MRI Case Study #1 Report

Greater Buffalo Spine & Injury Chiropractic

 Medical Building

191 North Street, Suite 104

Buffalo, NY

P- 716.200.0651

F- 716.939.3867

 

FACSIMILE COVER SHEET

Please deliver immediately

 ____________________________________________________________________

 

TO:                                         123                345                                            

 

FROM:                                    William J. Owens Jr DC

 

RE:                                          Mr. Thomas Krawiec

 

DATE SENT:                         06/11/2014

 

 

 

 

 

 

 

 

 

 

 

 

____________________________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Greater Buffalo Spine & Injury Chiropractic, PC

 

Adjunct Clinical Assistant Professor,  

University of Bridgeport College of Chiropra

 

Adjunct Associate Professor – Family Practice, SUNY Buffalo School of Medicine

and Biomedical Sciences

____________________________________________________________________________________________________________________

 

William J Owens Jr , DC, DAAMLP

Medical Building

191 North Street, Suite 104

Buffalo, NY 14201

P – 716.200.0651

F – 716.939.3867

 

 

Re:                                          Mr. Thomas Krawiec

Date of Birth:                         11/10/1948

Examination Date:                06/11/2014                 

 

Patient History  

The patient presents after a motor vehicle accident on June 3, 2014 where he was the belted driver of a vehicle that was struck from the front left side. He states that the impact with his car side to side and resulting in him being shaken up inside the vehicle he states that his body to contact the driver side door and the driver side window particularly his head on my shoulder. Immediately following the accident he experienced pain in his head, lost consciousness, pain in the neck and middle and lower back. He was evaluated at St Josephs Hospital. He was taken there by ambulance right after the accident. He presents today for further workup and evaluation for spinal pain.

 

Subjective Complaints

 On today’s visit, the patient reported he has developed a moderately severe constant headache pain bilaterally.  He additionally reported throbbing, dull, and achy pain localized in the right occipital area and left occipital area.  He states that he is feeling constant severe pain in the left neck area.  Mr. Krawiec continued to describe that he noticed pain radiating to the posterior left cervical area, posterior right upper shoulder, and posterior left little finger.  He also reports a he has been feeling constant severe pain bilaterally in the lower back area.  He has also noticed stiffness, restricted movement, and inflexibility pain localized in the right lumbar and left lumbar.    Mr. Krawiec was requested to evaluate his perception of the current status of his condition.

 

 On a pain scale of 1 to 10, he reports his headache at 8, neck pain at 9, and low back pain at 9.

 

Occupation

Electrical and refrigeration

 

Work Status

Temporally totally disabled

 

MEDICAL HISTORY AND REVIEW OF SYSTEMS

 

Past Medical History

High blood pressure   

 

Past Surgical History

Right shoulder

Left knee

 

Review of Systems

Denies any fever or chills, negative for any change in skin, head and neck, immune, cardiac, respiratory, digestive, urinary, hepatic, renal or psychiatric issues at this time.

Allergies

None reported

 

Medications

Lisinopril

Diclofenac

Indapamide

Atenolol

Bupropion

Glimepiride

Lyrica

Hydrocodone

Metformin

Byetta

Baby aspirin

Vitamin D

 

Social History

        Alcohol: Denied

        Tobacco:  Denied

 

Family History

None reported

 

PHYSICAL EXAMINATION

 

Vitals:                   

Ht: 6’0′

Wt:240lbs

 

Cardiovascular:  

Peripheral pulses are 2+ and equal in the bilateral upper and lower extremities.  Capillary refill brisk and less than 2 seconds.

 

Musculoskeletal:

On evaluation for spinal functional motoricity a substantial amount of fixation of the spinal joints at the occiput-C1, C3-C4, C7, T1, T3-T5, T7-T8, T10, L2-L3, L5, the left ilium-the right ilium, the left ilium and the right ilium was detected.  Evaluation of the muscles showed a severe hypertonicity in the suboccipital muscles bilaterally, cervical paraspinal muscles bilaterally, upper thoracic muscles bilaterally, mid thoracic muscles bilaterally, lower thoracic muscles bilaterally, lumbar paraspinal muscles bilaterally and gluteal muscles bilaterally.  Palpation of the spinal tissues revealed a strong pain level at the occiput to C1, C3 to C5, C7 to T4, T7 to T8, T10 to T11, L2, L4 to L5, and the left ilium bilaterally with a marked amount of edema at the occiput to C1, C3 to C5, C7 to T4, T7 to T8, T10 to T11, L2, L4 to L5, and the left ilium bilaterally.

 

Orthopedic Testing of the Cervical Spine revealed:

NAME: Jackson’s Compression_________________________POSITIVE LEFT

PERFORM TEST: As the patient is seated laterally flex the head to the affected side & then axially compress.

POSITIVE: Increased Radiating Arm Pain.

INDICATION: Nerve Root Encroachment.

 

NAME: Soto-Hall__________________________________POSITIVE

PERFORM TEST: As the patient lies supine, the doctor stabilizes over patient’s sternum.  Doctor then flexes patient’s head & neck onto his chest.

POSITIVE/ INDICATION: Pain helps to localize either:

A.Anterior Spinal Compression injuries   or

B.Posterior Spinal Stretching injuries

 

NAME: Distraction________________________________________POSITIVE

PERFORM TEST: The patient will be seated as the doctor rotates the patient’s head to point of pain, then distracts.  (If the patient has pain in the Neutral position, the head should be distracted in the Neutral position.)

POSITIVE: Decrease in Radiating Arm Pain.

INDICATION: Nerve Root Encroachment.

 

NAME: Shoulder Depression_________________________POSITIVE LEFT

PERFORM TEST: As the patient lies supine or seated the doctor laterally flexes the patient’s head away from affected side while compressing patient’s shoulder to point of pain.  Then rotate head away.

POSITIVE: Reproduction of Radicular Arm Pain upon lateral flexion, then exacerbation of that pain upon rotation.

INDICATION: ADHESIONS OF THE DURAL SLEEVE OR NERVE ROOTS.

 

NAME: Maximum Cervical Compression_________________________POSITIVE

PERFORM TEST: As the patient is seated laterally flex & rotate the head to the affected side, then extend.  If NO pain is produced at this point, axial compression can be added. POSITIVE: Increased Radiating Arm Pain.

INDICATION: Nerve Root Encroachment.

 

Orthopedic Testing of the Lumbar Spine revealed:

NAME: Iliac Compression……………………………………POSITIVE BILATERALLY

PERFORM TEST: The patient lies on side with either SI joint up while the doctor compresses down over the SI joint (avoiding pressure on the hips)

POSITIVE: Pain in either SI Joint

INDICATION: SI Lesion (as opposed to Hip pathology).

 

NAME: Lasegue_______________POSITIVE at  20  DEGREES BILATERALLY

PERFORM TEST:  The patient lies supine then does a SLR on effected area.

POSITIVE: Lower back and sciatic pain.

 

NAME: Kemp’s_____________________________________POSITIVE BILATERALLY

PERFORM TEST: The patient can stand or sit while anchoring the pelvis with one hand and from the shoulder, pull the patient into extension, lateral flexion and ipsilateral rotation.

POSITIVE: Radiating leg pain.

[NOTE: Lower back pain indicated Facet Imbrication, but is NOT considered to be a positive finding.]

INDICATION:

A. Pain to the ipsilateral leg when laterally flexing toward that side indicates a Lateral Disc.

B. Pain to the contralateral leg when laterally flexing away from that side indicated a Medial Disc.

 

Neurological Testing revealed:

The patient was oriented to person, place and time.  There was no evidence of speech pathology.  No ataxia or drift was noted.

 

Muscle testing in the upper extremity was within normal limits bilaterally and all myotomes were graded +5/5 bilaterally. Hoffman’s sign was negative.  Deep tendon reflexes were present and equal bilaterally being rates as +2/5.  There was no evidence of clonus.  

 

Muscle testing in the lower extremity was within normal limits bilaterally and all myotomes were graded +5/5 bilaterally.  Plantar response was down going bilaterally.  Deep tendon reflexes were present and equal bilaterally being rates as +2/5.  There was no evidence of clonus.

 

Decreased sensation at the left C7 dermatome.

 

During the examination, there was a visual restriction in the patient’s range of motion.  I ordered a specific range of motion test to further evaluation the range of motion deficits. 

All ranges of motion are based on the American Medical Association’s Guides to the Evaluation of Permanent Impairment, 5th and were performed by dual inclinometers. 

 

                                                Normal (Degree)         Patient (Degree)

CERVICAL ROM:

Flexion                                                50                                28                    = 44% deficit

                                                                                                                        Severe pain

Extension                                            60                                32                    = 47% deficit

                                                                                                                        Severe pain

Right Lateral Flexion                           45                                18                    = 60% deficit

                                                                                                                        Severe pain

Left Lateral Flexion                             45                                22                    = 51% deficit

                                                                                                                        Severe pain

Right Rotation                                     80                                78                    = 3% deficit

                                                                                                                        Moderate pain

Left Rotation                                       80                                75                    = 6% deficit

                                                                                                                        Moderate pain

 

                                                            Normal (Degree)         Patient (Degree)

LUMBAR ROM:

Flexion                                                60                                32                    = 47% deficit

                                                                                                                        Severe pain

True Lumbar Extension                      25                                5                      = 80% deficit

                                                                                                                        Severe pain

Right Lateral Flexion                           25                                8                      = 68% deficit

                                                                                                                        Severe pain

Left Lateral Flexion                             25                                5                      = 80% deficit

                                                                                                                        Severe pain

 

 

Skin:                      

Appears warm and dry and well oxygenated

 

Psychiatric:            

Alert and oriented to person, place and time.  There is normal mood and affect.

 

Diagnosis

These diagnosis were evidenced by the patient’s history, physical examination findings, range of motion testing and review of available diagnostic studies.

 

Prognosis

Mr. Krawiec’s overall prognosis is guarded. 

 

Assessment

Mr. Krawiec is determined to be at an overall status of acute pain status post MVA.

 

The patient has experienced injuries to multiple sites in the spine.  Each of these regions is a separate body part and may respond to care at different rates.   I have discussed this with the patient and they understood that they may feel better in different areas at different times.

 

The examination findings objectively confirm my diagnosis and clinically correlate with the patient’s subjective complaints.  Chiropractic care is therefore medically necessary.

 

There are some basic anatomical truths regarding the innervation to the intervertebral disc that is important in this case.  The pain being generated is consistent with peer reviewed medically indexed research. In a 2010 paper, the authors reviewed the scientific literature and stated, “The IVD [intervertebral disc] is innervated by branches of the sinuvertebral nerve or by nerves derived from gray rami communicates…  Furthermore, IVDs also receive innervation from two dense nerve interconnected plexuses located in the anterior and posterior common vertebral ligaments…”

 

García-Cosamalón, J., del Valle, M. E.,  Calavia, M. G.,  García-Suárez, O., López-Muñiz, A., Otero, J.,  & Vega, J. A. (2010). Intervertebral disc, sensory nerves and neurotrophins: Who is who in discogenic pain? Journal of Anatomy, 217(1), 1-15.

 

Physical intolerance of the body to the traumatic forces in an automobile crash are more likely to result in significant injury and should be considered more significant than other co-morbid factors. Physical intolerance factors listed in this paper were changes in “bone density, lean muscle mass, [and] pliability of tissues” (Newgard, 2008, p. 1503).

 

As occupants age, they become inherently more fragile and less tolerant to the multitude of forces involved in an MVC. Medical fragility, as measured by crash-related mortality rates, has been previously demonstrated (Li et al., 2003, p.1503). 

 

This study found there is no real cut off point relating to age. Pre-existing changes (AKA medical fragility) are the key factors. Therefore, the physiological age of the body is a more important prognostic factor than actual chronological age and arthritic degeneration, no matter the age of the occupant, This is a key risk factor (one of many) rendering an increased incidence of bodily injury.

 

Newgard, C. D. (2008). Defining the “older” crash victim: The relationship between age and serious injury in motor vehicle crashes. Accident Analysis and Prevention, 40(4), 1498-1505.

 

Disability

The patient has informed me during their history that they could not work, and based on the findings on physical examination I have concluded that the patient has consistent clinical findings that warrant temporary total disability at this time.   The patient also informed me that they are not working in any capacity.  The patient has affirmed this information with a signed copy of this disability note that has been added to the chart. 

 

The patient is temporarily totally disabled starting _6/11/14___and ending _7/11/14_ at which time they will be re-evaluated and their disability status updated.  A copy of these restrictions have been provided to the patient.

 

Causal Relationship

Mr. Krawiec has sustained significant injuries to his spine as a result of the injury on 06/11/2014 .  If it were not for the accident he would not have required examination, diagnostic testing or treatment.  Mr. Krawiec was in a normal state of good health and functioning at full capacity in both his personal and working lives prior to this injury.

 

The patient’s bodily injuries are consistent with the patient’s history of the accident.

 

The above stated injuries are 100% causally related to the accident in question as the patient did not have any prior conditions, was symptom free and in their usual state of good health prior this traumatic event.   

 

Plan

Three visits per week is warranted until modified by reexamination.  Adjustment was administered to correct misalignment and relieve joint fixation in the neck, area of the thoracic spine, and region of the low back.  Therapy included heat therapy to the cervical spinal region, thoracic spinal area, and lumbar spinal region to increase local circulation.  To decrease the degree of muscle tension and decongestion, electro-muscle stim. was administered to the cervical spinal region, thoracic area, and low back region.  To promote a reduction in muscle hypertonicity and intersegmental pressure, manually applied traction was administered to the area of the cervical spine, and area of the low back. 

 

I am referring the patient for imaging of the cervical spine to evaluate the health and integrity of the vertebrae and adjacent anatomical structures.  The MRI was ordered to rule out a space occupying lesion of the spinal canal or foramen to determine if a surgical consultation is required. I will review the actual study with the patient once the results are obtained.

 

“Approximately 70% of acute LBP patients can attribute their pain to spinal muscle strain or sprain. These patients are, in general, younger and have no clinical red flags. Under these circumstances, MRI should not be performed within the first 4-8 weeks of symptoms.” (p 551)  If this patient population’s pain persists, then advanced imaging in the form or MRI is clinical indicated to further evaluate the patient’s condition since now the lack of response is a clinical red flag.  The authors stated “MRI is the method of choice for the evaluation of disk morphology because of the good sensitivity (60-100%) and specificity (43-97%) for disk herniations (both protrusions and extrusion).  It has been suggested that disk morphology is associated with symptoms and as a result should influence pain management. Although bulging disks and protrusions are common and poorly correlated with symptoms, extrusions are rare in asymptomatic patients (1-5% prevalence) and may be a good predictor of response to treatment and patient outcome.” (p 553)

 

The treatment plan requires alteration based on the patient’s lack of response.  Based on the most current research from the American Journal of Neuroradiology, the patient’s lack of response, the findings on physical examination and the current scientific evidence the details of the future treatment plan will require additional investigation.  Changes to the treatment plan include some or all of the following, alteration of treatment modality, specialist referral, alteration of prognosis and disability management.  These changes will be impossible to calculate without the advanced imaging procedure outlined.  Lack of imaging would result in negative consequences based on the patient’s response to care.

 

Bahman Roudsari and Jeffrey G. Jarvik. Lumbar Spine MRI for Low Back Pain: Indications and Yield. AJR 2010; 195:550-559

 

I have discussed with the patient the diagnosis of MTBI or Mild Traumatic Brain Injury and how this correlates with their symptoms.  We reviewed the mechanism of their injury and the concept of Coupe Contracoupe injury and the trauma it produced on the brain.  We reviewed referral to a neurologist for further evaluation.

 

Greater than 50% of the encounter was spent coordinating care and counseling the patient.  The total visitation exceeded 45 minutes.  Thank you for the opportunity to provide this report.

 

Respectfully,

 

 

William J. Owens Jr DC, DAAMLP

 

 

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