New patient referrals to our clients: 781,392 Referrals as of 10/15/2018

Academy of Chiropractic’s

MD Relationship Program

CLINICAL CONSULTATION

MRI, Innervation, Surgical Referral, Prior Fusion

From:  William J Owens Jr DC DAAMLP

Here is a series of emails relating to working with surgeons, this case is particularly interesting and has lots of “Learning Issues”.  Please read!  The TOP starts with the email I sent out last week. 

Good morning, 

As you know I had a good meeting with a new neurosurgeon at University of Buffalo Neurosurgery last week when I hosted the Roundtable meeting in Buffalo. The interest level in chiropractic is coming NOT necessarily from chiropratic itself, but moreso due to our ability to assess the biomechanical balance of the spine.  That is perceicely WHY not ALL chiropractors will get the spine surgeons attention, the chiropractors that are working at the highest level clinically and are focused on spinal biomechanics are the ones that will be the most successful in this environment.  Being able to OBJECTIVELY demonstrate what is wrong with the patient mechanically, order and review imaging and then deliver the proper treatment protocols is critical to building this relationship.  The tide is turning toward medical groups, especially surgical brining chiropractic into their circles at a very high level both in patient referral as well as in publishing research and case studies. 

Remember that getting to the point in your practice where you can be part of this is a process.  Here is what you need to do to be successful and NEVER have to worry about getting another new patient in your practice ever again.  It is worth the time and effort and in fact, I have come to realize…is REAL CHIROPRACTIC.

1:  Get your reporting in order - it needs to be efficient and concise.  Your Assessment needs to be short but it must outline what you are “thinking” about the patient. 

2:  Get a system to effectively deliver that reporting to the medical community.  EVERY MD that touches that patient should get a copy. 

3:  Get your CV on www.uschiropracticdirectory.com and make sure you are planning your CE for the year properly.  Stay away from classes that do NOT fulfill your vision of clinical excellence and interprofessional care.  Learn from those that have DONE IT, not those that are talking theory, GET THEIR CV AND STUDY IT.   The USChiropractic Directory has a Social Media “Share” application once you post your CV.  USE IT ALL THE TIME! 

4:  Start reading the consultations I am sending on working with the surgeon.  Watch the VIDEO - SURGEON AS ADVOCATE in the Video Library, you can search for it on www.mdrferralprogram.com in the Video Library Section. 

5:  COLLABORATE on cases with a local surgeon, this is the future of spine care and you MUST be the DC in the area that leads the parade.  Do not wait for an “uncredentialed" chiropractor to mess it up.  The chess board is being organized now!

6:  Read the following paper and those that I continue to send to you.  This Journal is OPEN ACCESS which means I can send it out to you.  The KEY is to not worry so much about the details if you are getting started.  GET THE BIG PICTURE.  Understand that neurosurgery is acknowledging spinal balance, we are an integral part of that process for the patient.   These papers are not about reaching any sort of conclusion, that is what research is all about.  It is about LEARNING together, start reading today...

Bill,

I read the study.  Its great to try to quantify things like CBP (Deed Harrison) does but the biomechanical ideal is not reality.  Pettibon and Harrison have always seen the spine as a mechanical model.  Biomechanical Algorithms usually fail because they do not account for all the variables.  The conclusions are then weak.  Whiile the perfect cervical curve would be "nice" the fact is that many patients never will have this and slamming them into the "ideal spine" will not improve their outcomes.  

I concur that pre surgical manipulation+ instruction in proper biomechanics + extension exercises will improve outcomes after surgery.

STORY: Last week. 52 y/o pt with history of C5-6 fusion has a CC of Left arm pain and neck P.  L tricep is perhaps 10% of normal power. I want to check the stability of his fusipn before tx.  Send him to neuro surgeon who did the fusion.  MD does exam , MRI and CT. 'Doesn;t send me a report or call.  Pt comes back.  Says MD wants to do surgery on the disc above the fusion (C4-5) and below ( 6-7)  I review MRI.  Only the 6-7 disk is protruding.  Neuro findings show dramatic weakness of the left triceps but ASLO finger extention, lumbricals and index to thumb but the delts and biceps are fine. 

What disk level is most likely involved? 

Peter,

That’s study is only one in a series that is started in 2015, I will be putting to gather more information shortly. One single study is not meant to change how we perceive patient care or objectification of spinal inbalance. The key in this type of study is to be reading outside of the chiropractic profession.  although you quoted some of the most prominent name is in Chiropractic research we also have to look at what medicine is publishing. We can only work together if we understand each other (chiro and med) and that’s part of the process. Additionally we can only TEACH MDs if we understand what their mindset is, that is a blend of their experience, medical education and the research being published in THEIR journals.  I agree with you that there is no “perfect” spine, or maybe an ideal one either. However what we’re really interested in is balancing the loads from Occiput to sacrum on each individual patient. The point of analyzing the biomechanics is to help to get the patient there as quick as possible. That is the one thing that medicine is always struggled with in justifying Chiropractic, there has not been a way “objectify” what we do.

Getting to your clinical Question, the only way to know exactly what nerve is injures is to have an Electrodiagnostic test which can either be sensory in the form of pain fiber testing (pfncs) or motor in the form of a EMG. The fact that the patient actually has demonstrable weakness is an indication for surgery that’s exactly why the surgeon is looking to do that, our job is not to get miffed by that or upset with that but to help the patient as best we can by offering a biomechanical analysis of this pain pattern AND use that patient to educate the neurosurgeon and collaborative care.

What I suggest and this is exactly what I would do clinically, is I would analyze the cervical spine for biomechanical alterations using Dr. Ray Wiegand  software. I know you don’t have access to that but I do, I use it on a weekly basis. If you can send me the radiographs of the patient of the cervical spine (lateral, AP and flexion extension) as well as AP and lateral thoracic so I can have that digitize for you this week. If you do t have them please reshoot them.  Then we will take that data and you’ll meet with the neurosurgeon to discuss how the biomechanical and anatomical components are contributing to this pain pattern. Only when we raise our game to the highest level and offer concrete objective tools to help patients will you be able to really generate interprofessional referrals. This is exactly how it’s done and let me help you to make sure it works.

Here is a more detailed assessment of your patient’s findings.  I would also like to schedule a time on Monday to do a Gotomeeting to view the MRI with you.  What time can you do that?  Additionally, I am going to be scheduling GRAND ROUNDS starting in the next 1-2 weeks that will be an evening for 1 hour during the week.  I have to pick a day, HOWEVER I may use this case.  ITS A GOOD ONE! “)

STORY: Last week. 52 y/o pt with history of C5-6 fusion has a CC of Left arm pain and neck P.  

L tricep is perhaps 10% of normal power.  - This muscle’s motor innervation is by radial nerve which also innervates the wrist extensors and finger extensors providing motor function.   Radial nerve comes from the brachial plexus which contains branches from C5, C6, C7, C8 and T1.  Deltoid is axillary nerve which is nerve roots C5 and C6.  Biceps is innovated by musculocutaneous nerve which is nerve levels C5-C7.  So as you know there is considerable overlap in the innervation, BUT there is also some redundancy that would allow us to hone in on the level if injury. That is where the MRI comes in as well as the electrodiagnostic testing.  REMEMBER though, that a surgeon will not WAIT on motor weakness for surgery.

I want to check the stability of his fusipn before tx.  Did you order flex/extension films?

Send him to neuro surgeon who did the fusion.  MD does exam , MRI and CT. 'Doesn;t send me a report or call.  Have the patient sign Records Release and send over to them to get the report.  Did you send a written order to the surgeon or a copy of your last eval, or did you just tell the patient to call?  In order to be a player you have to have clinical information in the game, we can talk more about that…Also, I would like to know the “profile” of the surgeon, young, old etc. 

 Pt comes back.  Says MD wants to do surgery on the disc above the fusion (C4-5) and below ( 6-7)  I review MRI.  Only the 6-7 disk is protruding.  Neuro findings show dramatic weakness of the left triceps but ASLO finger extention, lumbricals and index to thumb but the delts and biceps are fine.   Lets review this together then correlate with the above review of neuroanatomy.   I LOVE THIS STUFF!!! 

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