Y our patient presents with severe anta-lgia with concomitant pain radiating down the posterior part of the leg into the top of the foot. After taking a history and determining PQRST. you may take x-rays, then have the patient lie on your table, and adjust him or her. You are confident because the technique course that you took told you that all that is required to make a patient well is to analyze the patient appropriately using that clinical approach of analysis. Here arc the results: some get well, some have no changes in cither symptomatology or clinical presentation, but others get worse. The real problem in the above scenario is the treating doctor has no clue as to what the result will be. In other words, too many doctors "spin the wheel" when creating a prognosis. According to The Free Dictionary (2013). "Prognosis: (noun) 1. a. A prediction of the probable course and outcome of a disease, b. The likelihood of recovery from a disease." (http://w w w .thefrcedictionan .com/prognosis). Although making a prognosis is at best a doctor" s best "guess." the question raised is: Can we. as practitioners, safely determine the probable course and outcome with the desired course of care armed only with a history and examination? The answer is a strong "yes" with main variables. The strongest variable is the symptomatology and clinical presentation of the patient. Too many practitioners cither ignore the symptoms and only want to treat the cause or. at the other end of the spectrum, only want to treat the symptoms and ignore the cause. Both approaches can be equally detrimental to the long-term health and well-being of your patient. When triaging your patient, the accepted protocol is to create a diagnosis, prognosis, and treatment plan followed by caring for your patient. The first step in helping the patient get well is to create an accurate diagnosis and understand all of the treatment parameters so that you can create an appropriate prognosis to determine if your care w ill result in a positive outcome that is most beneficial for your patient. For the patient described earlier, it appears that there is some type of space-occupying lesion in cither the foramen, neural canal, or spinal canal creating the radiculopathic (radiating) clinical presentation. The question begs: What is that space-occupying lesion? Is it some type of disc pathology, variccs (dilated veins), severe subluxation. tumor, foreign body, etc.? The reality is that without advanced imaging, you will never know. Not having that know ledge is like putting a blindfold over your eyes and saying the following while treating your patient. "I hope he'll get well." This is because you simph do not know the ultimate cause of the clinical presentation. An acceptable clinical guideline taught in professional schools today and mirrored in the scientific literature is that, in the presence of significant radiculopathic or myclopathic clinical signs and symptoms, an immediate MRI is warranted prior to executing a corrective care plan. Radiculopathy: compression of a nerve root in cither the neural canal, neural foramen, or spinal canal below the conus medullaris. Myelopathy: Compression of the spinal cord with ensuing neurological deficit distal to the level of lesion. It is both accepted and humane to treat the patient palliativcly during the course of concluding your final diagnosis. However, be thorough in documenting your care as such. It was reported by Fish. Kobayashi. Chang, and Pham (2009). "Perhaps the more meaningful portion of our study was the one in which we limited positivc-MRI findings to those with major severity because lower-grade radiologic findings can be common and clinically insignificant. Disk protrusions arc particularly common findings in cervical MRIs of asymptomatic patients. Mild cervical stenosis are very common, as well. Also, onh' significant nerve root compromises arc generalh expected to exert associated symptoms. It has been reported in a lumbar study tliat a mere contact of nerve root by disk material is usually not associated with neurogenic symptoms, whereas a compression docs seem to be important in this regard. To evaluate MRI"s ability to predict treatment outcome, it would be more valid to limit positive MRI findings to only those that will likely have symptomatic effects" (p. 243). In their final statement about limiting MRIs to those likely to have symptomatic effects, the comment reflects the current standard of ordering MRIs in the presence of radiculopathic or mvelopathic findings as stated above. Many insurance companies in states where prccertification is required will not approve an MRI prior to six to eight weeks of conservative care. I have verified this as being the insurance standard in order to limit expenditure on unnecessary care by speaking to doctors in 44 states and lawyers in 23 states. In tnic insurance fashion, the carriers have taken an acceptable standard and pervcrscd it at the expense of the public. The accepted standard is in the absence of any radiculopathic or myclopathic findings, conservative care should ensue fora minimum of four to eight weeks prior to considering advanced imaging such as an MRI. This standard docs not take into account those patients with significant radiculopathic or myelopathic findings or other comorbiditics. Roudsari and Janik (2010) reported. "Approximately 70% of acute |lo\v back pain] patients can attribute their pain to spinal muscle strain or sprain. These patients arc. in general, younger and have no clinical red flags. Under these circumstances. MRI should not be performed within the first 4-8 weeks of symptoms" (p. 551-552). If this patient population's pain persists, then advanced imaging in the form or MRI is clinically indicated to further evaluate each patient's condition because now the lack ol response is a clinical red nag. The authors stated. "MRI is the method of choice for the evaluation of disk morphology because of the good sensitivity (60-100%) and specificity (43-97%) for disk hcrniations (both protrusions and extrusion)" (Roudsari & Jarvik. 2010. p. 553). They go on to also report. "It has been suggested that disk morphology is associated with symptoms and as a result should influence pain management. Although bulging disks and protrusions arc common and poorly correlated with symptoms, extrusions arc rare in asymptomatic patients (1-5% prevalence) and may be a good predictor of response to treatment and patient outcome" (Roudsari & Jan ik. 2010. p. 553-554). Although the research is focused on a younger population in the absence of red Hags (clinical symptoms and signs of cither radiculopatln or myclopathy) this is an appropriate protocol for an entire demographic in the absence of any additional comorbidities. According to William J. Owens. DC. an adjunct professor of clinical sciences for both the University of Bridgeport's Col- lege of Chiropractic and the State University of New York at Buffalo's School of Medicine and Biomcdical Sciences. Family Practice. "The treatment plan requires alteration based on the patient's lack of response. Based on the most current research from the American Journal of Neuroradiology. the patient's lack of response, the findings on physical examination, and the current scientific evidence, the details of the future treatment plan will require additional investigation. Changes to the treatment plan include some or all of the following: alteration of treatment modality, specialist referral, alteration of prognosis, and disability management. These elianges will be impossible to calculate without the advanced imaging procedure outlined. Lack of imaging would result in negative consequences based on the patient's response to care." Once an accurate diagnosis has been concluded through advanced imaging, the next question is: How do you create an appropriate treatment plan? There arc very specific protocols that will ensure a favorable outcome, and in part two of this two-part report. I will outline how to know when to adjust the patient or co-treat with a specialist. In most cases, adjusting patients with disc hcrniations is an accepted standard and is safe for the patient. However, there arc "red flags" with defined guidelines to help you appropriately make a prognosis and triage these patients. This know ledge will help you create an accurate diagnosis, prognosis, and treatment plan. Armed with know!- edge and the chiropractic adjustment, this gives you a distinct advantage over all other providers in a nonsurgical scenario. References: Farlcx. Inc. (2013). Prognosis. The Free Dictionary. Retrieved September 9. 2013 from http://\v\v\v.thcfrccdictionary. com/prognosis Fish. D. E.. Kobayashi. H. W.. Chang. T. L.. & Pham, Q. (2009). MRI prediction of therapeutic response to cpidural steroid injection in patients with cervical ra- diculopathy. American Journal of Physical Medicine & Rehabilitation. 88(3). 239-246. Roudsari. B.. & Jan ik. J. G. (2010). Lumbar spine MRI for low back pain: Indications and yield. American Jour nal of Roentgenology. 195(3). 550-559. Dr. Mark Studin is an adjunct assistant professor in clinical sciences at the University of Bridgeport College of Chiropractic and a clinical presenter for the State of New York at Buffalo, School of Medicine and Biomedical Sciences for post-doctoral education, teaching MR1 spine interpretation and triaging trauma cases. He is also the president of the Academy of Chiropractic teaching doctors of chiropractic how to interface with the legal community (www.LawyersPIProgram.com) and teaches MRI interpretation and triaging trauma cases to doctors of all disciplines nationally (www.TeachDoctors.com). He can be reached at DrMarkciiJeachDoctors.com or at 631-786-4253.
