Subluxation vs. Disc Herniation
Special Feature
Written by Mark Studin, D.C., F.A.S.B.E.(C), D.A.A.P.M., D.A.A.P.L.M.   
Tuesday, 23 October 2012 19:32 Read : 1834 times

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hiropractic utilization in the United States remained static at 12.1 million from 2003 until 2006 as reported by Davis, Brenda and Williams in 2010. This represents 4.12% of the population, considering the 2003 population reported by the Encyclopedia of the Nations. Davis et al. also reported that in the early 1990s chiropractic utilization was 7.7% of the United States’ adults, realizing a net loss of utilization of 3.58% in just a decade. The reasons are many and in spite of the growing interest in the utilization of complementary and alternative medicine (CAM) nationwide, with chiropractic as the largest CAM provider, the numbers are still dwindling. The chiropractic profession must take an honest look at the numbers and realize that it can no longer be "business as usual" or risk that the utilization will continue dwindling until we no longer make the positive impact on society that we currently do. 
 
subluxationvsdischerniationFiore in 2012 reported that accurate diagnosing was critical to the success of the chiropractic profession in order to be credible in the health care community. He also reported that many chiropractors hide behind the definition of chiropractic as the "...art, science and philosophy of locating and correcting nerve interference..." and continued on to say "This allows the chiropractic profession to have great latitude...but does not excuse us from making an incorrect diagnosis." In order for us to understand a spinal related problem or any pain, we must not create a correct hypothesis, we must conclude an accurate diagnosis before we construct a prognosis and treatment plan. According to Frank Zolli, DC, the Dean of the University of Bridgeport College of Chiropractic for over 20 years, "every chiropractic student during their doctoral training learns at the most basic level of training that you must have an accurate diagnosis and then create a prognosis before you treat your patient." Dr. Zolli continued by saying that this is taught in every CCE accredited chiropractic college.
 
With the advent of new and not so new technology, we no longer have to hypothesize or theorize. It's called the MRI and every licensed doctor of chiropractic in the United States has within their scope the ability to refer a patient for an MRI (with the exception of Medicare, as the Federal Government, through their actions and regulations, has much less regard for the well-being of our seniors). Chiropractors have to realize that technology takes away much of the hypothesizing and allows us to conclude with a great degree of certainty an accurate diagnosis: the foundation of the treatment plan. 
 
When we look at disc issues, this gives the chiropractic profession a universal platform to becoming and being considered by medicine to be the "Spinal Primary Care Providers". Back pain, inclusive of disc pathology, is a thorn in the sides of most primary care providers (PCPs) and a diagnosis they universally refer to orthopedic surgeons for lack of a better alternative.Orthopedic surgeons are centered on surgery, with their $225,000+ malpractice costs, and summarily dismiss most non-surgical cases to physical therapists, who in turn render much poorer outcomes, according to Cifuentes et al. in 2011, for back related issues compared to chiropractic care.
 
Cifuentes  concluded that chiropractic care during the  disability episode resulted in:
 
  • 24%   Decrease in disability duration of first episode compared to physical therapy 
  • 250% Decrease in disability duration of first episode compared to medical  physician's care 
  • 5.9%  Decrease in opioid (narcotic) use during maintenance care compared to physical therapy care 
  • 30.3% Decrease in opioid (narcotic) use during maintenance care compared medical  physician's care
  • 19%   Decrease in average weekly cost of medical expenses during disability episode compared to physical therapy care
  • 43%   Decrease in average weekly cost of medical expenses during disability episode compared to medical  physician's care
 
According to the U.S. Department of Health and Human Services in 2008, there were 490.41 million visits to primary care medical doctors (PCPs) in the United States that year, when almost every United States citizen visited a primary care doctor across multiple health care platforms. The penetration of PCPs nationally is somewhere between 95-100% of the population, where chiropractic is 4.12% of the population. Understanding the penetration and influence PCPs have over the population and the positive "evidence based chiropractic results" that medicine has long asked for, the chiropractic profession is now poised to become the "Spinal Primary Care Providers", with one proviso. 
 
We need to take our place as spine specialists and not just subluxation specialists to conclude accurate diagnoses and converse in a language that is universal and inclusive to both chiropractic and medicine. In order to do that, we need to learn disc and spinal pathology as a beginning.
 
When utilizing MRI, there has to be a criteria or protocol for ordering a scan and then an understanding of the findings. This author has long held that in the presence of a significant radiculopathic or any myelopathic finding an immediate MRI is warranted BEFORE you create a prognosis and treatment plan. In short: don't touch the patient until you know what the diagnosis is. This protocol has been well documented in the literature as evidenced by the Fish, Koboyashi, Chang and Pham, who also concluded that symptomatic radiculopathic findings or central canal stenosis (as found in myelopathies) require MRI for conclusive diagnosis prior to treatment.
 
When interpreting MRIs it is imperative that each doctor be proficient in interpreting their own film. Lurie et al. reported in 2009 that “…the specific morphology of the herniation was not reported by the radiologist in 42.2% of cases,” meaning that general radiologists inaccurately report what is wrong with your patient almost half the time and you are often delivering a "high velocity thrust", known as an adjustment/manipulation, with wrong information. It is here that you start to become the spine specialist and can guide the PCP in their referral pattern based upon your clinical excellence. The "best of the best" read their own MRI images, no differently than the spine surgeons who will not operate unless they have firsthand knowledge that they know is accurate. Chiropractors are no different.
 
When interpreting MRI images it is important to understand accurate nomenclature. The following was reported by Bailey in 2005:
 
Disc Bulge: Synonymous to disc degeneration. 

Author's note: a circumferential degeneration over time evidenced by a thinning of the disc with the nucleus pulposis still within the confines of the annulus. The disc bulge or expansion must cover greater than 50% of the disc circumference and is usually close to 100% of the circumference.
 
Annular Tear: Tear or fissure in the annular fibers, either radially or concentrically. 

Author's note: The outer 1/3 of the annular fibers are innervated by the A, B and C fibers commonly known as the recurrent meningeal nerve and as reported by Lee et al. can cause pain in either annular tears or irritated degenerative discs.

Herniation: Displacement of the disc beyond the limits of the disc space.

Author's note: Tear in the annulus where the nucleus pulposis material goes outside the confines of the nucleus.
 
Focal Herniation: Less than 25% of the disc circumference.

Author's note: Where the herniation covers 25-50% of the disc circumference.
 
Broad Based Herniation: Between 25-50% of the circumference of the disc circumference
.
Author's note: Where the herniation covers 25-50% of the disc circumference.
 
Protrusion Type Herniation: Author's note: Where the base is greater than the apex in any plane.

Extrusion Type Herniation: Author's note: Where the apex is greater than the base in any plane.
 
According to Robert Peyster, MD, DABR-NR Neuroradiologist, Chief of Neuroradiology, State University of New York at Stony Brook, herniations are traumatically induced.
 
McMorland et al. (2010) found that 60% of surgical candidates had successful outcomes with chiropractic as an alternative to many disc surgeries. The evidence shows chiropractic was highly effective for patients with distinct one-sided lumbar disc herniations as diagnosed via MRI and had associated radicular (nerve root) symptoms. What about the other 40%?
 
Over the last 23 years, Magdy Shady, MD, Neurosurgeon, Neuro Trauma Fellow, has worked with this author to develop a clinical protocol to determine when chiropractic was indicated in a disc herniation patient. If there is room anywhere around the cord or root, then adjusting/manipulation is a clinically indicated first line treatment. In the absence of any room around the cord or disc, then chiropractic, based upon the increase in intrathecal pressure created in the adjustment/manipulation, puts active chiropractic care in the second position after the disc has been reduced. 
 
Over the decades, that protocol has been followed strictly to the benefit of thousands of patients, where surgery was needed only in a small population of those patients and the first line treatment was bed rest, cryotherapy or anti-inflammatory medication managed by the neurosurgeon until chiropractic was indicated via a combination of a follow up clinical evaluation and MRI.
 
Knowing the difference between aggressive chiropractic treatment or waiting a few days or weeks until the swelling has reduced is a result of making an accurate diagnosis, prognosis and treatment plan. That is also the foundation for relationships with PCPs and being part of a health care team involving multiple disciplines where the chiropractor is the "Spinal Primary Care Provider" and coordinator of health care. 
 
The PCPs appreciate the relationship because it relieves them of the spinal-related patients constantly ending up in their offices as though through a "revolving door" because orthopedics and physical therapy are not the solution and often only serve to delay the exacerbations that end up in the PCP's office over and over.
 
Becoming expert in disc pathology and reading MRIs is the first step towards becoming a spine specialist and tapping into the 95-100% of the population cared for by PCPs. Having control over an accurate diagnosis and orchestrating the triaging of the patient puts chiropractic in the epicenter of spinal-related care and relieves the PCPs of what they consider a "burden to their practice." 
 
It can no longer be business as usual and becoming proficient in disc, MRI and spine care does not change how you care for your patient, nor the philosophy with which you practice. There is room in both the subluxation and structural models of practice. This level of clinical excellence simply makes you a better doctor and opens doors to allow you to become part of the health care team in your community and will ultimately increase awareness and utilization of cost-effective chiropractic management of non-surgical spinal conditions. 

References:
  1. Davis, M., Sirovich, B., Weeks, W. (2010).Utilization and Expenditures on Chiropractic Care in the United States from 1997 to 2006. Health Research and Education Trust, 45(3), 748-761.
  2. United States Population (2012), Encyclopedia of the Nations, Retrieved from: http://www.nationsencyclopedia.com/Americas/United-States-POPULATION.html
  3. Fiore, J. (2012). Subluxation vs. Herniation: A New Paradigm for Chiropractic. The American Chiropractor, 34(8), 14-18.
  4. Primary Care Workforce Facts and Stats No. 1, The Number of Practicing Primary Care Physicians in the United States, (2008) U.S. Department of Health and Human Services, Retrieved from: http://www.ahrq.gov/research/pcwork1.htm
  5. Cifuentes, M., Willets, J., & Wasiak, R. (2011). Health maintenance care in work-related low back pain and its association with disability recurrence. Journal of Occupational and Environmental Medicine, 53(4), 396-404.
  6. Fish, D., Kobayashi, H., & Pham, Q. (2009). MRI prediction of therapeutic response to epidural steroid injection in patients with cervical radiculopathy. American Journal of Physical Medicine & Rehabilitation, 88(3), 239-246.
  7. Lurie, J. D., Doman, D. M., Spratt, K. F., Tosteson, A. N., & Weinstein, J. N. (2009). Magnetic resonance imaging interpretation in patients with symptomatic lumbar spine disc herniations. Spine, 34(7), 701-705.
  8. Lee, J. M., Song, J. Y., Baek, M., Jung, H. Y., Kang, H., Han, I. B., Kwon, Y. D., & Shin, D. E. (2011). Interleukin-1β induces angiogenesis and innervation in human intervertebral disc degeneration. Journal of Orthopedic Research, 29(2), 265-269.
  9. Bailey, W. (2005). A practical guide to the application of AJNR guidelines for nomenclature and classification of lumbar disc pathology in Magnetic Resonance Imaging (MRI). Radiology, 12(2), 175-182.
  10. McMorland, G., Suter, E., Casha, S., du Plessis, S. J., & Hurlbert, R. J. (2010). Manipulation or microdiskectomy for sciatica? A prospective randomized clinical study. Journal of Manipulative and Physiological Therapeutics, 33(8), 576-584.
Mark Studin, D.C., F.A.S.B.E.(C), D.A.A.P.M., D.A.A.P.L.M. -

Dr. Mark Studin is just one voice, a chiropractor seeking to attain 95% of the entire population under chiropractic care in his lifetime. He can be reached at or 631-786-4253.

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