Friday, 15 September 2023 18:06

Incidental MRI Findings Change Chiropractic Treatment plan, Even With Thorough Medical History and Extensive Examination

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Abstract


An accurate diagnosis, treatment plan and prognosis in chiropractic clinical practice is often difficult and may take time to develop during the span of a case, even with a skilled clinician. Care is often initiated based on 1) Avoiding harm and 2) Providing effective treatment. Within the context of imaging either being deemed by the doctor; unnecessary at the time, or imaging has been ordered and is pending, often with delays either due to carrier interruption or local facility overload, can postpone an accurate diagnosis and render changes in a treatment plan as well as significantly change the prognosis, and require the involvement of specialists.


Eliciting an accurate past medical history is an essential clinical skill that may become unreliable because of a patient withholding information, errors in comprehension, language barriers, recall, evaluation, and expression, no matter how capable the clinician.


This case study describes a case when the patient’s history was unreliable due to withholding information. Although there were multiple injuries, this report will focus on the lumbopelvic spine. Diagnostic testing was performed as indicated for a neuro-musculoskeletal condition along a timeline dictated by the case. The lumbar x-rays were unremarkable for significant pathology. The lumbar MRI however, revealed an incidental finding of a pre-existing condition that mandated a treatment change for the safety of the patient.


Keywords: Chiropractor, Clinical Decision-Making, Differential Diagnosis, Medical history, Incidental Findings, Treatment Plan.


Case Presentation


The patient, a 51-year-old Female. She explained that she was the front passenger of a Ford Ranger on 12/11/2022 when she was struck by a Nissan pick-up from the passenger's side. She denies loss of consciousness but states that she was unable to respond to a person at the scene who was questioning her if she was OK, then she recalled the paramedics at the scene. She is unsure if any part of her body hit any part of the interior of her vehicle.


She states she was taken by ambulance to the Hospital and states that she had an MRI (unsure if it was a CT). She was prescribed pain medication. Medical records requested.


She was also seen by her primary care doctor who ordered x-rays of her knees.


SUBJECTIVE:


She complained of intermittent sharp, burning and tightness in the front of the head (headache). She describes that the pain is the same with movement. On a scale of 1 to 10, with 10 being the most severe, she, using a VAS, describes the intensity as an 8 and indicates that the pain occurs approximately 80% of the time.


She also complained of continuous sharp and shooting pain in the back of the neck. She describes that the pain is the same with movement. On a scale of 1 to 10, with 10 being the most severe, she, using a VAS, describes the intensity as an 8 and indicated that the pain occurs approximately 100% of the time.

She also complained of intermittent sharp and tightness in the upper back. She describes that the pain is the same with movement. On a scale of 1 to 10, with 10 being the most severe, she, using a VAS, describes the intensity as an 8 and indicates that the pain occurs approximately 80% of the time.


She also complained of continuous sharp and shooting pain in the low back. She describes that the discomfort is the same with movement. On a scale of 1 to 10, with 10 being the most severe, she, using a VAS, describes the intensity as a 9 and indicated that the pain occurs approximately 100% of the time.
Rivermead post-concussion questionnaire. The patient had the following symptoms: Headaches, Dizziness, Nausea/Vomiting (vomiting 2 days after), Noise Sensitivity, Sleep Disturbance, Fatigue, Irritable/Easily Angered, Depressed/Tearful, Frustrated/Impatient, Forgetful/Poor Memory, Poor Concentration, Taking Longer to Think, Blurred Vision when dizzy, Sensitivity to Light and Restlessness because of pain.


She also notes ringing in the right ear.


She denies these symptoms prior to this injury.


REVIEW OF SYSTEMS: A complete review of systems was completed and revealed the following findings. The patient was quizzed on general health symptoms of weakness, fatigue, fever, chills, night sweats or fainting and she reported experiencing fatigue. In addition to the consultation, the patient also completed a questionnaire regarding review of systems which was reviewed by me in its entirety.


Eyes, Ears, Nose, Throat and Skin was reviewed and indicated: unremarkable.
Neurological System was reviewed and indicated: unremarkable.
Respiratory System was reviewed and indicated: unremarkable.
Endocrine System was reviewed and indicated: unremarkable.
Cardiovascular System was reviewed and indicated: unremarkable.
Gastrointestinal System was reviewed and indicated: unremarkable.
Genitourinary System was reviewed and indicated: unremarkable.
Psychiatric factors with the patient was reviewed and indicated: unremarkable.
Past injuries include: nothing remarkable.
The patient notes the following pre-existing conditions: Knee osteoarthritis bilaterally.
Reported family history: The patient shared that members of her immediate family had a medical history that included: asthma, kidney problems, thyroid problems and cancer.
Smoking: never


INITIAL EXAMINATION
The patient, a 51 year old Female. Her demeanor indicated she was in slight pain. She appears generally to be well-nourished and well-groomed.
JUDGEMENT, ORIENTATION & MOOD/AFFECT: The patient exhibits sound judgement. The patients’ responses during consultation indicated her basic cognition was normal in regards to person, place and time. Her responses to questions was slow and she lost track of thought often. Her mood/affect seemed to indicate she is concerned.

INSPECTION: No soft tissue abnormalities, no osseous deformation and no visible inflammatory processes are noted.

VITALS: Her vital signs are as follows:

Height: 5 feet, 4 inches; Weight: 210 pounds.

Blood Pressure (left sitting): 140/90.

Pulse Rate: 83 bpm.


ASYMMETRY/MISALIGNMENT OF GAIT & STATION: Her carriage and gait showed normal pattern and her movements were restricted. A standing postural examination using the plumb-bob gravity assessment was performed which revealed even and neutral head position, even shoulders and even iliac crests. The lateral spinal curves were visualized and appeared to be as cervical normal lordosis, thoracic normal kyphosis and lumbar normal lordosis.
ANTALGIC SIGN: The patient did not demonstrate any antalgic positioning due to pain or muscle spasm on today's visit.
RANGE OF MOTION: Active range of motion of the spine was evaluated visually. An increase or decrease in segmental mobility using observation and motion palpation was assessed today. No gross instability was noted in the neck, back or extremities. This finding does not rule out more subtle ligament instability in the spine; however, ligament instability must be ruled out on imaging studies.


Cervical active range of motion was mildly restricted (10-30% loss) with pain in forward flexion, extension, left lateral flexion, right lateral flexion, left rotation and right rotation.

Lumbar active range of motion was mildly restricted (10-30% loss) with pain in forward flexion, extension, left lateral flexion and right lateral flexion.
PAIN, TENDERNESS, ARTICULAR DYSFUNCTION AND MUSCLE SPASM: Mild to moderate digital palpation was performed on this patient to selectively evaluate tissue consistency and response to pressure, especially in regards to pain, tenderness, articular dysfunction and muscle spasm. Her areas of concern were inspected and palpated for any articular dysfunction as well as to assess pain, tenderness, muscle spasm, tissue tone, edema (swelling), and induration (abnormal hardening). This evaluation revealed point tenderness at the occiput, C1, C4, C5, C6, T2, T3, T9, T10, L5, sacrum and right
pelvis spinal and paraspinal levels. Specific tissue tenderness with spasm was also noted in the rectus and obliquus capitus, upper trapezius, levator scapula, erector spinae, quadratus lumborum and gluteus medius.
ORTHOPEDIC EXAMINATION OF SPINAL JOINTS, BONES, MUSCLES: Orthopedic testing was utilized in the examination of joints, bones and muscles.
Upper Limb Traction Test was POSITIVE on the on the right indicating nerve involvement. Cerebrovascular Maneuver was negative.

Maximum Cervical Compression Test was POSITIVE on the right for upper extremity . Perform test:: As the patient is seated laterally flex & rotate the head to the affected side, then extend. If NO pain is produced at this point, axial compression can be added.

Shoulder Depression Test was negative bilaterally for dural sleeve adhesion. Perform test: As the patient lies supine or seated the doctor laterally flexes the patient's head away from affected side while compressing patient's shoulder to point of pain. Then rotate head away.

Odonoghue's was POSITIVE and for ligament injury bilaterally. Perform test: The patient is told to press against resistance without moving the head and flexion, extension and lateral flexion and report pain indicating strain. Then the cervical spine is moved passively by the examiner looking for pain indicating ligament sprain.

Posterior to anterior Facet Challenge POSITIVE indicating ligament injury in the lower cervical-upper thoracic spine and lumbo-sacral spine.
Kemp's Test was POSITIVE bilaterally for lower back without leg pain.

Seated Lesage's (Seated SLR) was POSITIVE on the right for lower back and leg pain and POSITIVE on the left for lower back and leg pain. Confirmed with Braggard’s.

Fabere Patrick's test was negative bilaterally for low back joint pain.

Minor's Sign was POSITIVE for pathologic condition of lumbosacral origin.

ABNORMAL SENSORY EVALUATION OF UPPER EXTREMITIES: Cervical and thoracic nerve dermatomes
(C4-T3) were tested for sensory deficits in the upper extremities using a pinwheel. All were normal except the C6, C7 and C8 which showed a increased sensitivity, Right

ABNORMAL SENSORY EVALUATION OF LOWER EXTREMITIES: Lumbar and sacral nerve dermatomes (L1-S2) were tested for sensory deficits in the lower extremities using a pinwheel. All were normal except the L5 and S1 which showed a increased sensitivity, Right
NORMAL DEEP TENDON REFLEXES (DTR) rated +1 to +5 with +2 normal: Deep tendon reflexes were tested at the
biceps (C5, C6), brachioradialis (C5, C6, C7), triceps (C6, C7, T1), patellar (L2, L3, L4) and Achilles (S1, S2) and were all normal (2+) and symmetric.

NORMAL MANUAL MUSCLE TESTING (motor):

5/5 Full strength
4/5 Full range of motion with moderate resistance
3/5 Full range of motion with perceptible weakness
2/5 Movement with no gravity
1/5 No movement with minor gravity
0/5 No visible contraction
UPPER EXTREMITY MOTOR: Deltoid (C5), Biceps (C6), Triceps (C7), Finger Flexors (C8), Finger Adductors (T1) were all +5 within normal limits.

LOWER EXTREMITY MOTOR: Psoas (L3), Tibialis Anterior (L4), Extensor Hallicus (L5) and Peroneus Longus (S1) were all +5 within normal limits.
EXTRASPINAL EXAMINATION OF SHOULDER JOINT: An examination of the patient's right shoulder revealed no limited range of motion upon flexion, extension, abduction, adduction, internal rotation and external rotation. Palpable tenderness over the anterior bursa was not pronounced. Active trigger points in the upper trapezius and deltoid were not present. Shoulder joint crepitus was not noticeable upon movement.

SHOULDER PAIN AND TENDERNESS: Mild to moderate digital palpation was performed on this patient to selectively evaluate tissue consistency and response to pressure. Specific tissue tenderness was also noted at the rhomboids, supraspinatus, teres minor and teres major.

SHOULDER ORTHOPEDIC TESTS:

Wright's test was negative for hyperabduction thoracic outlet compression syndrome,
Dugas's test was negative for shoulder dislocation,
Apprehension test was negative for shoulder dislocation,
Yergason's test was negative for bicipital tenosynovitis,
Apley's Superior Scratch test was negative for tendinitis of the supraspinatus tendon,
Apley's Inferior Scratch test was negative for tendinitis of the supraspinatus tendon,
Codman's Arm Drop test was negative for tear in the rotator cuff complex,
Shoulder Impingement Test was negative.
Supraspinatus Press Test was negative.

Assessment:
CAUSE OF INJURY MOTOR VEHICLE COLLISION (V89.2XXA)
CONCUSSION WITHOUT LOSS OF CONSCIOUSNESS (S06.0X0A)
CERVICAL NEURALGIA NEURITIS (M79.2)
SPRAIN/STRAIN CERVICAL (S13.4XXA)(S16.1XXA)
SPRAIN / STRAIN THORAX (S23.3XXA) (S29.012A)
LUMBAR NEURALGIA NEURITIS (M79.2)
SPRAIN / STRAIN LUMBAR (S33.8XXA)(S39.012A)
RIGHT SHOULDER JOINT PAIN (M25.511)

COMPLICATING CONDITIONS: The patient's current condition is not complicated by anything known at this time. Complicating factors may require an increase in treatment frequency and duration, if present, and result in a delay or inability for her condition to fully recover and stabilize. Treatment time is not likely to exceed expected norms.

CONTRAINDICATIONS: Known contraindications to chiropractic treatment based on past and present history were assessed for the following:
Absolute Contraindications: no contraindications noted. (Examples of Absolute Contraindications include: upper cervical spine hypermobility, acute fracture, unstable os odontoidium, avascular necrosis, bone malignancy, bone infection, acute myelopathy or acute cauda equina syndrome.)
Relative Contraindications: no contraindications noted. (Examples of Relative Contraindications include: spondylosis, spondylolisthesis, bone demineralization condition, osteoporosis, vertebrobasilar insufficiency, abdominal aneurysm, pregnancy, cardiac pace maker/defibrillator, anticoagulant therapy, rheumatoid arthritis, or spine surgery).

TREATMENT PLAN:
EEG/ERP: Electroencephalograph with Event -Related Potential (EEG/ERP) to rule-out or confirm traumatic brain injury (TBI) as sufficient medical necessity indicates from her evaluation, mechanism of injury on 12/11/22 and Rivermead post-concussion questionnaire (see chart). The findings will indicate if further testing, referrals and/or treatment is indicated and necessary. The patient has the following symptoms: Headaches, Dizziness, Nausea/Vomiting (vomiting 2 days after), Noise Sensitivity, Sleep Disturbance, Fatigue, Irritable/Easily Angered, Depressed/Tearful, Frustrated/Impatient, Forgetful/Poor Memory, Poor Concentration, Taking Longer to Think, Blurred Vision when dizzy, Sensitivity to Light and Restlessness because of pain.

RADIOGRAPHIC EVALUATION: A initial analysis radiographic examination was ordered (outside clinic) to determine the patient's current structural status as is relates to treatment needs. Radiographs were ordered to provide a detailed assessment of underlying spinal biomechanical pathology and concomitant tissue/osseous pathology. Clinical rationale for radiographs was due to need of structural integrity assessment and history of significant trauma.

MRI ORDERED: An MRI was ordered regarding Mrs. Redacted today, of the cervical spine and lumbar spine to confirm or rule out herniated disc, space occupying lesion and ligament tear, due to clinical (radicular, ligamentous or myelopathic) findings of: radicular pain in the arm(s), radicular pain into the leg(s) and sensory changes. An x-ray evaluation alone is not sufficient for this purpose. Should the evaluation reveal an condition that would preclude chiropractic treatment or necessitate a specialist, a referral and/or modification to the treatment plan will be made. Based on the evidence, the patient's clinical findings, and the published research, this MRI is clinically and medically necessary. Pending the MRI results, the patient will be treated palliatively for pain management and changes may be necessary to the treatment plan once the results are rendered.

TREATMENT PLAN: The following initial treatment plan, initiated 12/28/2022, is prescribed for this patient:
Moist heat.
Electrical muscle stimulation.
Soft tissue mobilization.
Pending x-ray results, manipulation diversified and drop table method.
Home range of motion exercises.
PROGNOSIS is UNDETERMINED, TREATMENT INDICATED.

Below:
LUMBAR X-RAYS 01/03/2023, reviewed and I agreed with the impression.

 

im 1

RADIOLOGIST REPORT IMPRESSION:

1. Mild side bending of the lumbar curvature with mild lumbar myositis.
2. No fracture and/or subluxation.

FINDINGS:
Two views of the lumbar spine demonstrate side bending of the lumbar curvature to the right.
These changes are compatible with lumbar myositis. The vertebral body heights are maintained.
The disc spaces are maintained. There is no subluxation. Minimal narrowing of the posterior intervertebral space at L3-L4. Coned-down views of L4, L5 and S1 are unremarkable. Posterior processes are intact.

Im2

Above: 02/13/23 T2 weighted images, MRI LUMBAR SPINE W/O CONTRAST

Im3

Above: Magnified sagittal T2 weighted image shows high signal in the anulus at L2-3 and L5-1 disc with protrusion type herniations.  This may be directly attributed to the injury on 12/11/2022 and is considered a more acute finding.

 

Im4

Above: Magnified sagittal T2 weighted image shows protrusion type herniations of the L2-3 and L5-1 discs (outlined in red).  The L4-L4 and L5-S1 discs are indenting the thecal sac (outlined yellow).  These finding are due to the injury on 12/11/2022, as the patient states no prior history of injury to her low back and there is no sign of pre-existing degenerative disc disease.

Im5

Above: Marked enlargement of a nonhomogeneous uterus, changes compatible with a large
uterine fibroid (white arrows).


CASE SPECIFIC TREATMENT PLAN CHANGE:
Due to the incidental uterine fibroid finding, to avoid compression of the abdomen and pelvic region, treatment was amended to no longer utilize techniques that would compromise this region such as drop table or massage of the abdomen or lying prone, char massage was utilized instead.


DISCUSSION

Every case involves the evaluation of the patient’s history, followed by physical examination and then choosing if diagnostic testing and or any imaging is indicated and or beneficial to the patient’s health. A clinical impression is made after patient history and the physical evaluation to rule out serious conditions or prior complicating factors.
Knowledge of pre-existing conditions is often difficult if not impossible if the patient withholds medical information at the time of medical decision. Even ordering medical records from prior providers, although often of great value, may not be enough. In this case, x-rays were of no value regarding the pre-existing condition. Medical records were ordered but had not been received prior to the date of the MRI. A clinical impression was made after patient history, the physical evaluation and x-rays to rule out serious conditions or prior complicating factors. The MRI alone was responsible for the change in chiropractic treatment as well as reporting to her primary medical provider.
The patient’s response to the MRI findings speaks to the (what seems to be more than occasional) impossibility of always and only relying on the patient for a complete and accurate medical history.

When questioned if she was aware of the massive uterine fibroid tumor she replied, “Yes, but I did not think it was necessary to tell you since you were only working on my spine”.
Although the marked uterine enlargement was not a complicating factor to the injuries sustained as the result of the motor vehicle crash, it was massive enough to change the type of chiropractic and ancillary physio-therapeutics for this patient, as to avoid any incidental injury to the uterus or adjacent abdominal and pelvic structures.


References:

1) Uterine Fibroid Tumors: Diagnosis and Treatment: American Family Physician, Volume 75, Number 10, May 15, 2007.
2) Problems for clinical judgement: 2. Obtaining a reliable past medical history CMAJ. 2001 Mar 20; 164(6): 809–813.
3) Clinical decision-making to facilitate appropriate patient management in chiropractic practice:
'the 3-questions model', Chiropractic Manipulative Therapy, 2012; 20: 6.
4) Fardon, D. F., Williams, A. L., Dohring, E. J., Murtagh, F. R., Rothman, S. L. G., & Sze, G. K. (2014). Lumbar disc nomenclature: version 2.0: Recommendations of the combined task forces of the North American Spine Society, the American Society of Spine Radiology and the American Society of Neuroradiology. The Spine Journal, 14(11), 2525-2545.
5) Ryan D. Muchow, BS, Daniel K. Resnick, MD, Matthew P. Abdel, BS, Alejandro Munoz, PhD, and Paul A. Anderson, MD. Magnetic Resonance Imaging (MRI) in the Clearance of the Cervical Spine in Blunt Trauma: A Meta-Analysis. J Trauma. 2008;64:179 -189.
6) Edgar, M. A. (2007). The nerve supply of the lumbar intervertebral disc. The Journal of Bone and Joint Surgery, British Volume, 89(9), 1135-1139.
7) Konieczny, Markus Rafael, et al. "Signal intensity of lumbar disc herniations: correlation with age of herniation for extrusion, protrusion, and sequestration." International journal of spine surgery 14.1 (2020): 102-107.

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