JACCO
Journal of the
American College of Chiropractic Orthopedists
Volume 30 Number 1
April 2009
The American College of Chiropractic Orthopedists is not responsible for the contents of articles in this issue, nor does it approve or disapprove of certain statements made in the text. The accuracy of the information and the opinions are strictly the responsibility of the authors and are not necessarily the official position of the ACCO.
JACCO
April 2009 Volume 30, Number 1
A Publication of the American College of Chiropractic Orthopedists
Editor/Publisher Deanna O’Dwyer-Swensen, D.C. 40 West Foster Street Melrose, MA 02176 dosdc@aol.com
American College of Chiropractic Orthopedists Executive Board
President: 1st Vice President: 2ndVice President Treasurer: Secretary: Past President: Advisor: Alternate Advisor LaVerne Saboe, Jr., , D.C., F.A.C.O. Thomas Mack, D.C., F.A.C.O. Joseph Ferstl, D.C., F.A.C.O. David M. Swensen, D.C., F.A.C.O. Boyd Peterson, D.C., F.A.C.O. William Fischer, D.C., F.A.C.O. Rome Hanning, D.C., F.A.C.O. Jesse Rothenberger, D.C., F.A.C.O.
Committee Chairs
Convention: Exhibits: Archives: e-JACCO: Joseph Ferstl, D.C., F.A.C.O. Jim Vancho, D.C., FACO John Black, D.C., F.A.C.O., F.I.C.C. Deanna O’Dwyer-Swensen, D.C.
Letter from the Editor: My Dear Fellows in Chiropractic Orthopedics,
Every day I am amazed at the saying, “the more things change, the more they stay the same.” The New England Journal of Medicine just published a retrospective study by a researcher at Harvard (Professor Nicolas Christakis, a professor of medical sociology at Harvard Medical School) who claims that the epidemic of peanut allergies can be eradicated, in most cases, by administering low levels of peanut and tree nut allergens, over the period of two years, to a patient who suffers from peanut and tree allergies. Really? And further, the recommendation to give peanut and tree nuts earlier than 3 years of age could also help to desensitize the patient. Wow, the body healing itself, hmmm. Now THAT is a novel concept. But, the sad thing is, is that the world will accept that “outlandish” claim, BECAUSE it was published by a medical doctor. Where is Chiropractic? And, where, my friends are you? We need to be that bonded. We need to be putting out case studies and taking accurate notes and results, in our office, everyday; collating them and reaching out to each other as colleagues to show the world that we are the profession of the health minded. We can and do heal patients from within, naturally. We need to be the forerunners in holistic health. We can either be the leaders of the pack or the water packers. What would you choose? Lead, follow or get out of the way. And on a lighter note… This year brings new change to both the United States of America and to the Chiropractic profession. This year, we continue to elevate our profession as we journey through contemporaneous topics in education and research. The American College of Chiropractic Orthopedists, The Council of Chiropractic Orthopedists, and the Texas Council on Chiropractic, are joining together to further educate the enlightened doctors of chiropractic to a new level. The seminar that you have been waiting for is around the corner and rapidly approaching. It will bring new reputation to our profession as the leaders in neuro-musculoskeletal health care. The conference of “Investigations of Failed Low Back Surgery” will be presented on May 8-10. It is exploding with new research and information that you can utilize the very next Monday morning. Don’t be left behind, register now! See you in San Antonio, “pardner”. Become the change you wish for the world. Respectfully submitted, Deanna L.O’Dwyer, DC Editor, eJACCO
Important Message from the President There will be a general meeting on May 8th during the luncheon at 12:00 pm. This meeting will be open to all members. Nominations will be taken for the 2009-2010 Board elections. Please direct any questions or concerns to Vern Saboe, DC, in person, or at vsaboe@comcast.net
2008ACCO General Meeting April 9, 2008 Carlsbad, California Dr. Fischer called the meeting to order at 1:15 PM PDT. Dr. Evans made motion to approve the previous minutes. This was seconded and the minutes were approved unanimously. A moment of silence was had for Dr. Cassiopeia. Dr. Steven Capps was recognized as the ACCO CMCP lesion. Dr. Holly Williams recognized HT as a Platinum Sponsor. Select Comfort and NCMIC were also recognized as major sponsors. Dr. Vern Saboe (Golf Chair) recognized the different winners of the golf outing. Dr. Rome Hanning presented a $2000 from HTT, check to the Lipe Scholarship fund. Dr. James Brandt donated a $500 check from the Academy to the Lipe Scholarship fund. Steven Capps was recognized as a new FICC member. Distinguished service award members for the Academy were: Drs. Jim Demetrius, Bruce Gunderson, Warren Jahn, and Greg Norton. Distinguished Fellow Award was Dr. Steven Capps. Dr Brandt announced that NWCC agreed to undertake the 2010 project and he felt other schools would follow. Dr. Fischer presented the ACCO awards as follows: Lifetime Service award: Dr. James Brandt Distinguished Lifetime Member: Dr. Bill Valusek Presidential Award: Dr. Michelle Stueber Recognition award: Rose Marie Valusek Dr. Rome Hanning presided over the election of new officers. The slate is as follows: President - Dr. Vern Saboe 1St Vice President - Dr. Tom Mack 2nd Vice President - Dr. Joe Ferstl Secretary - Dr. Boyd Peterson Treasurer – Dr. David Swensen With the past president as Dr. Bill Fischer. Call was made 3 times for nominations from the floor and there was none. Motion was made, seconded and unanimously approved. Dr. Bill Valusek the Sergeant at Arms installed the new officers. The gavel was passed from Dr. Fischer to Dr. Saboe and the meeting was adjourned at 1:55 PDT.
We Have Choices
; Dale Huntington, D.C., F.A.C.O. President Council on Chiropractic Orthopedics
American Chiropractic Assoc. The CCO is mandated by our by-laws to have an annual general membership meeting at a place of our choosing. Our choice has been an obvious one where we can meet face to face with the general membership, among them our coalition partners, the A.C.C.O, Academy and Texas Council of Chiropractic Orthopedists. This enables us to engage in dialogue with all vested interests within our specialty. This conference is the chiropractic profession’s premiere orthopedic educational opportunity geared to bring us up to date on some of the latest topics available and presented by some of the best speakers in the nation to enhance our knowledge to better serve our patients. It is this group of like minded orthopedists that will move our specialty forward in this century. It is my hope you will choose to join us in the camaraderie that may prove to be one of the best orthopedic conferences ever. I will look forward to seeing you at the Hyatt Regency on the River-Walk May 8th-10th in San Antonio, Texas.
HOW CREDENTIAL CREEP IS AFFECTING THE CHIROPRACTIC PROFESSION AND THE ORTHOPEDIC SPECIALTY
Over the past century of its chronicled existence the Chiropractic profession’s degree program has progressed from professional certificate, to associate degree, to bachelor degree, and now new pathways have emerged to masters and doctoral degree programs. The chiropractic profession is experiencing the credential creep of the health care professions. Over time in the health profession the eventuality of credential creep has become a reality that has mandated the chiropractic profession, if it is going to survive and maintain a credible credential, must accelerate along academic pathways. There is an increasing awareness on the part of our patients as well as other health care professions of academic credentials to include not only board certified specialties but graduate level degrees as well. Across the board of health care fields there is an increasing need to maintain a higher level of academic credential. Whether we like it or not the public does look at the credentials a provider has following their name. The chiropractic profession can no longer rely on simply a competency model that is not tied to academic degrees. Along this same path board certified specialties based on post graduate studies and competency based models in the future will increasingly become based on graduate level studies as well as certification and re-certification by specialty competency exam. Graduate level degrees will ultimately determine the future of chiropractic specialties. Those specialties that do not progress to a graduate level of study will fall short of the bar with credible credentials. The Academy of Chiropractic Orthopedists position on this issue is one of increasing awareness and proactive development of graduate level pathways. The chiropractic college system has served the profession well over the decades. Now through the efforts of a team of the leading educators and academicians in the chiropractic college system the orthopedic coalition has developed a Masters of Science (MSc) program in Physical Medicine and Rehabilitation (PM&R) to meet the future needs of accelerated credentials and meet the criteria for orthopedic board specialty certification. The Academy strongly supports the board certified orthopedist continuing their education as well as obtaining further education along the graduate level masters and doctoral programs that meet the criteria contained in the orthopedic specialty field.
With the increased level of responsibility of the orthopedic specialist in both clinical and hospital practice the board certified chiropractic orthopedist clinically functions at the masters and doctoral academic level making graduate level of study an appropriately recommended academic credential for specialty certification, re-certification and maintaining ones credentials and privileges. This level of education will increase and further develop the skills and knowledge base of the orthopedic specialist in the present and future clinical and hospital environment. If the orthopedic specialist is to be viewed at the same level of competency in their respective field of neuro-musculoskeletal management as their medical and osteopathic counterparts then it is essential to possess equal if not greater credentials. Please visit the Academy web site www.dcorthoacademy.com often for the latest developments and encourage your respective alma mater to offer the MSc (PM&R) masters program.
STEPHEN D. CAPPS, DC, FACO, FICC President Academy of Chiropractic Orthopedists
Clinical Pearl: In the March, European Spine Journal researchers found that with an axial load in the supine position equal to half their body weight compared to a standard supine MRI, the central canal narrowing contributed by the ligamentum flavum was between 50 and 85%. “It was concluded that the ligamentum flavum not the disc had the dominating role for load induced narrowing of the lumbar spinal canal.”
The Center Ray
An Imaging Chronology of Degeneration Following Anterior Cervical Interbody Fusion
James Demetrious, DC, FACO1,2,§
2
Private practice, Wilmington, NC, USA Post-graduate faculty, New York Chiropractic College, Seneca Falls, NY, USA § Corresponding author Email address: JD: jdemetrdc@aol.com
1
Purpose
To provide an imaging chronology of pre-surgical and post-surgical degenerative change of a patient who had undergone an anterior cervical interbody fusion of the C4-C7 vertebrae.
Background
A 54-year-old Caucasian male presented to our office with complaints of cervical spine and left upper extremity discomfort. The patient reported a chronic history of neck pain and bilateral radicular arm symptoms for which he underwent anterior cervical inter-body fusion three years prior to seeking care in our office. The patient reported worsening of neck, left scapular and extremity symptoms immediately following the surgery and multiple medical interventions that included: repeated diagnostic evaluation; pain management care; a failed carpal tunnel release surgery that resulted in surgical iatrogenic sectioning of the median nerve and resultant disability; and extensive physical therapy.
Case Images
The following images depict progressive degenerative changes of adjacent segments above and below surgical arthrodesis. Descriptions of clinically relevant issues are presented.
Figures 1(Left). Pre-surgical radiograph. Figure 2 (Right). Post-surgical radiograph. Circles denote two year interval degenerative change following surgical intervention as evidenced by increased size of anterior C3 osteophyte [1].
Figure 3. Pre-surgical CT sagittal reconstruction reveals advanced degenerative joint disease with a prominent pneumatocyst [2].
Figures 4 (Left) and 5 (Right). Pre-surgical CT axial views (bone windows) reveal prominent pneumatocyst of the C5 vertebral body, central canal stenosis (measured 7mm AP diameter) and significant left foraminal stenosis affecting the left C5/6 intervertebral foramen due to uncovertebral degeneration [3].
Figure 6 (Left). Pre-surgical CT illustrates patent AP central canal diameter. Figure 7 (Right). Postsurgical CT reveals acquired central canal stenosis adjacent and superior to arthrodesis due to thickening of the posterior longitudinal ligament.
Figure 8 (Left). Pre-surgical MRI Axial T2 Weighted Image of C3/4 reveals central canal stenosis (measured 8mm AP diameter). Figure 9 (Right). Post-surgical CT axial image reveals prominent focal posterior mid-sagittal osteophyte producing central canal stenosis and deformation of the spinal cord. Thickening of the posterior longitudinal ligament is appreciated.
Figures 10 (Left) and 11(Right). Post-surgical images. MRI T1 (Left) and T2(Right) weighted images reveal increased signal intensity affecting the marrow space and endplate zones of the inferior bodies of C3 and C6. Increased signal reflects Modic 2 changes that is reflective of fatty degenerative change and may reflect inflammation within the marrow space of the vertebral bodies [4]. The small arrow at C3/4 denotes interval thickening of posterior longitudinal ligament with obliteration of anterior epidural space. Long arrows reveal T2/3 and T3/4 disc protrusions. Also note Schmorl’s nodes of the T2 and T3 superior endplates.
Figure 12. Post surgical CT reveals subluxated facet apposition of the left C5/6 zygapophyseal joint within the region stabilized by fusion [5].
Figure 13 (Left). Post-surgical MRI Fiesta images reveal normal appearing multifidi at C2/3. Notice the homogeneity of the signal intensity throughout. Figure 14 (Right). Post-surgical MRI Fiesta image of the multifidi at C3/4 reveals increased signal intensity of the posterior medial aspect of the muscles. This is consistent with atrophic changes [6].
Clinical Considerations and Key Points
Progressive post-surgical degenerative changes following anterior cervical interbody fusion may affect adjacent segments and present in multivariate ways. Chiropractors should be aware of progressive degenerative changes that may present following anterior cervical interbody fusion.
Acknowledgements
Written informed consent was obtained from the patient for publication of this case report and for the use of accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
References
1. Ishihara et al.: Adjacent segment disease after anterior cervical interbody fusion. Spine J. 2004, 4(6):624-8. 2. Yamamoto et al.: Natural course of an intraosseous pneumatocyst of the cervical spine. AJR Am J Roentgenol. 2002, 179(3):667-9. 3. Cantu RC. The cervical spinal stenosis controversy. Clin Sports Med. 1998, 17(1):121-6. 4. Peterson et al: prevalence of Modic degenerative marrow changes in the cervical spine. JMPT 2007, 30:5-10. 5. Haldeman et al: An atlas of low back pain. Parthenon Publishing, 2002. 6. Elliott et al.: Fatty infiltration in the cervical extensor muscles in persistent whiplash-associated disorders: a magnetic resonance imaging analysis. Spine 2006, 31(22):E847-E855.