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.
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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.