Category: Research Review

Pre-existing Injuries Increase Bodily Injury

by Dr. William J. Owens, D.C., D.A.A.M.L.P.

 

In practice, there are many challenges to overcome when rendering a proper diagnosis, prognosis and treatment plan. None is more challenging than establishing causal relationship in patients that have pre-existing degenerative changes in their spine and surrounding tissues. Degenerative changes include intervertebral disc herniation (one or more levels), surgical fusion (one or more levels), spondylosis and hypertrophy of the ligamentum flavum, to name a few. How do pre-existing changes affect the forces of trauma? Does this put the body at increased risk?

Until recently, there has been little information to be found in peer reviewed, Medline indexed journals addressing this frustrating clinical presentation. In order to properly protect the patient and diagnose what is truly related to the traumatic event, we can look to a very recent publication, Defining the “older” crash victim: The relationship between age and serious injury in motor vehicle crashes, Newgard, Craig 2008. This manuscript was published in Accident Analysis & Prevention 40 (2008) 1498-1505.

Accident Analysis & Prevention provides wide coverage of the general areas relating to accidental injury and damage, including the pre-injury and immediate post-injury phases. Published papers deal with medical, legal, economic, educational, behavioral, theoretical or empirical aspects of transportation accidents, as well as with accidents at other sites. Selected topics within the scope of the Journal may include studies of human, environmental and vehicular factors influencing the occurrence; type and severity of accidents and injury; the design, implementation and evaluation of countermeasures; biomechanics of impact and human tolerance limits to injury; modeling and statistical analysis of accident data; policy, planning and decision-making in safety.

This paper looked to establish a baseline age in which trauma victims can expect to be injured more severely in a motor vehicle accident. Is there a distinct relationship between the age of the occupant and the severity of the injury? This study included 100,156 adult front seat passengers, of which 14,128 were seriously injured. While mortality in drivers seems to be a major focus in research, serious injury continues to be a serious issue in morbidity and mortality, especially in the elder population. The author writes, “One question that arises from these results is why age is such an important predictor of injury. Age is a surrogate for increasing rates of comorbid conditions (e.g., cardiovascular disease, diabetes, pulmonary disease, renal dysfunction), any of which may result in increased morbidity and mortality after injury.” (Newgard 2008, p1503). The paper goes on to say, “However, the assessment of serious injury as the outcome may be less affected by the presence of comorbid conditions and more reflective of the inherent physical intolerance to the biomechanical stress of traumatic events. That is, as occupants age, they become inherently more fragile and less tolerant to the multitude of forces involved in a MVC.” (Newgard 2008, p1503). What the author actually demonstrated in this article is that chronological age has less to do with injury severity than physiological age. We all know patients that age gracefully and those that unfortunately do not. When assessing the trauma patient, physiologic age will have an important influence on diagnosis and prognosis of the injury. Factors that are influenced by physiologic age include:

1. Reduced Tissue Elasticity—This factor has a profound impact on how forces are distributed during a traumatic event. A flexible spine is more resilient than a stiff spine. This also includes surgical or developmental fusion.

2. Decreased Bone Density—The more brittle the bone matrix, the more susceptible the victim is to compression fractures and acute Schmorl’s Nodes. Bone mass can be affected by early entry into menopause, smoking, lack of weight bearing exercises and some metabolic/hormonal disorders.

3. Damaged Vascular Beds—Ligament and tendinous structures have limited vascularization, which prolongs healing time and increases the risk of re-injury. With increased physiologic age, these conditions get worse. Examples include cardiovascular disease, pulmonary disease, smoking and diabetes mellitus. Patients with vascular claudication may be at a much higher risk as well.

When evaluating patients for potential causally related injuries, the physiologic age of the victim is a very important concept to address. This should not only be considered during the evaluation process, but it also needs to be articulated to the patient. This not only helps to justify care but will also increase patient compliance.

 

Each issue, a clinical topic will be provided by Dr. William J. Owens of the American Academy of Medical Legal Professionals (AAMLP), which is a national non-profit organization comprised of doctors and lawyers. The purpose of the organization is to provide its members with current research in trauma and spinal-related topics to keep the professional on the cutting edge of healthcare. Members may also sit for a Diplomate examination and be conferred a DAAMLP. The organization also offers support to the individual member’s practice. To learn more, go to www.aamlp.org or call 1-716-228-3847.

 

The above review is provided for educational purposes only. It is not designed or intended to reproduce or replace the authors’ work. Readers are encouraged to obtain full licensed versions of the article as determined by Copyright Law. For information on how to obtain a licensed copy, please contact the Academy and Dr. Owens directly at [email protected].

Controlling that Carotid Artery

by Dr. Daniel J. Murphy D.C., D.A.B.C.O.

 

KEY POINTS FROM DR. DAN MURPHY

1. Intima-media thickness is a measure of arterial atherosclerotic stenosis. In patients with severe carotid artery stenosis, consumption of 3 oz. of pomegranate juice reduced intima-media thickness as follows:

3 months 13%

6 months 22%

9 months 26%

12 months 35%

2. In contrast, the control group that did not consume pomegranate juice, carotid intima-media thickness increased by 9% during one year.

3. Serum total antioxidant status was increased by 130% after one year of pomegranate juice consumption.

4. Systolic blood pressure was reduced after one year of pomegranate juice consumption by 21%.

5. Oxidative stress is a major contributor to cardiovascular diseases. “Oxidized low density lipoprotein is linked to atherosclerosis.” Pomegranate juice “possesses impressive antioxidative properties due to its polyphenolics, tannins and anthocyanins.”

6. Pomegranate juice “administration to the patients substantially reduced their serum oxidative status and could, thus, inhibit serum lipid peroxidation.”

7. “Pomegranate juice consumption resulted in a significant reduction in the levels of LDL associated lipid peroxides by up to 90% after six months.”

8. “A substantial increase in the lesion glutathione (GSH) content, by 2.5-fold, was observed after pomegranate juice consumption for three or twelve months.”

9. “The present study clearly demonstrates for the first time that pomegranate juice consumption by patients with carotid artery stenosis possesses anti-atherosclerotic properties, as it significantly reduced common carotid intima-media thickness in association with a decrement in systolic blood pressure, and a substantial inhibition of lipids peroxidation in serum and in LDL.”

10. “Pomegranate juice was used in our study as the antioxidant of choice, as it is very rich in polyphenols and demonstrates high capability to scavenge free radicals and to inhibit LDL oxidation in vitro and in vivo.”

11. “A reduction in oxidative stress was demonstrated already after one month of pomegranate consumption, (though it was much more pronounced with duration of pomegranate consumption).”

12. Substantial inhibitory effects of pomegranate consumption on carotid atherosclerosis were demonstrated after nine to twelve months.

13. “The ability of pomegranate juice to inhibit LDL oxidation could be related to the high potency of pomegranate juice major polyphenols (tannins and anthocyanins) to scavenge free radicals.”

14. “Pomegranate juice contains very potent anti-oxidants.”

15. Another anti-atherogenic effect of pomegranate juice consumption that leads to decreased intima-media thickness is its blood pressure lowering effect.

16. “In humans, pomegranate juice consumption (by patients with carotid artery stenosis) possess anti-atherosclerotic properties, as it substantially decreased serum oxidative stress and, in parallel, reduced common carotid intima-media thickness.”

17. The results of the present study, thus, suggest that pomegranate juice consumption by patients with carotid artery stenosis decreases carotid intima-media thickness and systolic blood pressure and these effects could be related to the potent antioxidant characteristics of pomegranate juice polyphenols.

 

COMMENT FROM DAN MURPHY: Our family, and many friends, colleagues, and patients consume a daily nutrient shake. The juice we use in the shake is pomegranate juice.

Dr. Dan Murphy graduated magna cum laude from Western States Chiropractic College in 1978. He received Diplomat status in Chiropractic Orthopedics in 1986. Since 1982, Dr. Murphy has served part-time as undergraduate faculty at Life Chiropractic College West, currently teaching classes to seniors in the management of spinal disorders. He has taught more than 2000 postgraduate continuing education seminars. Dr. Murphy is a contributing author to both editions of the book Motor Vehicle Collision Injuries and to the book Pediatric Chiropractic. Hundreds of detailed Article Reviews, pertinent to chiropractors and their patients, are available at Dr. Murphy’s web page, www.danmurphydc.com

Review by Dan Murphy, D.C

 

Journal of Bone and Joint Surgery – British Volume,
Volume 92-B, Issue 6, pp. 853-855
J. Rooker, M. Bannister, R. Amirfeyz, B. Squires, M. Gargan, G. Bannister

Key Points

This is the longest study of whiplash-injured patients that I have seen in the PubMed database: a 30-year follow-up study. The results are: Continue reading “Neck Disability: 30-Years Post Whiplash”

Notes:

Elizabeth Blackburn, from the Department of Biochemistry and Biophysics, University of California, San Francisco, was awarded the Nobel Prize in Medicine/Physiology, October 2009, for her work pertaining to telomeres.

Background

In 1953, Leonard Hayflick, Ph.D., from the University of California, San Francisco, discovered that human cells divided about 50 times, and then die. This is known as the Hayflick Limit. Dr. Hayflick continues to research and publish on human aging and longevity.

About 30 years ago, scientists discovered the reason for the Hayflick Limit was telomeres. Telomeres are short caps of DNA on the ends of chromosomes. Each time the cell divides, the telomere shortens a little. When most of the telomere disappears, the cell dies. Consequently, telomere length has been proposed as a marker of biological aging.

Continue reading “Effect of Omega-3 Fatty Acid Levels Shown to be Significant in Telomeric Aging”

Key Points from Dan Murphy, D.C.

1) “The Departments of Agriculture and Health and Human Services recommend daily intake of less than 5.8 g of salt (2300 mg of sodium), with a lower target of 3.7 g of salt per day for most adults (persons over 40 years of age, blacks, and persons with hypertension).”

2) Despite these guidelines, the average man in the US consumes about 10.4 g of salt per day and the average woman 7.3 g per day.

3) The US diet is high in salt, and most of this salt comes from processed foods. “75 to 80% of the salt in the US diet comes from processed foods, not from salt added during food preparation or consumption.”

4) “Despite evidence linking salt intake to hypertension and cardiovascular disease, dietary salt intake in the U.S. is on the rise.”

5) Reducing dietary salt by 3 g per day (1200 mg of sodium per day) is projected to reduce the annual number of new cases of:

CHD by 60,000 to 120,000

Stroke by 32,000 to 66,000

Myocardial

infarction by 54,000 to 99,000

Annual number of deaths from

any cause by 44,000 to 92,000

6) In reducing dietary salt by 3 g per day, “all segments of the population would benefit, with blacks benefiting proportionately more, women benefiting particularly from stroke reduction, older adults from reductions in CHD events, and younger adults from lower mortality rates.”

7) Reducing salt intake by 3 g per day would save 194,000 to 392,000 quality-adjusted life-years and $10 billion to $24 billion in health care costs annually.

8) “Reducing dietary salt lowers blood pressure and the risk of cardiovascular disease.”

9) “All adult age groups, both sexes, and blacks and nonblacks would be expected to benefit from reductions in salt intake.”

10) “Our postulated dietary reduction of 3 g of salt per day, which is within the range targeted by other developed countries, is projected to benefit the entire US population and yield substantial reductions in morbidity, mortality, and health care costs.”

11) “The magnitude of the health benefit suggests that salt should be a regulatory target of the Food and Drug Administration, which currently designates salt as a food additive that is ‘generally regarded as safe’.”

12) The benefits of salt reduction may be even greater than we have projected “by lowering salt intake even earlier, during childhood and adolescence.”

13) “Modest reductions in dietary salt would yield substantial health benefits across the US population of adults by lowering rates of cardiovascular events and death and reducing medical costs.”

 

Dr. Dan Murphy graduated magna cum laude from Western States Chiropractic College in 1978. He received Diplomat status in Chiropractic Orthopedics in 1986. Since 1982, Dr. Murphy has served part-time as undergraduate faculty at Life Chiropractic College West, currently teaching classes to seniors in the management of spinal disorders. He has taught more than 2000 postgraduate continuing education seminars. Dr. Murphy is a contributing author to both editions of the book Motor Vehicle Collision Injuries and to the book Pediatric Chiropractic. Hundreds of detailed Article Reviews, pertinent to chiropractors and their patients, are available at Dr. Murphy’s web page, www.danmurphydc.com.

KEY POINTS FROM DR. DAN MURPHY

1) The results of this study are “the most comprehensive and comparable quantitative assessment of the mortality burden of important modifiable risk factors in the US population, and the only one to include the effects of multiple dietary and metabolic factors.”

2) “A number of modifiable factors are responsible for many premature or preventable deaths. For example, being overweight or obese shortens life expectancy, while half of all long-term tobacco smokers in Western populations will die prematurely from a disease directly related to smoking.”

3) “Of the 2.5 million US deaths in 2005, they estimate that nearly half a million were associated with tobacco smoking and about 400,000 were associated with high blood pressure.” These two risk factors, therefore, each accounted for about 1 in 5 deaths in US adults.

4) “Overweight, obesity and physical inactivity were each responsible for nearly 1 in 10 deaths.”

5) “Among the dietary factors examined, high dietary salt intake had the largest effect, being responsible for 4% of deaths in adults.”

6) Findings: US deaths from risk factors, 2005

 

Tobacco smoking	467,000
High blood pressure	395,000
Overweight–obesity	216,000
Physical inactivity	191,000
High dietary salt	102,000
Low dietary omega-3 fatty acids	84,000
High dietary trans fatty acids	82,000
Alcohol use	64,000

 

Although 26,000 deaths from ischemic heart disease, ischemic stroke, and diabetes were averted by current alcohol use, they were outweighed by 90,000 deaths from other cardiovascular diseases, cancers, liver cirrhosis, pancreatitis, alcohol use disorders, road traffic and other injuries, and violence.

7) “The mortality-reducing effects of omega-3 fatty acids and of replacing saturated fatty acids (SFA) with polyunsaturated fatty acids (PUFA) have been confirmed in randomized trials.” [IMPORTANT]

8) In the year 2005, 2,448,017 US residents died.

A)) 96% percent of all deaths in the US were in people ≥30 yrs. of age.

9) The four most common causes of death were:

 

Ischemic heart disease	434,000 deaths
Lung cancer	163,000 deaths
Stroke	150,000 deaths
Chronic obstructive pulmonary diseases	124,000 deaths

 

10) “The single largest risk factor for cardiovascular mortality in the US was high blood pressure, responsible for an estimated 395,000 cardiovascular deaths (45% of all cardiovascular deaths), followed by overweight–obesity, physical inactivity, high LDL cholesterol, smoking, high dietary salt, high dietary trans fatty acids, and low dietary omega-3 fatty acids.”

11) “Smoking had the largest effect on cancer mortality compared with any other risk factor, causing an estimated 190,000 (184,000–194,000) or 33% of all cancer deaths.”

12) “40% or more of all deaths attributable to high LDL cholesterol, overweight–obesity, high dietary trans fatty acids, low dietary PUFA and omega-3 fatty acids, low intake of fruits and vegetables, alcohol use, and smoking occurred before 70 years of age.”

13) “Smoking was by far the leading cause of death in both men and women ≤70 years, followed by overweight–obesity.”

14) “29% of the chronic disease mortality effects of alcohol use occurred among heavy drinkers (i.e., men who consumed more than 60 grams of pure alcohol or 4 drinks per day and women who consumed more than 40 grams per day); this group did not have any mortality benefits from alcohol use. In contrast, in those who had light alcohol consumption (up to 40 g per day for men and 20 g per day for women), the protective effects on ischemic heart disease and diabetes mortality were larger than the hazardous effects from other chronic diseases, leading to an overall reduction in mortality in this group.”

[As long as one does not drink and drive a vehicle, 2 alcoholic drinks per day for men and 1 alcoholic drink per day for women reduces their chance of death; however, any more than that and alcohol increases death.]

15) “If the entire adult US population had light alcohol consumption, a total of 12,000 cardiovascular deaths would be prevented, largely among adults aged ≥45 y. However, this level of alcohol consumption would also cause an estimated 8,000 deaths due to road traffic accidents, largely among adults aged <30 y.”

16) One hour of vigorous physical activity per day would prevent 62,000 deaths per year compared to doing only 20 min of moderate activity every day.

17) “The results of our analysis of dietary, lifestyle, and metabolic risk factors show that targeting a handful of risk factors has large potential to reduce mortality in the US, substantially more than the currently estimated 18,000 deaths averted annually by providing universal health insurance.”

COMMENTS FROM DR. DAN MURPHY:

In light of current discussion concerning universal health insurance, this article notes that vigorous exercise would save 3.4 times the lives (62,000) as would universal health insurance coverage (18,000).

High blood pressure is a significant problem in America. This underscores the importance of the results of the 2007 article by Marshall Dickholtz, D.C:

G. Bakris, M. Dickholtz Sr., P. M. Meyer, G. Kravitz, E. Avery, M. Miller, J. Brown, C. Woodfield and B. Bell. Atlas vertebra realignment and achievement of arterial pressure goal in hypertensive patients: a pilot study. Journal of Human Hypertension. March 2, 2007.

 

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Dr. Dan Murphy graduated magna cum laude from Western States Chiropractic College in 1978. He received Diplomat status in Chiropractic Orthopedics in 1986. Since 1982, Dr. Murphy has served part-time as undergraduate faculty at Life Chiropractic College West, currently teaching classes to seniors in the management of spinal disorders. He has taught more than 2000 postgraduate continuing education seminars. Dr. Murphy is a contributing author to both editions of the book Motor Vehicle Collision Injuries and to the book Pediatric Chiropractic. Hundreds of detailed Article Reviews, pertinent to chiropractors and their patients, are available at Dr. Murphy’s web page, www.danmurphydc.com. TAC

 

Side or lateral impacts are the second most severe type of motor vehicle collision and have a very different effect on the body.

 

The forces transmitted from the bullet car to the target car are different from those of a frontal or rear collision. There are many different considerations to be aware of, but none is as unique as the near versus the far side occupant response. If the impact was from the passenger side of the vehicle, the forces and kinetic energy have a different effect on the passenger than they do on the driver. In a paper published in 2006 by Kumaresan, et al., at the Proceedings of the 28th IEEE EMBS Annual International Conference in New York City, NY, the authors tackled the issue of the effectiveness of the three point safety belt on the driver of a far side collision. The three point harness is the typical seat belt consisting of a lap belt and a diagonal shoulder harness. The authors state: “However, the lap/shoulder restraint is not effective in a far-side crash (impact is opposite to the occupant location) since the occupant may slip out of the shoulder harness.” (pg 87)  

In fact, in a study done in 1991, “The study found that the AIS 2+ head injury was twice as much in far-side impacts compared to near-side crashes.” (pg 87) Further into this paper, the authors mention another study stating: “Diggs and Dalmatos also conducted vehicle to vehicle crash tests with 60 degree crash vectors and found that the shoulder belt was ineffective in preventing the head extrusions.” (pg 89) This study showed that the impact of the driver’s side occupant was to the passenger door panel. That should give you something to think about; I know it did for me. If you are not completely familiar with the AIS and MAIS injury scales, please email me directly and I will provide you with a FREE description of what the different levels represent in chart form from the Academy archives.

It is important to understand the basics of body kinematics in the frontal, rear and side impact crashes. This is beneficial to the clinician, as it allows us to focus our attention on the areas that are most commonly injured. When we are discussing these injuries in a medical-legal context, research is critical. Research allows us to compare our single crash victim to an entire cohort involved in a research study. This puts the causality portion of the injury in perspective and allows us to concentrate on correlating the traumatic event to the bodily injury and, then, to the patient’s functional losses. Side impacts are a different animal and they have to be treated as such. Specific examinations, such as brainstem evaluations, cranial nerve examinations and advanced imaging procedures, may be more commonly used since the possibility of head trauma in a far sided lateral impact is twice that of other vectors. Being familiar with research not only increases your credibility as a patient advocate, it also allows you to look a patient in the eye and honestly say, “You are not alone.”

In each issue, a clinical topic will be covered by Dr. William J. Owens of the American Academy of Medical Legal Professionals (AAMLP), which is a national, non-profit organization, comprised of doctors and lawyers. The purpose of the organization is to provide its members with current research in trauma and spinal related topics, to keep the profession on the cutting edge of healthcare. Members may also sit for a Diplomate examination and be conferred a DAAMLP. The organization also offers support to the individual member’s practice. To learn more, go to www.aamlp.org or call 1-716-228-3847.

Key Points from Dr. Dan Murphy

1. “Dr. Ruth Jackson was the first woman physician to be elected to membership in the American Academy of Orthopedic Surgery and to be certified by the American Board of Orthopedic Surgery.”

2. At least half of patients suffering from cervical syndrome causing shoulder disability will also complain of headache as one of their principle symptoms.

3. The cervical syndrome is caused by “cervical nerve root irritation.”

4. There is a relationship between the cervical syndrome, cervical nerve root irritation, and the sympathetic nervous system. It is this sympathetic nervous system involvement that is responsible for headaches, including migraines.

5. “The cervical nerve roots are more vulnerable to pressure or irritation from ruptured discs, hemorrhage, inflammatory processes of the capsules, spurs, and abnormal motion of the joints due to relaxation or tearing of the capsular and ligamentous structures.” [NOTE: “abnormal motion of the joints.”]

6. “Irritation of the cervical nerve roots before they divide into anterior and posterior primary rami may occur as a result of any mechanical derangement in or about the intervertebral foramina. The most common cause of irritation is abnormal motion or subluxation of the joints due to relaxation of the capsular and ligamentous structures following trauma.”

7. Following whiplash trauma, as time passes, “abnormal motion or subluxations of the articular processes will cause irritation of one or more nerve roots.”

8. “Any unguarded motion or prolonged relaxation of the neck in one position may allow a subluxation to occur,” which may cause cervical nerve root irritation.

9. In a patient with a “crick in the neck” the “crick is a result of cervical nerve root irritation from subluxation, pressure from a ruptured disc, or irritation from an inflammatory process in the capsules.”

10. Cervical trauma can cause chronic pain syndrome, including pain, decades later.

11. If the C1-C2-C3 nerve roots are involved, typical symptoms include:

A. Neck pain

B. Limitation of neck motion

C. Headache, which usually “starts at the back of the neck or base of the skull and then involves one or both sides of the head, and pain in the mastoid region or in the ears”

D. Blurring of the vision (found in 20% of patients)

E. Dizziness and nausea

F. Numbness of the sides of the neck

G. Tightness of the neck muscles

H. Pain in the supraclavicular region

12. “If C4 is involved, there may be shortness of breath, palpitations, anterior chest pain and pain and muscle spasm in the muscles supplied by C4.”

13. “When the lower nerve roots are involved, the symptoms are commensurate with the segmental character of the nerve roots which are irritated.” These patients often have numbness or tingling of the fingers when they awaken.

14. “There is always tenderness to deep pressure over the vertebrae, usually just lateral to the spinous process of the side of the nerve root irritation.” [Important] “If the irritation is above the fourth nerve root, there may be tender areas over the occiput and the mastoid. If the fourth nerve root is involved, there may be tender areas in the ridge of the trapezius and/or in the sternomastoid muscles.”

15. “The most constant finding in all of our cases was the presence of myalgic areas in the upper or lower cervical portion of the rhomboid muscles, which is indicative of fifth nerve root irritation.”

16. “Often there seems to be localized fibrosis of the muscle. Irritation causes spasm which, if allowed to persist, causes ischemia with eventual formation of localized fibrosis.” [Important, Fibrosis of Repair].

17. “X-rays of the cervical spine are of real diagnostic aid in cervical nerve root irritation.” A Davis series of X-rays must be taken in all cervical trauma cases, and emphasize the importance of maximum flexion and maximum extension views.

18. “In 70% of cases, there is obliteration of the curve and, in 20% of these, a segmental reversal of the [cervical lordotic] curve.

19. The abnormal forward or backward slipping of a vertebral segment on flexion or extension is called a “subluxation.” Ninety percent of patients have forward subluxations and 56% have backward subluxations.

20. Ninety-six percent of patients with cervical syndrome headaches will show subluxations at more then one level and, in 77%, the subluxation was of C2 on C3, irritating the C3 nerve root. “This indicates that the irritation of the third cervical nerve root must have been responsible for the greatest percentage of headaches.”

Notice how often Dr. Jackson uses the concept and word “subluxation” and nerve irritation.

21. Dr. Jackson believes that the blurring of the vision (and ipsilateral pupil dilation, when present) seen in many cervical syndrome/headache patients is caused by irritation of the superior sympathetic ganglion caused by cervical muscle spasm.

22. “Cervical nerve root irritation (C3 usually) is an etiological factor in migraine.”

23. “The upper cervical nerve roots supply the major portion of the scalp, the middle and posterior scalenes, and the sternomastoid muscles. Spasm of these muscles which surround the superior sympathetic ganglia may, and do, cause irritation of the ganglia or the postganglionic fibers. Therefore, irritation of the upper cervical nerve roots (C2 to C4), with or without the associated irritation of the cervical sympathetics, can certainly cause symptoms of migraine.”

Dr. Dan Murphy graduated magna cum laude from Western States Chiropractic College in 1978. He received Diplomat status in Chiropractic Orthopedics in 1986. Since 1982, Dr. Murphy has served part-time as undergraduate faculty at Life Chiropractic College West, currently teaching classes to seniors in the management of spinal disorders. He has taught more than 2000 postgraduate continuing education seminars. Dr. Murphy is a contributing author to both editions of the book Motor Vehicle Collision Injuries and to the book Pediatric Chiropractic. Hundreds of detailed Article Reviews, pertinent to chiropractors and their patients, are available at Dr. Murphy’s web page, www.danmurphydc.com

When evaluating a patient that was traumatically injured, there are two important aspects to consider. The first is rendering an accurate diagnosis and the second is clearing the patient to administer the chiropractic adjustment. Both are important to the patient’s health, your license and your reputation as a doctor. In an important article published some time ago in Spine, the authors took a look at the effects of a narrowed central canal pre-disposing a trauma victim to further neurological injury. In other words, would a patient with congenital or spondylitic stenosis of the central canal be susceptible to worse injury when compared to a healthy control?

The authors state: “The available space occupied by the spinal cord and nerve roots is determined primarily by the diameter of the bony spinal canal.” (p1996) They also state: “The purpose of this study was to evaluate the relation between the severity of concurrent neurologic symptoms after soft cervical disc herniation and the sagittal and transverse diameters of the bony spinal canal, the cross sectional diameter of the bony spinal canal, the minimal intervertebral foramen diameter, and the sagittal diameter of the hernia.” (p1996) Interestingly, the authors reference an article from 1954 which “defined” developmental stenosis as a narrowing of the bony spinal canal caused by an inadequate development of the vertebral arch. Although this stenosis often remains asymptomatic over time, it can become a major influence in the production of radiomyelopathic compressors disturbances and other conditions such as spondylosis discal hernia, and trauma become superimposed.” (p1999)

When evaluating the traumatically injured patient, taking into consideration the anatomy prior to the traumatic event is an important aspect of your diagnosis, prognosis and treatment plan. It gives you a safer platform to operate from and will allow you to confidently render a safe chiropractic adjustment, especially in patients with pre-existing conditions or congenital abnormalities.

A multidisciplinary approach is the most effective way to accomplish this type of evaluation. If you are regularly examining and treating the traumatically injured, building a “dreamteam” of spinal specialists in your area will not only increase your effectiveness as a practitioner but will also solidify your reputation as the “go to” doctor when you’re injured. Focusing on the diagnosis and coordination of care, even in patients who are out of the paradigm of conservative care, will allow you to maintain a positive relationship with the patient for life.

The authors concluded from the study that “the severity of the neurological symptoms after soft cervical disc herniation is determined by the relation between the sagittal diameter of the bony spinal canal and the sagittal diameter of the hernia.” (p2001) Finally and most profoundly they conclude, “people with a sagittal diameter and cross-sectional area of the bony cervical spinal canal significantly smaller than those of normal healthy individuals seem to be more susceptible to the development of neurologic symptoms in the event of soft cervical disc herniation.” (p2001) 

  

As clinicians, we understand that all bodies are not created equal, and everybody responds to trauma to different degrees. That is why patients do not fit into a flowchart, algorithm or pre-determined treatment plan. They deserve and require a competent doctor that truly understands human anatomy and the effects traumatic forces have on those structures. That is why, in the medical-legal arena correlating bodily injury to causality and ensuing functional loss, is what will ultimately determine the outcome of their case. Understanding how bodily injury affects different patients is the foundation of becoming an expert in the medical-legal arena.

Disclaimer: The above preview is provided for educational purposes only. It is not designed or intended to reproduce or replace the author’s work. Readers are encouraged to obtain full licensed versions of the full article as determined by Copyright Law. For information on how to obtain a licensed copy, please contact the Academy directly.

In each issue, a clinical topic will be covered by Dr. William J. Owens of the American Academy of Medical Legal Professionals (AAMLP), which is a national, non-profit organization, comprised of doctors and lawyers. The purpose of the organization is to provide its members with current research in trauma and spinal related topics, to keep the profession on the cutting edge of healthcare. Members may also sit for a Diplomate examination and be conferred a DAAMLP. The organization also offers support to the individual member’s practice. To learn more, go to www.aamlp.org or call 1-716-228-3847.