Introduction
The history of the chiropractic profession is one of the numerous conflicts with medicine. The authors believe that trends in the current era may be different, based on anecdotes from colleagues.
A recent article in the Journal of Chiropractic Medicine notes “expanded collaboration with and participation in mainstream health care delivery systems,” and “an increasing demand for and acceptance of chiropractic within mainstream allopathic medicine.”1
There are a number of publications in recent literature describing examples of interdisciplinary communication and cooperation, including Doctors of Chiropractic working in military facilities, hospitals, and primary care settings.2-9
In the case described below, interprofessional consultation between the treating surgeon and a DC altered the planned course of treatment and contributed to a successful outcome for the patient.
Presentation
A 15-year-old female patient is presented to a neurosurgery center with back pain, bilateral lower extremity pain, and difficulty walking. Her initial injury occurred in 2012 when she was performing a “clean-and-jerk” type overhead weight press and lost control of the weights.
She suffered a lumbar hyperextension injury and had an immediate onset of back and bilateral posterior leg pain. She was diagnosed with a herniated nucleus pulposus and received conservative treatment that included chiropractic care, physical therapy, thoracolumbar sacral orthosis (TLSO) bracing, and epidural steroid injections.
She continued to have a left lateral flexion deformity, however, and an inability to flex the left hip, which she compensated for by rotating the left pelvis forward and internally rotating the right hip. This resulted in a persistent transverse plane pelvic rotation of approximately 45 to 50 degrees.
Examination
A 2014 physical exam, conducted by the neurosurgery center’s nurse practitioner, revealed no neurological deficits, and quite brisk reflexes—felt most likely to be normal given her young age. She had an obvious coronal shift, with the central vertical axis, shifted to the left, and prominent left-sided paraspinal musculature, but without the “rib hump” that is typically seen with idiopathic scoliosis.
She was able to flex her right hip to 90 percent when standing, but she was unable to do so with the left hip, and she could extend the right hip but not the left. She walked with a somewhat flexed-forward posture. It was suspected that she had developed intractable left-psoas spasm.
In a review of her 2014 lumbar spine MRI study, it was apparent that the patient had 6 lumbar vertebrae. The L5–L6 level was clearly transitional, as evidenced by the morphology of the psoas muscle and the vessels anterior to the spine. There was a large disc herniation at L5–L6 that was primarily central, which caused rather severe spinal stenosis.
There were no formal coronal slices, but on the scout views, the left side of the disc space was quite collapsed, resulting in a significant coronal deformity. A focal kyphotic deformity was noted at L5–L6. In comparing these findings to an MRI done in 2012, she had the same disc herniation at that time, though slightly smaller and without the asymmetric disc space collapse or coronal deformity. The left psoas was clearly shortened; the asymmetrical appearance of the left and right sides may be seen in Figure 1 (coronal, A-P view) and Figure 2 (transverse view).
The MRI was reviewed by the neurosurgeon in collaboration with the chiropractor. The surgeon’s perspective focused on the spinal pathology of the L5–L6 segments; the chiropractor’s view was that the severe spasm of the psoas muscle was key to the overall dysfunction of the patient’s gait.
It was determined that her pain and ambulatory impairment were the results of the disc herniation, unilateral disc-space collapse, and intractable psoas spasms. Her flexed-forward posture was postulated to be an attempt to reduce buckling of the ligamentum flavum and open up the spinal canal.
An anterior lumbar interbody fusion was proposed. To address the dysfunction caused by the psoas muscle spasm, an intraoperative injection of Botox into the left psoas muscle was deemed necessary by the consulting chiropractor. This was accepted as a reasonable treatment option.
Treatment and Response
Surgery was performed in July 2014 and consisted of retroperitoneal exposure of the L5–L6 disc space, extensive discectomy, and placement of a 16 mm polyether ether ketone (PEEK) spacer with 12 degrees of lordosis. The spacer was filled with 5 mL of cellular allograft and local bone from posterior osteophytes.
The spacer was anchored to the L5 and L6 vertebral bodies with two 4.5 x 30 mm screws at L5 and two 4.5 x 25 mm screws at L6. The left psoas was exposed, and the genitofemoral nerve identified. A total of 200 units of Botox were injected at four different sites in the psoas muscle, well away from the genitofemoral nerve, in increments of 50 units.
The patient did well following the operation. Her gait began improving almost immediately. Observation of her gait on post-op day one revealed improvement of her left hip flexion and less pelvic rotation. On discharge, she was referred for gentle psoas stretching.
At her initial follow up appointment two weeks later, she had no complaints of back or leg pain. Her gait had improved markedly, and she was able to ambulate for approximately four hours a few days prior to her visit without significant pain.
Radiographs showed improvement in the coronal deformity.
Discussion and conclusions
The chiropractor brought a perspective of “balance” to the case, in an anatomical sense. While the surgeon focused on the disc injury and its consequences, the chiropractor focused on the psoas muscle imbalance. In the process, both doctors learned something about expanding their viewpoints.
Without the DC’s perspective, the plan for the Botox injection might not have been considered or implemented. The chiropractor agreed that the injection seemed particularly appropriate for this case, as it had the potential for a more rapid impact than the stretching and strengthening methods he would normally have employed, and it seems to have had a lasting effect.
In this case, both the surgeon and the chiropractor were exposed to thinking beyond what they might normally consider in their regular course of practice, and the patient’s outcome was the better for it. Bridges need to be built and cooperation should be sought between chiropractors and surgeons. There are many patients who would benefit from this approach.
By Salvatore Minicozzi, DC, CCEP; Kaveh Khajavi, MD, FACS; Anthony Hutchinson, ACNP; and Brent Russell, MS, DC
Originally Published – ChiroEconomics August 28, 2017
References
1 Bronston LJ, Austin-McLellan LE, Lisi AJ, Donovan KC, Engle WW. A survey of American Chiropractic Association members’ experiences, attitudes, and perceptions of practice in integrated health care settings. J Chiropr Med. 2015;14(4):227-239.
2 Kruse RA, Cambron JA. Large C4/5 spondylotic disc bulge resulting in spinal stenosis and myelomalacia in a Klippel-Feil patient. J Altern Complement Med. 2012;18(1):96-9.
3 Deleo T, Merotto S, Smith C, D’Angelo K. A posterior ring apophyseal fracture and disc herniation in a 21-year-old competitive basketball player: a case report. J Can Chiropr Assoc. 2015;59(4):373-82.
4 Wong JJ, Di Loreto L, Kara A, et al. Assessing the change in attitudes, knowledge, and perspectives of medical students towards chiropractic after an educational intervention. J Chiropr Educ. 2014;28(2):112-22.
5 Salsbury SA, Goertz CM, Vining RD, et al. Interdisciplinary practice models for older adults with back pain: a qualitative evaluation. Gerontologist. 2017; Jan 11. pii: gnw188. doi: 10.1093/geront/gnw188.
6 Green BN, Johnson CD, Daniels CJ, et al. Integration of chiropractic services in military and veteran health care facilities: a systematic review of the literature. J Evid Based Complementary Altern Med. 2016;21(2):115-30.
7 Branson RA. Hospital-based chiropractic integration within a large private hospital system in Minnesota: a 10-year example. J Manipulative Physiol Ther. 2009;32(9):740-8.
8 Garner MJ, Birmingham M, Aker P, et al. Developing integrative primary healthcare delivery: adding a chiropractor to the team. Explore (NY). 2008;4(1):18-24.
9 Kligler B, Brooks AJ, Maizes V, et al. Interprofessional competencies in integrative primary healthcare. Glob Adv Health Med. 2015;4(5):33-9.
For Your Health,
Dr. Salvatore Minicozzi