A 27-year-old man suffered injuries from a high-speed, head-on vehicular collision with a dump truck. Astute chiropractic assessment led to the correct diagnosis.
Posted in Examiner eNewsletter on Wednesday, December 16, 2020
Matthew Gregory, DC, had a patient who reported acute severe lower back pain. The patient denied any lower extremity symptoms, weakness, bladder/bowel retention or incontinence. He denied any saddle paresthesia or erectile dysfunction.
The patient’s range of motion was grossly limited by pain. Palpation revealed paraspinal muscle spasm and spinous tenderness. Kemp’s test elicited severe lumbar pain on the right. Double leg raise produced mid-lumbar pain. Seated straight leg raise and Patrick Fabere tests were negative.
The patient was neurologically intact on examination. Lower extremity motor evaluation revealed 5/5 upon assessment of the quadriceps, knee flexors and foot dorsi/plantar flexion. Patellar and Achilles deep tendon reflexes were graded +2/5. Lower extremity sensory assessment was within normal limits.
Dr. Gregory performed lumbar spine X-rays and noticed a subtle irregularity of the superior L3 endplate for which he sought my opinion.
Upon reading the X-ray study, I agreed with Dr. Gregory’s assessment and the need for advanced imaging. We considered the American College of Radiology (ACR) Appropriateness Criteria. For trauma due to a high-risk mechanism of injury affecting the thoracolumbar spine, the ACR criteria suggest CT without IV contrast or MRI without IV contrast.*
Due to the high-speed collision and severe pain without neurologic sequelae, CT evaluation of the lumbar spine without IV contrast was prescribed. If clinically indicated, MRI evaluation could be performed pending the CT scan. Dr. Gregory made the referral.
Interestingly, on X-rays reviewed by the initial medical radiologist, no fractures were reported, and the patient’s attending physician advised against further imaging. Despite these medical opinions, Dr. Gregory advocated for CT evaluation of the lumbar spine. The patient agreed and underwent the CT scan.
CT images of the lumbar spine revealed an acute comminuted fracture of the anterior, superior L3 vertebral body with no significant loss of body height, affecting less than 20 percent of the superior endplate. No retropulsion was noted.
Dr. Gregory immediately referred the patient to a medical orthopedist for follow up. The medical orthopedist prescribed pain medication, a brace and a light-duty work authorization not to exceed lifting objects greater than five pounds.
The patient has complied with the work restrictions and use of his brace. He progressively improved under care.
Dr. Gregory carefully documented the case in his office notes.
Astute Assessment and Follow up Led to the Correct Diagnosis and Care
This case is instructive for many reasons. The attending chiropractor performed a careful history and examination and obtained high-quality diagnostic images. When uncertain, he sought the opinion of a board-certified chiropractic orthopedist.
The chiropractor made appropriate advanced imaging recommendations and properly advocated for CT evaluation despite the patient’s initial radiologist and the medical doctor’s erroneous findings and recommendations. Upon diagnosing spinal fracture, the chiropractor made a timely referral to a medical orthopedist.
- Carefully assess. Carefully conducted history and examinations may provide insight for subsequent evaluations.
- Seek help. When in doubt, consult with respected chiropractic physicians who have attained advanced board certifications. When possible, confer with other clinical specialists.
- Consider appropriateness criteria. Upon deciding whether advanced imaging is necessary, consider reviewing established appropriateness criteria and make decisions based upon your training and clinical intuition.
- Errors occur. In healthcare, sometimes, errors occur due to the complexity of patient presentations. Chiropractic physicians are highly trained. You may appreciate a serious clinical entity when others may not.
*American College of Radiology ACR Appropriateness Criteria® Suspected Spine Trauma. Revised 2018. Accessed at: https://acsearch.acr.org/docs/69359/Narrative/.
About the Authors
James Demetrious, DC, FACO
Dr. James Demetrious is a distinguished Fellow of the Academy of Chiropractic Orthopedists. He conducts a private practice in Wilmington, North Carolina. He teaches advanced post-graduate chiropractic coursework throughout the U.S. on behalf of the NCMIC Speakers Bureau.
Christopher Bocchino, DC
Christopher Bocchino, DC, is a 1996 graduate of Logan College of Chiropractic in St Louis, Mo. He conducts a private practice in Easley, South Carolina.