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Standards of Care for Post-Traumatic Cervical Instability

James J. Lehman, DC

The purpose of this article is to clarify the definition of cervical instability and the chiropractic standard of care for this high-risk condition. With acceptance of this data, the chiropractic physician should avoid negative outcomes, improve quality of care, and reduce the possibility of a malpractice suit. If necessary, specific practice patterns should be altered. An inappropriate clinical outcome with chiropractic mana gement of an unstable cervical spine could jeopardize a practitioner’s integration into a health care system.

Acceptance of standards of care is no longer an internal dispute.1 Chiropractic participation in this process is an essential step if external credibility is to be attained in the world of managed care. The only remaining question is the extent of participation by chiropractic physicians.

Historically, most chiropractic physicians would agree that spinal manipulation is both safe and effective for the treatment of neuromusculoskeletal disease. Risk management history also reveals that liability costs for chiropractic providers is much less than for our allopathic colleagues. Although this data is somewhat comforting for the doctor of chiropractic, it does not alleviate the responsibility of each manual therapy provider to identify the risk factors that contraindicate manipulation of the spine. Since spinal manipulation is the primary therapeutic procedure used by chiropractic physicians,2 and since manipulation involves the forceful passive movement of a joint beyond its active limit of motion,3 spinal instability must be ruled out prior to the implementation of spinal manipulation.

Manipulation is defined as “a passive maneuver in which specifically directed manual forces are applied to vertebral and extravertebral articulations of the body with the object of restoring mobility to restricted areas.”4 Successful spinal manipulation involved the application of a mobilizing force to the areas of the spine that are stiff or hypomobile while avoiding areas of hypermobility or instability.5

Numerous authors debate the exact definition of instability and hypermobility. White, Southwick, and Panjabi define instability as “the loss of the ability of the spine under physiological loads to maintain relationships between vertebrae in such a way that there is neither damage nor subsequent irritation to the spinal cord, or nerve roots and, in addition, there is no development of incapacitating deformities or pain due to structural changes.”6 Their checklist for the diagnosis of clinical instability in the lower cervical spine should be familiar to all chiropractic physicians who treat patients with posttraumatic neck pain.

Element Point Value

A total of 5 or more indicates an unstable condition.

Hypermobility of the cervical spine is probably a more common condition in the chiropractic clinical situation than instability. Segmental hypermobility has been defined as: the mobility of a given motion unit which is excessive but not so extreme as to be life threatening or require surgery.7

McGregor and Mior reported that radiographs may not reveal underlying instability at first because of technologically inadequate X-rays, inappropriate views, or latent evidence of trauma.8 This “subacute instability” as described by Herkowitz and Rothman as latent evidence of trauma9 may become obvious with the classic signs of instability upon re-examination.8 With this knowledge base, every competent spinal physician that employs manual spinal therapy should exert ample investigative efforts to discover a state of instability or hypermobility prior to the application of either provocative orthopedic testing or manual therapy. According to Bartol, manipulation, mobilization, and adjustments are all manual therapy procedures. An excellent description of osseous manual thrust techniques is proved by Bartol in the text “Foundations of Chiropractic” by Gatterman. This is an essential and scholarly book that should be studied by every contemporary spinal physician.

Post-traumatic spinal injuries should initially be worked up by the chiropractic physician prior to manual therapy. West and Haldeman agree that there are four fundamental reasons why any primary care practitioner must perform on adequate clinical evaluation in reaching a diagnosis.10

  1. To identify the patient’s healthy problem and correlate the subjective symptoms with the objective clinical findings.
  2. To determine whether the patient is a candidate for manipulative therapy or whether the patient’s health problem could best be treated by another health care provider.
  3. To identify any unrecognized health problems.
  4. To determine how the patient’s problem is to be managed and whether there are any contraindications to manipulative therapy.
Yochum states that for examination of the skeleton, there is no modality to match the time and cost-effectiveness of the plain film radiograph.11 Consequently, post-traumatic cervical spine injuries should first be imaged with the use of an X-ray exam that includes AP, APOM, and lateral views at a minimum. When fracture is suspected, either “pillar views” and/or CT bone scans should be performed,11 according to Zimmer. Yochum and Barry agree that conventional radiographs frequently demonstrate quite well traumatic lesions of the musculoskeletal system. They go on to recommend the use of CT when radiographs are equivocal or when suspicious clinical findings are not substantiated by the present plain film study.12 In spinal trauma, CT helps to exclude or confirm the presence of small bone fragments near the spinal cord by eliminating overlapping structures that may obscure the fractures on plain X-rays. They further elucidate that when cord compression and/pr intramedullary lesions are suspected clinically, the CT examination must be complemented by magnetic resonance imaging. MRI is capable of clearly displaying spinal cord injury whereas CT does not have the necessary contrast resolution to adequately evaluate post-traumatic cord injury. In addition, the chiropractic physician should avoid use of flexion and extension plain film studies if the neurological findings of cord trauma present or if the initial lateral neutral view reveals fracture and/or instability. Experts agree that more than 3.5 mm of anterior translation of a vertebral body or 11 degrees of angulation indicate instability.

As stated succinctly by Gatterman, manipulation is a relatively safe and effective means of relieving painful biomechanical problems of the spine, including the neck. AS with all treatments, however, complications can arise.13 One of these complications is a neurological condition, “central cord syndrome or anterior cord syndrome,” which is one of the more common incomplete spinal cord injuries.14 This syndrome, as described by Cassidy and North typically consists of:

  1. Profound weakness of the hands.
  2. Aberrant deep tendon reflexes either increased or decreased.
  3. Sensory deficits in the upper extremities.
No longer is cervical laminectomy aggressively pursued with this acute traumatic insult to the cord. Contemporary surgical protocols prefer more conservative immobilization of the spine in a Philadelphia collar or two-poster brace for several weeks post trauma.14 Certainly, cervical instability with a fracture and neurological deficits warrants a multidisciplinary approach to care for a chiropractic patient. Immediate immobilization of the cervical spine and safe transport to the hospital should be arranged by the chiropractic physician. It is this author’s opinion that all of the doctor’s efforts should be focused on this patient’s well being. The chiropractic physician should accompany the patient in the ambulance to the hospital in order to improve quality of care. It is essential the E.R. physician receive accurate data directly from the attending chiropractic physician. This effort should also eliminate frivolous litigation based on a profession prejudice or ignorance of the clinical facts. This patient should be referred to a neurosurgeon by the chiropractic physician and manual therapy should be avoided. Gatterman verifies this recommendation with her standard #6: Hypermobile and unstable vertebral motion segments represent an absolute contraindication to forceful, non-specific manipulation.13

In order to prevent the serious neurological consequences that may follow manual spine care of a patient with cervical hypermobility or instability, the chiropractic physician should render a meticulous examination. A thorough history should explore the mechanism of injury. If the patient is unable to related and accurate history then the investigation of other records (hospital or police reports) and the interview of other witnesses and family members must be performed. Judicious research of medical records should include request of records rather than only brief telephonic communication with medical personnel. This effort may reduce miscommunication and subsequent misdiagnosis with resultant inappropriate treatment. Disastrous clinical consequences such as post-manipulative myelopathy may be prevented with a protocol that provides a meticulous neuromusculoskeletal examination. Every spinal physician must determine if the patient is presenting with a non-manipulable subluxation prior to manual therapy of the spine.15

Glossary

  1. Adjustment: Any chiropractic therapeutic procedure that utilizes controlled force, leverage, direction, amplitude, and velocity, and which is directed at specific joints or anatomical regions. Chiropractors commonly use such procedures to influence joint and neurophysiological function. (Gatterman)
  2. Amplitude: Wideness in range or extent. (Dorland)
  3. Hypermobility: Excessive mobility of a motion segment that is not severe as to be incapacitating, life threatening, or requires surgery.
  4. Instability: Excessive mobility of a motion segment to the extent that there is potential for development of incapacitating deformities or pain nd as result of structural changes in the articular holding elements. (Gatterman)
  5. Manipulable Subluxation: Subluxation in which altered alignment, movement, and/or function can be improved by manual thrust procedures. (Gatterman)
  6. Manipulation: Manual procedure that involves a directed thrust to move a joint past the physiological range of motion without exceeding the anatomic limit. (Gatterman)
  7. Manual Therapy: Procedures by which the hands directly contact the body to treat the articulations and/or soft tissues. (Gatterman)
  8. Meric System: Treatment of visceral conditions through adjustment of vertebrae at the levels of neuromeric innervation to the organs involved. (Gatterman)
  9. Mobilization: Movement applied singularly or repetitively within or at the physiological range of joint motion, without imparting a thrust or impulse, with the goal of restoring joint mobility. (Gatterman)
  10. Myelopathy: Any functional disturbance and/or pathological change in the spinal cord. (Dorland)
  11. Non-manipulable Subluxation: Is a vertebral motion segment with radiologic or clinical features indicting that an adjustive force or osseous manipulation to this motion segment would be harmful or dangerous and is therefore contraindicated. (Gatterman)
  12. Sprain (cervical): May be defined as stretching disruption of the supportive soft tissues about the cervical spine. (Turek)
  13. Standard of Care:
    1. Those acts performed or omitted that an ordinary prudent person would have performed or omitted. It is a measure aga inst which a defendant’s conduct is compared.
    2. Statements describing specific diagnostic or therapeutic maneuvers that should or should not be performed in certain clinical circumstances. (Vear)
  14. Subluxation: A motion segment, in which alignment, movement integrity, and/or physiologic function are altered although contact between joint surfaces remains intact. (Gatterman)
  15. Velocity: Quickness of motion. (Webster)
References:

1 Vear, H.J., “Chiropractic Standard of Practice and Quality of Care,” Aspen Publishers, Inc. 1992; 19-20
2 Vear, H.J., “Standards of Chiropractic Practice,” JMPT 1985; 1-33-43
3 Gatterman, M.I., “Indications for Spinal Manipulation in the Treatment of Back Pain,” ACA Jchiro 1982; 19(10): 51-66
4 Dorland’s Illustrated Medical Dictionary, 25th Edition, Philadelphia, W.B. Saunders; 1965:909
5 Cassidy, J.D., Potter, G.E., “Motion Examination of the Lumbar Spine,” JMPT 1979; 2:3
6 White, A.A., Southwick, W.D., Panjabi, M.M., “Clinical Instability in the Lower Cervical Spine: A Review of Past and Current Concepts,” Spine 1976; 1:15-27
7 McGregor, M., Mior, S.A., “Anatomical and Functional Perspectives of the Cervical Spine, Part II. The ‘Hypermobile’ Cervical Spine,” J. Can Chiro Assoc. 1989; 33:177-183
8 McGregor, M., Mior, S.A., “Anatomical and Functional Perspectives of the Cervical Spine, Part III. The ‘Unstable’ Cervical Spine,” J. Can Chiro Assoc. 1990; 145-152
9 Herkowitz, H.N., Rothman, R.H., “Subacute Instability of the Cervical Spine,” Spine 1985; 9:138-357
10 West, H.G., “Physical and Spinal Examination Procedures Utilized in the Practice of Chiropractic” In: Haldeman, 5 ed. Modern Developments in the Principles and Practice of Chiropractic, New York: Appleton-Century-Crofts; 1980: 269-296
11 Zimmer, A.E., “Radiologic Imaging of the Cervical Spine.” In: Tollison, C.D., Satterthwaite, J.R., ed., “Painful Cervical Trauma,” Baltimore: Williams and Wilkins 1992: 49-50
12 Yochum, T.R., Barry, M.S., “Diagnostic Imaging of the Musculoskeletal System,” In: Yochum, T.R., Rowe, L.J. ed “Essentials of Skeletal Radiology,” Second Edition Baltimore: Williams and Wilkins 1996: 477
13 Gatterman, M.I., “Standards for Contraindication to Spinal Manipulative Therapy,” In: Vear, H.J., ed. “Chiropractic Standards of Practice and Quality of Care,” Gaithersburg: Aspen Publishers, Inc. 1992: 231
14 Cassidy, J.R., North, R.B., “Indications for Surgical Intervention in Cervical Spine Trauma,” In: Tollison, C.D., Satterthwaite, J.R., ed “Painful Cervical Trauma,” Baltimore: Williams and Wilkins 1992: 284
15 Peterson, C.D., “The Non-Manipulable Subluxation,” In: Gatterman, M.I., ed. “Foundations of Chiropractic,” St. Louis: Mosby; 1995: 124-144

Glossary References:

Conwell, T.D., “Documenting Patient Progress,” 11th Edition, 1992; Clinical Advancement Plus Seminars
Dorland’s Medical Dictionary, 23rd Edition, Philadelphia, Saunders
Gatterman, M.D., “Foundations of Chiropractic,” 1995; St. Louis, Mosby
Turek, S.L., “Orthopedics,” 4th Edition; 1984, Philadelphia, J.F. Lippincott Co.
Vear, H., “Chiropractic Standards of Practice and Quality of Care,” 1992, Aspen Publications
Webster’s New Collegiate Dictionary, 1974, G.&C. Merriam Co.


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