DC = Disc Chiropractor
SEMINAR RECAP
Eric Kaplan, DC, FIAMA, Perry Bard DC, and Jason Kaplan, DC
It was an exciting weekend at the national certification program for nonsurgical spinal decompression (NSSD), sponsored by Life University. More than 350 attended the 12 CEU program that took place in Florida last November.
One of the highlights of the weekend was Duane Clemons. Duane is a former number one draft pick for the NFL who became captain of the Cincinnati Bengals and the Kansas City Chiefs.
He discussed how spinal decompression put him back on the field. He gladly showed off a Super Bowl ring for his work with the Kansas City Chiefs and graciously signed autographs for chiropractors from 42 states.
One of the areas discussed in detail was failed back surgery syndrome (FBSS). Norman Shealy, MD, PhD, said, “I knew after performing my first back surgery that back surgery was not the answer.” He was not alone in his thinking. Renowned neurosurgeon Lali Sekhon, MD, PhD, said, “When a spine surgeon tells you not to have back surgery, you should probably listen.”
Secondly, she added “I never thought I would be a neurosurgeon who does mostly spine surgery, but that’s what I do. My PhD was in cerebral blood flow, and most of my residency and early career was doing a lot of brain tumors and such. The spine was a black box. When I trained, a lot of cases didn’t go well; we didn’t have all the tools, and our techniques were not as polished.”
Dr. Sekhon continued, “I have a reputation for being conservative (but I think it’s because I follow the national society’s guidelines), although I do about 350 surgeries a year. I think the national average is about 220 for a neurosurgeon, so for a “conservative surgeon,” I do a lot. I know my trade well. When I was in medical school and training in neurosurgery, back pain was something we didn’t really talk about. It was in the “too hard” basket, along with chronic headaches, dizziness, irritable bowels, and fatigue.”
“I was taught there was no surgery done for back pain, and surgery did not do well for it. In my residency, we were just starting to put in plates and screws. I went on and did some advanced training in spine surgery at the Mayo Clinic and in Toronto and learned more about fixing spine problems. I started out in academic neurosurgery. I was salaried, and we did things because they needed to be done, not because we got paid more for them. When I started out, we fixed broken necks with pieces of wire that you could buy at The Home Depot for two dollars. At one time, I was a pioneer of artificial disc surgery and published a lot. I sat (and still sit) on a lot of editorial boards and have seen a lot of what has come and gone. Most is fluff. Most you would not read a year later.”
We can go on, but now surgeons and NFL players are looking for answers, and chiropractors offer a safe solution with NSSD. We also learned and discussed back surgery with orthopedic surgeon Dr. Glen Zuck, who once worked with the NFL’s Philadelphia Eagles. He said, “I’ve learned so much from working at these seminars. I would readily refer to a doctor who performed NSSD prior to any surgery.”
Dennis Egitto, MD, said, “I was amazed how much I learned about disc disease in one day and how qualified your doctors are.” With my partner, Dr. Perry Bard, we founded Disc Centers of America, now in 43 states, and we advise our clinics and all doctors to learn as much about the disc as possible. We teach that a subluxation becomes a bulge, and a herniation is the progress of degenerative disc disease (DDD).
The fact remains that back pain and back problems are exceedingly common disorders that affect the general community, and up to 40% of the population will suffer from this ailment at some time. The essence of the assessment and evaluation of patients with back problems centers around the following key issues. Our approach to this problem is for every doctor to realize the process and importance undertaken in their evaluation and management.
Process
• A careful history is taken.
• A thorough physical examination is performed. •Appropriate investigations are ordered, which are
correlated to the clinical picture.
Three questions are asked:
1. When was the onset of pain?
2. Have you seen any other doctors?
3. Have you had an X-ray or an MRI?
We believe most back disorders can be managed nonsurgically, with a very small subset requiring surgical referral or intervention. Robert Burke, MD, a radiologist, discussed this in detail as he reviewed numerous MRIs.
The conditions that can be helped by surgery comprise the following categories:
1. Compression, e.g., disc, tumor, fractured bone fragments
2. Tension, e.g., tethered cord
3. Instability
4. Cauda equina syndrome
5. Loss of bowel function
6. Total leg drop
Dr. Sal Larusso, former chairman of the Chiropractic Board of Examiners, taught the importance of doing a good history and having the proper intake forms.
History
In general, up to 80% of back and spinal disorders can be diagnosed on history alone. In taking a back-related history, the following are important:
• Details of the onset of the illness
• What brought on the pain?
• Was there a correlation to any activity?
Specific questioning should be asked about the following areas:
• Pain
• Gait
• Sensory symptoms
• Bowel function
• Motor symptoms
• Bladder function
When questioning about pain, it is important to develop a pain history encompassing the what, where, when, and how. It is important to understand some neuroanatomy in an attempt to correlate radicular symptoms to spinal pathology. In general, if the innervation of C6 and C7 in the upper limb (C6 supplies biceps, wrist extensors, thumb, and index finger sensory regions as well as the biceps jerk; C7 supplies finger flexors, wrist extensors, and triceps, as well as sensation to the dorsum of the hand and middle finger and triceps jerk).
L5 and SI in the lower limb are known, and 90% of root lesions can be localized (L5 supplies the ankle dorsiflexors and sensation on the lateral aspect of the calf and dorsum of the foot; SI supplies plantar flexion in the foot and sensation on the sole of the foot, as well as the ankle jerk).
Important points about taking a pain history are:
• Pain quality is important
• Neuropathic pain (burning in quality)
•Mechanical pain (worse on movement; relief with
bed rest)
• Constipation is a poor symptom of bowel dysfunction
• More important questions about sphincters:
• Loss of feeling of fullness
• Loss of feeling of urethral stream
• Numbness on wiping
Physical Examination
The physical examination should not only encompass a general examination, but a thorough neurological examination also should be performed. To be as thorough as possible, the following regions need to be examined:
• Gait
• Roots, peripheral nerves
• Back, neck
• Joints
• Mechanical
• Vascular
Sometimes differentiation between neurogenic and vascular claudication is required, and an understanding of the differences between these two is necessary. In general, the former is associated with back pain and is worse with standing and unaffected by cycling, whereas the latter is unaffected by posture, may be associated with diabetes or peripheral stigmata of vascular disease, and is typically worsened by either walking or cycling. Disc pain is often associated with peripheral neuropathy and vice versa. Therefore, balance testing needs to be added to your examination.
X-rays, Bone Scans, and MRIs
Plain X-rays still play an important role in the investigation of back disorders, scoliosis, subluxations, and DJD, as well as particularly in the background of possible metastatic spinal disease or if spinal instability is suspected (e.g., in patients with rheumatoid arthritis). Plain X-rays can also give an assessment of the severity of degenerative disease and exclude fractures/dislocations.
Bone scanning allows for the exclusion of metastatic disease as well as occult fractures. It is a good screening for the aforementioned pathologies in the face of cancer or osteoporotic disease.
CT scanning is a good baseline investigation for myelopathy or radiculopathy. It is not so good for intradural disease and may miss subtle degenerative changes causing neural compression.
MRI scanning is our current “gold standard” in the unraveling of spinal disorders. It allows for excellent soft tissue delineation and for the assessment of the craniocervical junction. MRI also allows for postoperative differentiation of scar tissue from disc material. MRI is unparalleled in the assessment of intradural disease.
The ABCs of unraveling back problems are:
• Careful history
• Thorough physical examination
• Appropriate X-rays and MRI at appropriate time
• Correlate testing to clinical picture
• Refer when needed
• Diagnose any neurological deficit
• Sciatica or arm pain that fails conservative treatments
• Likely instability
• Education/reassurance (we like videos in this arena)
• Patience
Yes, patience, which will equal new patients. Every patient wants to go to a doctor they believe in; every patient wants to go to the best. It is your job to become the best. That is why we do programs like the national certification, and we bring a host of medical doctors and specialists to train you to become the best doctor you can be.
During 34-plus years as business partners, Dr. Eric Kaplan and Dr. Perry Bard have developed Disc Centers of America, Concierge Coaches, and the first national certification program for non-surgical spinal decompression a 12 CEU credit event. Being held for the 10th anniversary on November 5,6. This event has been sold out for two years running.
Dr. Jason Kaplan is a Parker University graduate practicing in Wellington, Florida with his wife, Dr. Stephanie Kaplan. Jason also is an Instructor for Disc Centers of America and teaches techniques for the National Certification Program at Life University. To learn more, call 888-990-9660 visit thechiroevent.com or decompressioncertified.org.
