Academy of Chiropractic Personal Injury & Primary Spine Care Program

Quickie Consult 212

From the Desk of Dr. Mark Studin
Academy of Chiropractic
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.

“Spondylolysis and the Time for a Surgical Consultation”

The following protocols are not published; they are my personal protocols after caring for patients for 30 years and encountering innumerable spondylolysis cases. You have to triage your patient according to his/her clinical presentation, understanding each patient, although following a pattern of consistent physiology has a unique set of circumstances.

I am not going to discuss what a spondylolysis is as that is inherent within everyone's basic professional training. I am going to remind you of what we have discussed previously about imaging of the lumbar spine. Click here to see a picture that is presented with permission from Medical Legal Arts Press.
It is and always has been my personal protocol that if a patient presents with low back pain either from trauma or non-trauma and you are going to introduce a force into the spine, you must completely image the area you are going to be adjusting/manipulating. A spondylolysis is a separation of the pars and as we have previously discussed, is never congenital and is always a result of a traumatic insult or in older adults, can be degenerative. Many spondylolyses were caused in childhood, only to be dismissed as simple back pain by parents and primary care providers, who admittedly are not well versed in musculoskeletal issues, including paediatricians. However, in a chiropractic practice with the core component of treatment plans including the adjustment/manipulation, it becomes essential to understand all pathology of the spine, which includes, but is not limited to spondylolysis. 
Spondylolysis is a pathology of the pars and basic AP-lateral x-ray views will not allow you to fully visualize and henceforth, accurately diagnose the region. As I lecture nationally to doctors, I have informally asked 1000's of DC's, "What x-ray views do you take of the lumbar spine?" 95% respond, "AP-lateral only." My next question to them in underscoring the issue is, "How do you ensure that there is no spondylolysis in a patient with low back pain with only those 2 views?" The response, as you are well aware, is that you can't and you are exposing the patient to potential negative sequellae without the requisite oblique views. My personal protocol for all patients with any type of lumbar pain is an AP-lateral with 2 oblique views.
I have gotten the argument that the insurance companies might look at that as over utilization. My answer is that your standard of care is not dependent on an insurance company's desire to limit payment at the expense of your patient and the exposure of your license. Your standard of care is to do what is clinically indicated for your patient and seen as a normal standard of care by a licensure board. In order to create an accurate prognosis and treatment plan, you must have an accurate diagnosis. It is impossible to diagnose a spondylolysis with a simple clinical evaluation. You do not have x-ray beams in your fingertips and I don't want to hear the nonsense of you being an excellent healer. 
Should the patient have a spondylolysis, the next step is to take flexion-extension x-rays and if the result is an anteriolisthesis or posteriolesthesis of the segment, even 1 mm, then an immediate surgical consultation with a neurosurgeon is warranted prior to adjusting/manipulating your patient. By now you should have created the relationship with the medical specialist as being part of "your healthcare team" and not you as part of theirs (as we have previously discussed).
By rendering an adjustment/manipulation, you risk the chance of affecting the cauda equina negatively should there be an unstable lysis. It should be your standard of care to ensure an accurate diagnosis prior to creating a prognosis and creating and delivering a treatment plan. Will this be problematic in the majority of your patients? No. In fact, a lysis will be somewhat common and an unstable lysis will be seen very infrequently. Trauma patients obviously have more risk than non-trauma cases. However, my standard is the same with all patients to ensure the safety and appropriate triaging of the patient and I urge you to adopt that same standard of care. The safety of your patients first and then your license secondarily.
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