Cervical Myelopathy

Detecting and Communication Cervical Myelopathy to the Medical Community

Chiropractic’s Role in Clearing the Spine

As you build you referral network with the medical community, it is CRITICAL to understand that the more they trust you diagnostically the sooner they will send patients.  The sooner they send patients the greater the likelihood they will send complex patients that have underlying conditions that MUST be recognized and properly worked up.  You miss that it is GOODBYE REFERRAL NETWORK, GOODBYE TRUST AND GOODBY CAREER.   When looking at diagnosis, it is important to understand that it is about taking the best care of your patient as possible AND about using those situations to market to the medical community.  These are opportunities to co-manage complex clinical issues and most MDs are not used to a chiropractor being in the position to take the lead. 

We were all taught in school relative and absolute contraindications to chiropractic care and there were specific orthopedic and neurological tests that could be performed in order to assess the patient.   We believe that what we were taught was up to date and effective, but for ME that was 18 years ago…what about YOU?  So where do we look for updates and direction to stay current?  We look at the published evidence and see what the “scientific consensus” is and that is what gives us direction.  What we are looking to do is study at the highest level of clinical excellence possible and that is in peer reviewed medically indexed journals.  That is where the information is that will protect your patients, protect your licenses and generate referrals for the life of your practice.  If the spine is NOT CLEARED you do NOT ADJUST.  The MD community will need to rely on you for this…trust me I do it every day. 

I hope that you are starting to see what I am taking you through…once YOU know the information, then you TEACH the MDs…When the MDs see you as a resource for clinical education they will also see you as a resource for their patients.  The goal of this program is to get you UP to a level of clinical excellence then put you in a position to TEACH the medical community in your area.  That is where all the patients are.  In this consultation, let’s take a look at cervical spinal myelopathy and a recent Systemic Review titled “Clinical Tests for Screening and Diagnosis of Cervical Spine Myelopathy: A Systemic Review” published in the Journal of Manipulative and Physiological Therapeutics, October 2011.  I want to share with you because the objective of this paper is to “investigate the diagnostic accuracy for screening and confirmation of clinical tests for cervical spinal myelopathy (CSM) and to investigate the quality of the studies that have investigated these values.” (pg 539) In other words how accurate are the tests that we can do IN our clinics to detect an absolute contraindication to chiropractic adjustment.  

The authors define the condition as “Cervical spine myelopathy (CSM) is a progressive, degenerative condition, which is a consequence of degeneration and structural changes to the inter-vertebral disks in folding, thickening, and encroachment of ligamentous tissue into the spinal canal and/or loss of flexibility of the capsule. Nondegenerative, structural-based conditions may be associated with conditions such as syringomyelia or tumors. The encroachment may lead to structural and vascular changes to the spinal cord (and corresponding neurological deficits) and originates from sagittal narrowing of the spinal canal.” (pg 539)   The go on to state “Cervical spine myelopathy is present in 90% of individuals by the seventh decade of life and is recognized as the most common form of spinal cord dysfunction in an individual over the age of 55 years. The condition most commonly affects males and those of Asian descent. Symptoms may present as hyperreflexia, clumsiness in gait, neck stiffness, shoulder pain, paresthesia in one or both arms or hands, or radiculopathic signs. Nonetheless, these findings are not always present, thus lending to the difficulty of the diagnosis of CSM.” (pg 539)

SO DID I SCARE THE CRAP OUT OF YOU!  I HOPE SO…

We know that the official diagnosis of CSM is made only after confirmation with MRI, MRI is the imaging modality of choice for CSM.  Protecting the cord from further damage via the chiropractic adjustment, rehabilitative exercises or traction is paramount.  So what are the other tests that can be done to assist the screening of these patients?  Here is a short list of the most common as well as a description of how they are done.  BTW, these should ALL be loaded into your EMR system as macros to be used as needed.  When you are creating macros make sure you include a description of the test not just the name.  Many of the people reading your reports do NOT have extensive healthcare knowledge.  If you are lazy then go join www.emrmacros for $50 per month and just download them and others.  For now, these are for you for free…

Take a look at this patient of mine…Came in after MVA, no neuro signs at all except some decreased sensation on left C7.  Patient is 67 years old at time of evaluation.  

             Upper Limb

NAME: Hoffman R.

PERFORM TEST: As the patient’s palm is facing downward, extend the patient’s middle finger.  Then flick the distal phalanx downward into flexion.

POSITIVE: Flexion & adduction of the thumb & flexion of the other fingers.

NAME: Tromner S.

PERFORM TEST: As the patient’s palm is facing downward, extend the patient’s middle finger.  Then flick the distal phalanx upward into extension.

POSITIVE: (Same as Hoffman’s)

            Lower Limb

            NAME: Babinski Reflex/Sign

PERFORM TEST: With a blunt instrument, stroke the plantar surface of the patient’s foot up the lateral side & across the metatarsal heads toward the medial side.

POSITIVE: A slow, tonic extension of the big toe, with fanning of the other toes.

NAME: Choddock S.

PERFORM TEST:  With a blunt instrument, the doctor will stroke a “c” shape behind & below the lateral malleolus.

POSITIVE: (same as Babinski Sign)

NAME: Crossed Extension R.

PERFORM TEST: As the patient is lying supine with knees bent slightly so that their heels are pressed into the table, the doctor will perform a Babinski Reflex on one foot.

POSITIVE: Extension of the opposite leg.

NAME: Gordon R.

PERFORM TEST: Squeeze the calf muscles tightly.

POSITIVE: Dorsiflexion of either the big toe or all the toes.

NAME: Heel Tap R.

PERFORM TEST: As the patient is lying prone, flex the knee to 90 degrees then tap the heel with a reflex hammer.

POSITIVE: Plantar flexion of the lateral four toes.

NAME: Mendel-Bechterew S.

PERFORM TEST: As the patient is lying supine, tap the dorsum of the cuboid bone with a reflex hammer.

POSITIVE: Plantar flexion of the lateral four toes.

NAME: Oppenheim S.

PERFORM TEST: Using your knuckles (or index finger & thumb (the doctor will firmly stroke the tibia downward from the tibial tuberosity.

POSITIVE: (Same as Babinski Sign)

NAME: Schaefer R.

PERFORM TEST: Squeeze the patient’s Achilles’ tendon behind the medial malleolus.

POSITIVE: (Same as Babinski Sign)

It should be noted that the authors stated “Manually oriented clinicians will likely use thrust and non-thrust procedures on a variety of patients, many of whom do not exhibit signs associated with CSM such as hyperreflexia, clumsiness in gait, neck stiffness, shoulder pain, paresthesia in one or both arms or hands, or radiculopathic signs. These signs or symptoms may not demonstrate until significant disease progression.” (pg 543) 

Although there was no definitive answer on which test is best, the authors concluded that they are all non-specific based on their literature review.  What they did list in the Practical Applications section of the report is the following:

“The majority of published studies for clinical tests to detect CSM are poor to moderate in quality.”

 “Clinical examinations for CSM are mostly specific and lack sensitivity.”

 “Clustered test findings may be able to improve sensitivity and the specificity, depending on the combination used.” [They did not offer suggestions, but the idea is a group of tests such as Deep Tendon Reflexes, Hoffman’s Test, Babinski.  My  basic philosophy is when in down IMAGE…it is easier to defend WHY you ordered an $800 MRI than it is to defend your license after you paralyzed a patient!] 

Lastly consider this, when ordering MRI it is clinically indicated with neurological signs and symptoms IMMEDIATELY following the examination.  In the absence of neurological symptomatology, it is indicated within 4 weeks’ time if there is less than adequate response to care.  I use this EMR Macro when I order MRI after 4 weeks (8-12 visits) as well as the MACRO for cervical spine trauma and MRI orders. 

“Approximately 70% of acute LBP patients can attribute their pain to spinal muscle strain or sprain. These patients are, 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)  If this patient population’s pain persists, then advanced imaging in the form or MRI is clinical indicated to further evaluate the patient’s condition since now the lack of response is a clinical red flag.  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 herniations (both protrusions and extrusion).  It has been suggested that disk morphology is associated with symptoms and as a result should influence pain management. Although bulging disks and protrusions are common and poorly correlated with symptoms, extrusions are rare in asymptomatic patients (1-5% prevalence) and may be a good predictor of response to treatment and patient outcome.” (p 553)

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 changes 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.

Bahman Roudsari and Jeffrey G. Jarvik. Lumbar Spine MRI for Low Back Pain: Indications and Yield. AJR 2010; 195:550-559

The patient has presented with an injury to the cervical spine as outlined above.  Imaging is medically necessary based on the history, mechanism of injury, physical examination findings and current published scientific evidence.  Muchow et al (2008) stated the following.

“Cervical spine clearance protocols traditionally include a three-view plain radiograph series and then CT, flexion or extension radiographs, or MRI depending on the clinical situation. When the results of the clinical examination are unreliable or positive, and plain radiographs disclose nothing abnormal, physicians often place a greater emphasis on advanced imaging to help identify an injury. Concomitantly,  this patient group harbors a higher incidence of cervical spine injury, compared with asymptomatic patients with a clear sensorium. A greater probability for the presence of a cervical spine injury coupled with a strong desire to avoid the complications from missed injury has provided justification for aggressive imaging protocols.” (p 179)

“A clinically suspicious patient is a symptomatic patient who reports persistent neck pain or has cervical spine tenderness.” (p 180)

“The practical use of MRI involves its ability to directly guide therapy in the blunt trauma patient. Three therapeutic options remain for the clinician and each one is specifically indicated based on the results of the MR image. A complete ligamentous injury where instability is clearly documented is an absolute indication for surgical stabilization. The lack of an abnormality on MRI is a clear indication for the removal of cervical collar immobilization supported by the NPV of 100% calculated in this meta-analysis. Lastly, an MR image that details significant edema or hemorrhage or both or evidence for an incomplete ligamentous injury allows the clinician to keep the patient in cervical collar immobilization. Thus, the implementation of MRI into a cervical spine clearance protocol has a clear relationship between the image result and the corresponding therapy.” (p 187)

This MRI was ordered specifically to diagnosis ligamentous injury in this patient and is in accordance with published evidence and is in line with modern scientific consensus on the diagnosis, treatment and management of this disorder.  Without the MRI an accurate diagnosis, prognosis and treatment plan will not be possible.  Based on the evidence, the patient’s clinical findings and the published research, this MRI is clinically and medically necessary.

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.