Chiropractic Co-Management of Pre and Post Surgical Spine Cases
FEATURE
INTEGRATED CARE
Matt Erickson
DC, FSBT
Mark Studin
DC, FASBE(C), DAAPM, DAAMLP
Ashraf Ragab
MD, Orthopedic Spine Surgeon
Introduction
When a patient presents in a chiropractic office and has clinical signs of either radiculopathy (nerve root compression) at the neural canal or central canal regions or any myelopathic findings (cord compression with ensuing neurological deficit distal to the level of the lesion), immediate referral for an MRI should be considered. Based on your clinical findings, triage then ensues as a result of creating a clinically driven diagnosis, prognosis, and treatment plan. In a smaller percentage of cases, it will be discovered that the patient has a condition that requires a referral to a spine surgeon or a pain management provider. Regardless of where the patient is directed, having the patient fully worked up (examination, X-rays, and advanced imaging) before the referral takes place is an important aspect of what a doctor of chiropractic can and should do and is within the lawful scope of practice within all 50 states and the United States territories.
Among those patients referred to the spine surgeon, some will not require or be a candidate for surgery. This is an area where a doctor of chiropractic with postgraduate training in primary spine care and spinal biomechanical engineering can be a big help to the surgeon by ensuring that a higher portion of the referred patients present with a condition that likely requires the surgeon’s services. By triaging those patients who more likely need a spine surgeon’s or pain management doctor’s services, it allows the specialist to save time on screening patients in the clinic who do not need their services, and instead, it allows them to spend more time performing medically necessary spine-related procedures, which allows patients to be taken care of more efficiently.
In the event that a patient does not require surgery, unless there is a contraindication to correcting a patient’s neuromuscular-biomechanical failure leading to structural imbalance, the doctor of chiropractic can comanage the patient with the pain management provider. For the pain management provider, they may recommend various pain management procedures, such as a spinal epidural injection, a medial branch block, or a facet injection. Given that pain management providers don’t focus on spinal biomechanics while doctors of chiropractic do, this collaborative approach is ideal for better outcomes for most patients.
Surgical Considerations
For patients who do require surgery, the treatment plan can be as simple as a referral to a spine surgeon. This, however, brings the question: What is the doctor of chiropractic’s role in managing patients before and after surgery?
In some cases, immediate surgery may be required. That would be the case when the patient has a spinal cord injury such as myelomalacia, which is regarded as softening of the spinal cord due to damaged neural tissue that fills in with a glial scar. A glial scar, according to Silver and Miller (2004), “consists predominately of reactive astrocytes [star-shaped glial cells, or cells without neurons, in the brain or spinal cord] and proteoglycans [molecules made of sugar and proteins]” (p 146). Further, myelomalacia forms with pressure on the spinal cord, which may be due to biomechanical failure and ensuing cord pressure in post-trauma cases. Immediate surgery may also be required with a disc extrusion (a type of disc herniation), which presents with myelopathic findings (ensuing neurological deficit distal to the site of the spinal cord lesion following trauma) and in patients with an advanced nerve root compression leading to pain, numbness, tingling, and weakness in the upper or lower extremity at the level the nerve root has been compressed.
For other patients, however, while surgery may be indicated, the doctor of chiropractic can work to improve the patient’s biomechanical balance before surgical intervention. This is another area where a doctor of chiropractic trained in primary spine care has the postgraduate training necessary to comanage this type of case. Regardless, these considerations must be coordinated with the spine surgeon if surgery is required. Sagittally balancing the spine means better patient surgical outcomes, as reported by Makhni, Shillingford, Laratta, Hyun, and Kim (2018). “Adult spinal deformity with sagittal imbalance is associated with significant pain and disability, as well as directly and negatively influencing health-related quality-of-life scores. The spine surgeon has to understand the whole global and regional alignment changes after sagittal imbalance to address the multiplanar deformity. Restoration of global alignment and minimization of complications through various surgical options can successfully improve the pain and function of spinal deformity patients”(p l76_l77).
Importance of Sagittal Balance
Sagittally balancing the lumbar spine is further supported in an article published on Helia.com related to lectures on the outcomes of lumbar spine surgery about sagittal balance. Hu , LeHuec, and Gibson (2016) reported, “Surgical outcomes for spine surgery are improved when spinal, pelvic, and hip alignment is considered in both degenerate and deformity cases, and how we better understand these will help us better improve outcomes for our patients”(para 3).
Hu et al. (2016) also reported, “Sagittal imbalance in a patient can negatively affect the outcomes of a surgical procedure. But, how extensive the surgery required is to correct the imbalance must be carefully considered for the individual patient”(para 4). Hu et al. (2016) added, “Sagittal balance is an active phenomenon for patients. The best course of action is to strive to achieve sagittal balance in patients” (para. 8)
In a study by Tang et al.(2015) regarding the thoracolumbar spine-sagittal balance, the authors concluded, “Our findings demonstrate that, similar to the thoracolumbar spine, the severity of disability increases with positive sagittal malalignment following surgical reconstruction”(p S21).
Finally, in an article by Yeh et al. (2018), they concluded, “The results of this study support previous findings that functional outcomes are closely associated with sagittal radiographic parameters in the patients with the degenerative thoracolumbar spinal disease who received long-segment fusion. The achievement of global and regional sagittal alignment balance is a crucial factor for improved postoperative functional outcomes”(p 1361).
Post-Surgical Management
According to a publication titled “A Detailed Guide to Your Surgery and The Recovery Process” by the Johns Hopkins Spine Service (n.d.), “Walking is the best activity you can do for the first six weeks after surgery. Further, there will be restrictions for the first six weeks after surgery... the patient should ‘avoid twisting and bending’ and avoid lifting, pushing, or pulling objects greater than 5 lbs”(p 16).
From the Johns Hopkins publication (n.d.), patients are advised to call the surgeon’s office to make a six-week follow-up appointment. At that appointment, x-rays will be performed to evaluate how the surgical area is healing. If everything checks out, “patients may be given a handout of lower back exercises to begin at home.” Patients may also be provided a prescription for outpatient physical therapy, but that is dependent upon the patient’s recovery (p 24).
When physical therapy begins, the goal is to gradually improve strength, flexibility, and endurance. The patient may also receive help with activities of daily living, such as gait training (learning how to walk properly again). However, while beneficial, physical therapy is limited because a physical therapist does not focus diagnosing and correcting the spinal biomechanics. Further, a physical therapist is not licensed to manage patients on a physician level. This is where the doctor of chiropractic is needed as part of the long-term recovery solution.
Following the initial six-week evaluation, according to Hayeri and Tehranzadeh (2009), “Evaluation of the postoperative spine usually begins with conventional radiographs in AP and lateral projections. It usually takes six to nine months for a solid bone fusion to be established radiographically” (para. 21). Hayeri and Tehranzadeh also reported, “Postoperative imaging plays an important role in the assessment of fusion and bone formation. It is also helpful to detect instrument failure and other suspected complications. It is necessary to compare current images with previous studies to identify any subtle changes and disease progression”(para 20).
Hayeri and Tehranzadeh (2009) added, “Currently, computed tomography (CT) with multiplanar reconstruction (MPR) is considered the modality of choice for imaging bony details and assessing osseous formation and hardware position despite artifact formation”(para 22).
It is important to understand that patients don’t need to wait six to nine months to start treatment with the doctor of chiropractic. About six weeks following surgery, if the patient is healed enough to begin physical therapy, the patient should be able to tolerate gentle mechanical corrections above and below the level of the surgical fusion. However, the patient will need to first be cleared to do so by the surgeon. Doing this can help in the patient’s recovery process and prepare the patient’s spine for a more comprehensive correction process once the patient is cleared. It can also help shorten the time needed for correction.
The doctor of chiropractic (trained in primary spine care), therefore, can take on a critical and important role in the management of patients before and after spine surgery. Further, unlike the physical therapist, the doctor of chiropractic has physician class status and is licensed to fully diagnose, manage, and treat biomechanical pathology of the spine when indicated.
Primary Spine Care
Despite this, not all doctors of chiropractic have additional postgraduate training or experience to manage complex spine cases. This is no different from a medical doctor having just completed medical school not being able to function in the capacity of a specialist short of residency or a fellowship program.
One solution that provides the doctor of chiropractic with the additional training and experience to manage complex spine cases is an extensive postgraduate training program in primary spine care, as previously discussed. Currently, the Academy of Chiropractic is offering such an extensive postgraduate program and as a result, there is a growing body of doctors of chiropractic becoming qualified in primary spine care who are well prepared to take on the role in managing patients with complex spine-related issues (www.academyofchiropractic.com/component/ content/article.html?id= 1224).
The concept of the doctor of chiropractic taking on the role of a primary spine care provider was discussed in an article by Erwin, Korpela, and Jones (2013). They stated, “Chiropractors have the potential to address a substantial portion of spinal disorders; however, the utilization rate of chiropractic services has remained low and largely unchanged for decades. Other healthcare professions, such as podiatry/chiropody, physiotherapy, and naturopathy, have successfully gained public and professional trust, increases in the scope of practice, and distinct niche positions within mainstream health care. Due to the overwhelming burden of spine care upon the healthcare system, the establishment of a ‘primary spine care provider’ may be a worthwhile niche position to create for society’s needs. Chiropractors could fulfill this role, but not without first reviewing and improving its approach to the management of spinal disorders”(p 285).
Conclusion
In conclusion, the doctor of chiropractic has the foundational training to diagnose, manage, and treat patients when indicated, both before and after spinal surgery. However, with additional postgraduate training in primary spine care, the doctor of chiropractic can obtain the necessary skills to manage more complex spine conditions, which includes coordinating care with spine surgeons, pain management doctors, and even primary care doctors. With the current opioid crisis in the United States, there is a need for a frontline provider to lead in the management of nonsurgical spine care, and the doctor of chiropractic as a licensed physician is positioned to take on that role, especially with additional training in primary spine care.
References
1. Silver Jerry and Miller Jared H. (2004, February). Regeneration Beyond the Glial Scar. Nature Publishing Group, Volume 5, 146-156. Retrieved from https://www. nature, com articles nrn1326.pdf.
2. Makhni Melvin C., MD, MBA, ShUlingford, Jamal, N. MD, Laratta, Joseph, L. MD, Hyun, Seung-Jae, MD, PhD and Kirn Yongjung, MD. (2018). Restoration of Sagittal Balance in Spinal Deformity. Journal of Korean Neurosurgery Society, 61(2), 167-179.
3. Serena S. Hu, MD, Jean Charles LeHuec, MD, PhD and J.N. Alastair Gibson, MD, FRCS(Ed), FRCS(Tr &Orth), MFSTEd. (2016 Jan Feb). “Proper sagittal balance may correlate with better surgical outcomes. ” Retrieved from: https://www. healio. com/spine-surgery/ lumbar news print spine-surgery-today %7B54ac5ca27939-407d-96a5-31fa9c0fc904%o7D prop er-sagittal-balance-may-correlate-with-better-surgical-outcomes.
4. Jessica A. Tang, BS Justin K. Scheer, BS, Justin S. Smith, MD, PhD, Vedat Deviren, MD, Shay Bess, MD, Robert A. Hart, MD, Virginie Lafage, PhD Christopher I. Shaffrey, MD, Frank Schwab, MD and Christopher P. Ames, MD. (2015). The Impact of Standing Regional Cervical Sagittal Alignment on Outcomes in Posterior Cervical Fusion Surgery. Neurosurgery 76, S14-S21.
5. Kuang-Ting Yeh, MD, PhD, Ru-Ping Lee, RN, PhD, IngHo Chen, MD, Tzai-Chiu Yu, MD, Kuan-Lin Liu, MD, PhD, Cheng-Huan Peng, MD, Jen-Hung Wang, MD, and Wen-Tien Wu, MD, PhD. (2018). Correlation of Functional Outcomes and Sagittal Alignment After Long Instrumented Fusion for Degenerative Thoracolumbar Spinal Disease. Spine, 43(19), 1355-1362.
6. Johns Hopkins. (h.d., pp. 1-36). “A Detailed Guide to Your Surgery and The Recovery Process. ” Retrieved from: https://www. hopkinsmedicine. org orthopaedie-surge ry/ do cum e n ts/pat ient-informatio n/pa tient-formsguides JHULumbSpineSurgeryGuide.pdf
7. Hayeri Mohammad Reza, MD, Tehranzadeh Jamshid, MD. (August 6, 2009). “Diagnostic imaging of spinal fusion and complications. ” Retrieved from: appliedradiology.com/articles/diagnostic-imaging-of-spinal-fusion-and-complications.
8. Studin Mark, D.C., Primary Spine Care Qualified, “What is Primary Spine Care?” Retrieved from: https ://www. academyofchiropractic.com/component/content/article. html?id=1224.
9. W. Mark Erwin, DC, PhD, A. Paulina Korpela, BSc and Robert C. Jones. (2013) Chiropractors as Primary Spine Care Providers: precedents and essential measures, Journal of the Canadian Chiropractic Association, 57(4), 285-291.
Mark Studin, DC, FASBE(C), DAAPM, DAAMLP, is an adjunct associate professor of chiropractic in 3 colleges of chiropractic across the country. He teaches MRI spine interpretation, spinal biomechanical engineering, and triaging trauma cases. He is the president of the Academy of Chiropractic teaching doctors of chiropractic how to interface with the medical and legal communities (www.DoctorsPIProgram.com) and teaches MRI interpretation and triaging trauma cases to doctors of all disciplines nationally (www.TeachDoctors.com). Reach Dr. Studin at: [email protected] or at 631-786-4253.
Dr. Erickson is the President of Body Right Chiropractic in Clearwater, Florida. He graduated from Hope College in 1994 with a BA in Chemistry (Biochemistry emphasis) and a Physical Education minor. Dr. Erickson graduated from Palmer College of Chiropractic in 1998 earning the President's List Award for clinical excellence. Through the Academy of Chiropractic he is Trauma Qualified, Primary Spine Care Qualified and Interprofessional Hospital Qualified. In 2018, Dr. Erickson completed a 2-year Fellowship in Spinal Biomechanics and Trauma. Reach Dr. Erickson at [email protected] or 727-498-5208.
Ashraf Ragab MD, founded the Comprehensive Spine Institute in Clearwater, Florida. Dr. Ragab is a fellowship-trained Orthopedic Spine Surgeon and a Board-Certified Orthopedic surgeon. He was an Associate Professor of Orthopedics at the University of Mississippi. He earned the Kappa Delta Award from the American Academy of Orthopedic Surgeons and the Orthopedic Research Society William Harris Hip Award. He is an editor for and has been published in peer-reviewed medical journals. You can reach Dr. Ragab at 727-953-8090.
