Ever since my early days in chiropractic college, I have heard speakers comment on the prevention of surgery with chiropractic care. I have always wondered, however, where the actual evidence was. If this statement is true, it would be nice to have some legitimate evidence. Now that chiropractic has emerged into the military and community hospital system, perhaps those of us who are hospital-based chiropractors need to give a report of findings of surgical cases.
In my hospital setting, I routinely evaluate and treat spinal cases with radiculopathy findings that ultimately are seen by a spinal surgeon. So, here is the report of findings for the previous year, July 2006 through July 2007.
We performed a retrospective review and located 162 patients diagnosed with radiculopathy. Data reviewed were initially collected at baseline, during and at the end of active treatment. The treatment basis retrospectively reviewed was manipulation, neuromobilization and exercise stabilization. Of the 162 total cases reviewed, 85.5 percent resolved their radicular complaints. There were three unresolved cases that underwent surgery. This represents 1.85 percent of the 162 total cases, and none of these three cases showed any symptom improvement prior to referral.
As reported by our radiologist, the radiographs demonstrated straightening of the normal cervical curvature, posterior osteophytes on the left at C4-5, C5-6, C6-7. There was also flexion subluxations note C2 on C3, C3 on C4, C4 on C5 with 15-degree flexion instability at C4-5 during flexion with overpressure (Figures 1a and 1b).
In this case of cervical spine radiculopathy, low-velocity mani-pulation techniques, namely dis-traction manipulation (DM) and motion-palpation technique (MPT), were utilized. The maneuvers were always delivered in a direction that did not cause peripheralization of the pain, which consisted predominantly of cervical lateral flexion and cervical translation.
Neuromobilization was used, which is a manual/exercise-oriented method theorized to mobilize nerve roots that are suspected to be the source of nerve-root pain. It was performed on the ulnar nerve root, which was suspected through examination to exhibit neural tension. With this method, tension was gently applied to the involved nerve roots, which caused mild "pulling," but no pain during in-office treatment. A low-amplitude repetitive movement was introduced in the direction of perceived neural tension for at-home exercise. The complete technique can be performed on any adjusting table, but particularly one with cervical motion that accommodates cervical passive motion during the specific neuromobilization procedure.
The spine stabilization procedures utilized are progressive, meaning beginning procedures are performed prior to intermediate and advanced procedures. The patient was given a handout of each actual procedure, along with a DVD of the procedures to be performed. The patient demonstrated the assigned procedure correctly before they left the office. The cervical spine stabilization progressions utilized were:
What does our evidence show? Other than this one case, it is impossible to determine how many of the resolved cases may have elected for surgery. Recently, Thomas2 assessed the health-related quality of life after lumbar disc protrusion causing radiculopathy (as measured by the North American Spine Society neurogenic symptoms score), treated with either microdiscectomy or nonsurgical care. One-year findings demonstrated similar improvement in both treatment groups and were not meaningfully associated with the treatment received. Perhaps chiropractic needs to step up and offer the nonsurgical solution.
References
Many relevant diagnostic signs are not performed deliberately by the examiner or by the patient at the examiner’s direction. They are observed as the patient reacts to their condition. Fortin’s finger sign, Minor’s sign, and Vanzetti’s sign are three examples of this principle.
On Feb. 1, 2024, two more legislators – John R. Carter (R-Texas) and Robert “Bob” Good (R-Va.) – co-sponsored the Chiropractic Medicare Coverage Modernization Act of 2023, bringing the co-sponsor total to 155, two more than the total achieved over the entire two-year congressional cycle in which identical legislation last appeared (2021-22).
While working at the Lovelace Medical Center in Albuquerque, N.M., one of the primary care physicians stated that imaging every patient prior to receiving chiropractic was not medically necessary. It was at that point I reconsidered the need for the imaging of every patient to avoid malpractice.
