Objective: A single case study involving a 55-year-old female who presented to a chiropractic office with insidious onset of unilateral low back pain without history of regional trauma or radiculopathy.A second objective was to provide this case's clinical chiropractic rationale of evidence-based spinal radiology of an unusual presentation. A third objective was to provide the radiographic presentation of the pathoanatomy pelvic abnormalities in response to the donor site from a previous cervical fusion surgery as explanative for this patient's low back pain.
I recently reviewed an article on Medscape titled "Evidence-Based Radiology - A Primer for Referring Clinicians and Radiologists to Improve the Appropriateness of Medical Imaging." The article cited that the following practice is outdated and went on to provide rationale for changes: "Most radiological practice is based on anecdote, habit, and a literature that is heavily weighted toward uncontrolled observations and nongeneralizable single-institution research studies. There is genuine reason for concern that a sizable fraction of the medical imaging performed is of marginal value or frankly inappropriate. Inappropriate use means potential harm to patients and wasted expense." The goal of this well-researched article was to bring current radiology rationale into the light (no pun intended).
I wondered then, was this outdated method of thinking how the insurance industry (and those that manage the chiropractic benefit plans) first attempted to establish radiographic criteria for chiropractic X-ray procurement standards? This wasn't the way I and hundreds of other chiropractors were taught after the mid 1990s. Was the chiropractic profession's concept of X-ray imaging "medical necessity" (and hence its "chiropractic protocols" for X-ray imaging) born out of this?
Where are we then as a profession in the development of our rationale? I support the basis of critical thinking or what the Medscape authors coined "diagnostic efficacy." I do this on the basis of the very instruction that influences my practice today: my chiropractic academic curriculum, identified as the LACC "Advantage Program," and Terry Yochum, DC, DABCR (an adjunct professor of radiology at LACC).
For example, the "Chiropractic Physician's Abilities" LACC Advantage Curriculum was predicated on nine abilities that a chiropractic physician should possess upon graduation. It was believed that knowledge, skills and integration were established as essential to being a competent chiropractic physician in the 21st century. I believe the first three of the nine are required to fulfill "diagnostic efficacy": (1) effective communication, (2) diagnostic skills, and (3) reason-based used in science and evidence on practice.
Drs. Dennis Fryback and John Thornbury, citing the Medscape article, proposed a hierarchy of assessment for scientific technology that has stood the test of time with only minimal rethinking. This hierarchy can serve as a framework for understanding how assessing a technology relates to its clinical implementation.1
The first level of evaluation can be called diagnostic efficacy: "How well does the imaging technology detect specific disease conditions?" While diagnostic efficacy is principally of interest to radiologists, clinicians may be more interested in how the information derived from an imaging test affects how they care for patients, represented by the concepts of diagnostic thinking and therapeutic thinking efficacy.
Eliciting these estimations before and after imaging can help determine what imaging adds to diagnostic and therapeutic decision-making.2,3 I propose that these standards must be upheld in chiropractic practice. I present the following case as an example.
History of Present Illness
A 55-year-old nurse presented as an urgent walk-in for initial examination with respect to severe, right-sided low back pain. Reportedly, friends assisted her in hygiene and dress that day. Mechanism reported as several weeks ago insidious onset with immediate low back pain (right > left) without limb pain. That day, the pain level was rated as an 8/10, with 10 being severe pain with moderate interference in activities of daily living. The quality of the pain was aching at lateral hip and stabbing at mid buttock. Provocative: side-bending activity such as picking up after her dog. Palliative: limited relief with Soma, Naproxyn. She was taken off duty by her internist, who reported that she strained her back "somehow." No X-rays were obtained at the PCP examination.
Significant Past Medical History
Surgery: Cervical fusion (C3-7) in 1983; right pelvic crest donor site. Patient frequently calls "hip donor site" (confusing, but patient is actual donor to self and site is really pelvis).
Occupation: The patient has been employed approximately 20 years at a local Medical Hospital in labor and delivery.
Review of Systems
Constitutional: denies low-grade fever, denies weight loss.
Musculoskeletal: no history of painful joints or swollen joints, only recent backache; reports some chronic history of limited movement in her right shoulder. Patient is right-handed.
Neurological: recent history of frontal headaches; denies numbness or weakness.
Statistics: Height: 5'5"; weight: 172 lbs; vital signs: B/P: 140/84 LA; P: 84; RR: 18.
Inspection: splints right lower limb. Posture altered; Tripod sign and Minor's sign exhibited.
Gait: slow with right lower extremity toe-out and hip hiking; no scissors gait or toe steppage.
Palpation: marked myospasm at right psoas, some piriformis. Chiropractic fixations noted throughout lumbopelvis region. Purposeful withdraw at right iliolumbar region.
Percussion: negative spinous test.
Sensory: negative for hypoesthesia.
Thoracic-lumbar spine - active range of motion yields: right bending 20/30; left bending 28/30; left rotation 24/30.
Orthopedic and neurological examination: seated deep tendon reflexes: +2 symmetrically using the Wexler Grading Scale: L4 and S1. Myotone or motor tests and circumferential measurements strong, without atrophy and good symmetry.
The right iliac crest is notably smaller from surgical excision and yields a two-thirds loss in size and height. No osteoblastic or osteolytic features are apparent - this appears consistent with the reported donor site vs. congenital. There is a failure of segmentation of the lumbosacral region identified as a spinal bifida occulta. There is no further evidence of any further gross pathology or obvious fracture. Note: Foreign body evidenced as zipper.
The focus of care places emphasis on patient and internal medicine provider education with referral need for special imaging studies. Patient is with managed care and without any chiropractic benefits; hence, medical referral for imaging is required.
The treatment plan included lumbar brace for anatomical support. Limited lumbar and pelvic radiographs were obtained and palliative intervention with chiropractic care was undertaken. Instructed in immediate follow-up: MD for all duty-status modifications, prescription control and for ordering of special diagnostics to determine extent of pathology and clinical correlation. Technique: flexion/distraction. Muscle therapy to address myofascial component.
Instructed that should symptoms worsen or experience increase pain in sneezing or coughing, or incontinence of stool or urine, to contact 911 and proceed to the emergency room for evaluation. Radiographic release of digital image for internist.
Patient care can be improved by chiropractic physicians becoming more critical readers of the imaging literature, by regular consultation between both the radiologists and referring clinicians about problem cases, by adherence to updated and available appropriateness guidelines, and by clinical documentation of why the chiropractic image obtained was appropriate, even if so-called available "chiropractic" appropriateness guidelines fails to support "medical necessity."
- Fryback DG, Thornbury JR. The efficacy of diagnostic imaging. Med Decis Making 1991;11:88-94.
- Thornbury JR. Intermediate outcomes: diagnostic and therapeutic impact. Acad Radiol 1999;6(suppl 1):S58-S65.
- Tsushima Y, Aoki J, Endo K. Contribution of the diagnostic test to the physician's diagnostic thinking: new method to evaluate the effect. Acad Radiol 2003;10:751-755.
Click here for previous articles by Nancy Martin-Molina, DC, QME, MBA, CCSP.