Dr. H's Blog

Abstract: In this interesting case, the patient suffered injuries to the back and neck as a result of a MVC (motor vehicle crash). During routine radiological imaging, we noticed a number of pre-existsing issues including frank thoraco-lumbar scoliosis. The X-Rays tell the story. Note also the damage to the vehicle itself.

1/10/08: Mr. T presented to us seeking treatment for injuries received in a MVC (motor vehicle crash) on or about 1/1/08. He stated that he was the restrained driver in a 1990 Nissan Pick-up that was stopped at a stop sign when a mini-van slammed into the rear of his vehicle. The offending van was apparently going at a high rate of speed because the entire rear window of the Nissan exploded upon impact. Mr. T indicated that prior to impact he was facing forward, his head rest was set and the crash came as a surprise to him. He stated that the impact thrust him forward and backwards in his car seat and he furthermore slammed his chest against his own steering wheel. He denied any loss of consciousness, but did mention that he was dazed from the impact. He stated that there were no police or EMS called to the scene and that after exchanging papers, he opted to go home. Mr. T added that the pain became worse by the next day and that his wife drove him to Somerville hospital. He stated further that when he arrived at Somerville Hospital, he was attended by an ER doctor. He stated further than he was examined, received no X-Rays, was scripted for meds and told to go home and to rest. He stated that the reason he presented to our office (BSCs-Somerville) was because of continued chest, neck and back pain. He described the primary locus of pain as being in his L spine that was of a constant achy/sore pain in nature in which most activities such as bending, lifting, getting up aggravated his condition and was temporarily relieved with rest. He stated further that his neck and chest were not quite as painful as the LB but still extremely sensitive and sore. Mr. T stated that the entire region of his neck (like the entire region of his LB) was achy/sore/constant in nature where lifting and movement aggravated and rest offered slight relief. The same was true of his chest pain. All areas were sensitive and painful to touch. He stated that he did not smoke or drink. He informed us he did get yearly physical exams and that he was in otherwise in good condition. He added that he was feeling fine prior to the MVC without the abovementioned pain. Mr. T reminded us that he was a patient here in 2004 for injuries resulting from a MVC at that time. He was discharged at the time with few residuals. Upon further questioning, he could not recall any other significant past personal or family medical history including traumatic accidents. He further stated that the crash disrupted his ADLs; this included activities such as walking, going up/down stairs, getting in/out of the car, job activities, carrying groceries, lifting things, turning door knobs, getting dressed. *The patient was asked to obtain all of his relevant hospital records. He stated that he would attempt to do so.  

JOB DESCRIPTION:  Steward at the FOUR SEASONS Hotel in Boston. A Steward assists in the kitchen cleaning, washing, lifting etc.

VEHICLE PICTURE(S):  

Note tape holding right rear light assembly in place. Noted also here is the exploded rear window as well as the bumper damage.

GENERAL PHYSICAL EXAMINATION:
Mr. T presented as an alert, cooperative, right handed, 61 year old, WDWNHaitianM standing 5’8” and weighing 131.6 lbs.

HEAD-RESTRAINT GEOMETRY: An inquiry with the Insurance Institute for Highway Safety (www.iihs.com) on the efficacy or lack thereof on the patient’s particular vehicle tells us that a) the truck hasn’t been made by Nissan in years, b) the only year it was rated was 1997 and it received a mixed rating of A-M-P (acceptable, marginal, poor).  As one can see from the picture below, Mr. T’s back set is sizeable. As well, the head-restraint is situated low on his truck, at the “marginal” to “poor” zone. 

>Head restraint geometry explained: The necessary first attribute of an effective head restraint is good geometry. If a head restraint isn't behind and close to the back of an occupant's head, it can't prevent a "whiplash" injury in a rear-end collision. Institute researchers regularly evaluate the geometry of head restraints in passenger vehicles based on the height and backset relative to an average-size male. A restraint should be at least as high as the head's center of gravity, or about 9 centimeters (3.5 inches) below the top of the head. The backset, or distance behind the head, should be as small as possible. Backsets of more than 10 centimeters (about 4 inches) have been associated with increased symptoms of neck injury in crashes.

>Geometric ratings: Geometric ratings are good predictors of how well people will be protected in rear-end crashes — drivers with restraints rated good are less likely than those with poor restraints to claim neck injuries. Head restraint geometric ratings for hundreds of passenger vehicles are listed by vehicle make and series. Various head/seat combinations are rated (not every available seat option in every series has been measured). The restraints are measured with the angle of the torso at about 25 degrees, a typical seatback angle. Each restraint is classified according to its height and backset into one of four geometric zones — good, acceptable, marginal, or poor.

Note Back set of head restraint.

RADIOLOGICAL EXAMINATION:
A clinical decision was made to take the necessary X-rays today on this patient. This would normally include a cervical Davis Series as well as AP-Lat lumbar films.

Extension view of DT’s cervical spine.

Neutral Lateral view of DT’s C spine.

 Lumbar AP view of DT’s low back. Left side is on left here, we are viewing this film from “behind.” 33 Degrees of scoliosis was measured.

DIAGNOSIS (original):
Initial working diagnosis: Based on the patient's subjective comments, the case history, and the DDX analysis during the physical exam, it was opined that the patient sustained a Cervical-Lumbar/sacral strain/sprain Grade II with full spine pathomechanics and gross  myospasms, all as a result of the accident the patient suffered on or about 1/1/08. This all compounded by the patient’s pre-existing scoliosis. This is to a reasonable degree of medical certainty.

Analysis: The patient responded very well to care. Treatment parameters extended just over 30 visits.

Our first case study shows us a number of interesting things about an interesting patient. It also points out that plain film X-Rays still have a place in the everyday practice and can reveal postural issues that may have been fomenting for years only to have "pain" appear years later. Let's see how this patient's history and findings came together:

HISTORY AND PRESENTING COMPLAINTS: 
Haley (39 yo female) presented seeking treatment for acute upper mid back pain, right arm radiculopathy and neck pain. She told us that although she has had discomfort in the back for a fairly long time, it was very recently that the pain in her back and arm became so profound that she “felt like her arm was coming off.” She told us further that she had sought two massages and began taking Ibuprophin. As a result of that, she continued, her pain seemed to calm down. Haley presented to us due to continual pain in the areas described. She stated that the worst of it is in her upper middle thoracic region, medial scapular area. She described the pain as being heretofore stabbing in nature but more of a noticeably achy sensation now as well as constant. She stated that stress issues as well as sitting at a desk all day aggravate as does sleeping. Haley added that movement relieved the pain somewhat. She further described the right arm pain along a specific C7 locus to the elbow. That is to say, a pure triceps pattern. She described this pain as achy/sore now, constant, where again, stress and sitting all day aggravate and movement offers some relief.  Haley further told us that the neck pain is right sided and more of a casual ache and least bothersome of her three big pain issues. It is also constant with the same aggravating and relieving factors.

RADIOGRAPH DISCUSSION:
Due to the patient’s presenting complaints and objective findings, a clinical decision was made to perform AP/Lat/APOM views of the C-spine. Of note:

C-spine: The AP view reveals most prominently, a gentle dextro scoliosis reaching from the upper thoracics to the cephalad portion of the C spine. See documenting digital photos of the region in this view as well as the lateral view. The unco-vertebral joints were clear and well maintained. The lateral view is the other view that revealed much about Ms. H’s situation: noted was a frank kyphosis of the entire region. As well, her entire C spine is tilted slightly forward. Disc and body heights appear proportional and are well maintained. Finally, we have the APOM shot. Ms. H’s C1-2 segmental interface is intact and perfectly normal in relative body spacing. Due to the possible involvement of the thoracic spine in her scoliosis, we may opt to shoot an additional AP Thoracic X-Ray in the near future.

No evidence of fx, dislocation or neoplastic activity to the extent visualized on these films. *800 speed Rare Earth systems were used with full lead collimation and the inclusion of the thick lead gonadal shield to absorb lower limb/abdomen scatter. Ms. H was also given a lead apron for another layer of protection. Technique was good in this set. All views were weight bearing.

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  Ms. H’s lateral Cervical shot. Note the frank kyphosis (curve reversal, as opposed to a normal “lordosis”). Disc spacing is good and there is a minimum of any other indication of early DJD.

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DIAGNOSIS:
Based on the patient's subjective comments, the case history, the DDX analysis and the physical exam, it was opined that the patient suffers from a chronic Cervico -Thoracic scoliosis that has finally begun to cause cognizant pain to this patient. Thus, a variant of the pathomechanical syndrome, the scoliosis is a long term issue. Noted also, pathomechanics in the entire spine with appreciable muscle spasm and cervicogenic radiculopathy. This to a reasonable degree of medical certainty.

Analysis: The patient enjoyed her first two treatments and felt markedly better. She was admonished to use the ortho pillow regularly and sleep on her back henceforth. Patient involvement with care is crucial to ongoing success in treatment, especially in a "wholistic" approach to care in which a patient's lifestyle, postural and sleeping habits and exericise are taken into consideration.

Judicial used of X-Rays are indicated in many cases. When findings like we have here come up, they make for a compelling "Report of Findings" when explaining a diagnosis to a patient.

Remember, pain is NOT a reliable criteria with which to judge one's health. The deformation in this woman's spine took years to happen, yet she only felt serious pain more recently. Get checked by your chiropractor when there is the slightest suspicion of back/leg/arm pain and any of the other common issues we regularly treat such as headaches.

Yours in Good Health, Dr. Haberstroh

Dear Friends,

Please bear with me. This blog option literally just went up today, May 5, 2009. I will begin posting interesting chiropractic case studies and other issues as soon as possible.

Thank you for your patience.

Dr. Haberstroh