you bring your educational binder, as you now have leverage over that lawyer to get him/her to meet with you quickly.
If the lawyer asks why an MRI wasn’t done initially, my answer would be, “It should have been.” I always believe in articulating the obvious and the truth, as the lawyer will be saying that to himself/herself the entire time. He/she will respect you more for admitting what he/she already knows.