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KATZ CHIROPRACTIC AND REHABILITATION CLINICFRONT RANGE DIGITAL MOTION X-RAY2727 Pine Street, Unit 1, Boulder, Colorado 80302Office: 303-938-9070 ~ Fax: 303-938-9170Patient : PATIENTDate: November 7, 2016Based on my diagnoses, the following is a clinical impression with regard to her injuries that she sustained on XX from a motor vehicle crash.PATIENT reported to my office with injuries sustained in a motor vehicle crash. Based on her history before and after the crash, my clinical impression is the injuries and symptoms are from this trauma. Loss of the cervical lordosis: PATIENT images as well as her posture and complaints clearly show a reversal of the normal cervical lordosis (1-2). Many studies show that motor vehicle crashes, such as the one PATIENT was involved in, causes this significant pathology (3-6). I have also published data on this mechanism of injury being caused by car crashes and presented it at international spinal conferences. Several health consequences are associated with a loss of the cervical curve; these have been reported in the literature and I have seen this first hand in my clinic. Problems include pain, increased muscle spasm, increased pressure on the discs leading to earlier osteoarthritis, and a higher chance of disc bulges and herniations. If not corrected, it can lead to central nervous system inflammation and eventually neuronal death, as well as a change in hemodynamics of the vertebral artery (7-14). I am listing some studies that also show that a loss of the cervical lordosis leads to increased disability and suggests that once the pathology starts, the likelihood of it becoming worse increases. (15). Fusion surgery has been shown to try and improve a loss of the cervical curve(16). The authors also describe “Worsening of the cervical sagittal parameters is associated with decreased health-related quality of life.” PATIENT had MRIs of her cervical spine on to occasions as well as x-rays. I mentioned above that a kyphotic alignment of the cervical lordosis untreated has a higher likelihood of degeneration and increased disc and CNS pathology. July 3rd 2013 she had a x-ray at “Alpine Orthopedics & Sports Performance Center” that reads “3 view shoulder show normal x-ray without fracture and 5 view cervical show loss of cervical lordosis and no acute fracture.” On Sept. 6th 2013 PATIENT had a supine MRI of her cervical spine. The radiologist from Gunnison Valley Hospital reported, “there is straightening of the normal cervical lordosis. This is predominately at C5-6.” PATIENT had another cervical MRI on September 30, 2015 at the Steadman clinic. Radiologist Richard Shin, M.D. reports “Findings: Cervical spine straightening and slight mid to lower kyphosis is decreased from previous study. Dr. Shin M.D. also reports “C5-6: Moderate to severe disc degenerative change, with moderate to severe disc height loss and moderate discogenic endplate degenerative change, worsened from the comparison study..” On March 23, 2016 another MRI was done that shows similar findings. It seems clear that in 2013 PATIENT had very little degenerative change at the C5-6 level and in approximately two years, this one level had rapidly accelerated degeneration. I have listed my clinical experience, and some physiologic studies to show this is what is expected to happen with a loss of the cervical lordosis. I feel if she had this pathology prior to the crash, she would have had these findings on her initial MRI. I would compare her MRIs and her X-rays to compare the curve, however, supine MRIS are not the best at evaluating the lordosis as the patient is not weight bearing. In fact on September 7, 2016 published in “International Journal of Spine Surgery” published a paper titled Magnetic Resonance Imaging of the Cervical Spine Under-Represents Sagittal Plane Deformity In Degenerative Myelopathy Patients. Cervical instability: It is evident on PATIENT digital motion x-ray that was recommended by Dr. Stieg MD, that she does have instability in her cervical spine(14-15). Instability of the neck is a consequence of damaged ligament(s) that hold her bones together in place. The consequences of instability are increased inflammation, increased pain, and altered biomechanics resulting in the spine in a weaker state. This is a very similar to an injury that is seen in sports such as football when a player tears their ACL in their knee. Unfortunately for, PATIENT having this type of injury in her neck is very significant. The bones in her spine surround the spinal cord and brainstem making these areas susceptible to further injury. Cervical instability is difficult to manage due to the complexity of the cervical spine.The instability in her neck was evaluated with a digital motion x-ray. On x-ray, instability is determined by measurement on a lateral view. Based on the AMA guidelines, the angle between two cervical vertebrae should not exceed 11°, and translation should not exceed 3.5mm. If the cervical vertebrae exceed these parameters, it is considered an unstable segment and according the DRE guidelines, it is a 25-28% whole body impairment. PATIENT measurements at C3/4 during extension measures -12.3°, signifying damage to the ligaments at this level of the spine. Based on these radiographic findings, the structures that are most likely damaged would include the anterior longitudinal ligament, posterior longitudinal ligament, interspinous ligaments, ligament flavum, and the disc. Many studies demonstrate, and my clinical experience has shown that car crashes causes damage to the ligaments of the spine, which will lead to instability. I have also published a study that demonstrates this phenomenon. (17-18). Dr. Oppenheimer MD of Boulder Community Hospital read her DMX on December 17,2016 and one of his impressions is ”2. Abnormal amount of movement in flexion between C2 and C5 in consistent with instability.”With respect to her upper cervical spine, during left lateral flexion of C-1/ C-2, it measures 3.4 mm. According to my clinical experience as well as many scientific papers and textbooks, this finding signifies that the upper cervical spine ligaments are damaged. The ligaments are most likely the accessory, alar, and transverse ligaments. Dr. Oppenheimer MD of Boulder Community Hospital read her DMX on December 17, 2016 and one of his impressions is “4. Abnormal motion of C1 on C2 indicates laxity or tearing of the transverse, alar, and/or accessory ligament complex.” Interestingly from a clinical perspective is during the DMX, PATIENT could not see her spine on the screen. During the APOM movement to analyze her upper cervical lateral flexion maneuvers, she pointed to her upper cervical spine during C1 sliding too much. This along with her history and exam, and her images correlate with a upper cervical injury. On her March 23, 2016 MRI, which again is non weight bearing and doesn’t show movement, the radiologist from the “Steadman Clinic” also reported “C1-2/foramen magnum: Mild atlantoaxial degenerative change with sclerosis at the anterior arch of C1 and odontoid with transverse ligament thickening.” This too is a sign of trauma in the upper cervical ligaments. These ligaments connect the skull to C1 and C2 and minimize movement to protect the brainstem from getting compressed by one or more of these bones (see picture below of upper cervical spine anatomy). The problem with ligamentous injuries is they are permanent and progressive in nature requiring ongoing treatment and monitoring. This also leaves PATIENT more susceptible to further injuries; as this area is now weaker because of the damaged ligaments.Facet damage: the facets of the spine are large pain generators and are made up of one part of the cervical vertebra meets another part of the vertebra. When these joints are damaged it can lead to significant pain and discomfort on an ongoing basis. This can cause a sclerotogenous pain pattern (19) similar to PATIEN TS pain. PATIENT had some of the joints numbed with facet injections and it seemed to minimize her pain until the medication wore off. This again is one more diagnostic test to help with a proper diagnosis of facet damage. Many studies also suggest that car crashes like the one PATIENT was in cause facet damage. Dr. Oppenheimer MD of Boulder Community Hospital read her DMX on December 17, 2016 and one of his impressions is “3. Abnormal facet gapping and malalignment indicates laxity or tearing of the facet joint capsules. In 2013, Australia Phys Eng Sci Med published a study “straightened cervical lordosis stress concentration: a finite element model study”. In this paper they correlate how a loss of the curve will irritate many structures including the facets, “The result demonstrated?that the active movement range of straightened cervical?spine decreases 24–33 %, but stress increases 5–95 %.?Also, there was stress concentration at the facet joint cartilage,?uncovertebral joint and the disk, which implied there?might arise abnormal tensions on the hind-brain, cranial?nerves, cervical cord, and cervical nerve roots.” Disc Patholgy: PATIENT had cervical MRIS as mentioned above. The radiologists mention disc pathologies primarily at C5/6. All the above pathologies that PATIENT presented at my office are direct results of this motor vehicle crash. I have based my diagnosis and clinical impression on several factors. PATIENT has no history of spinal trauma or symptomatology as it relates to these pathologies in her previous health history. After this crash, PATIENT had subjective complaints of headaches, neck pain, and certain movements hurt her neck and other clinical impressions such as palpation and orthopedic exams that led to the impression that there is structural damage. The images provide another objective test which clearly correlates with her subjective complaints and physical exam. I am also aware both clinically, as well as in research ,that motor vehicle crashes such as the one PATIENT was involved in causes these pathologies. She was also asymptomatic before the crash, and after the mechanism of injury she was symptomatic and had positive objective findings to correlate with her subjective complaints.Treatment I have recommend is chiropractic adjustments, proprioceptive rehabilitation, deep tissue work, spinal extension traction, heat and ice, and ergonomics training. All of this is being done with the goal to improve the normal cervical lordosis, improve biomechanics, minimize the chances of long-term health consequences, minimize her symptoms, and increase her quality-of-life and function. Because of the permanency and chronicity of her injuries and instability of her spine, she is more likely and more susceptible to flare ups and pain. I am recommending treatment in my office three times a week . Activities may cause some pain and headaches but I urged her to continue as long she's using proper mechanics as moving will only help the areas heal. Treatment would average $100/visit. Another DMX may need to be done every few years at a cost of $975. Based on her images I would like a upright cervical MRI to evaluate what her CNS looks like in a weight bearing position, in her most symptomatic positions. I do not believe that PATIENT had any pre-existing or pre-disposing conditions that would relate to these injuries. Based on her health history, or lack of any spinal issues and no diagnosis of any other pathologies that are identified here, I believe all of these pathologies are one-hundred percent (100%) from the motor vehicle crash in which she was involved in. Plus, we can see how quickly her neck decreased in health after the initial images after the crash. I did show her my animation videos on the consequences of the cervical lordosis and the video with the DMX and spinal cord and ligaments.If you have any questions please feel free to call.SincerelyDr. Evan Katz DCPATIENT 50673012915920Kyphosis with DDD0Kyphosis with DDD cervical curve Normal cervical curve 3)Whiplash produces an S shape curve. Panjabi et al,. 1997 spine 22(21): 2489-94.4Total Cervical Translation as a Function of impact Vector as Measured by Flexion-extension Radiography. Pain Physician 2007: 10:667-671 Christopher Centeno Md, Whitney Elkins, MPH, Micheal Freeman, PhD, James Elliot, Phd, MSPT, Michelle Sterling, PhD, and Evan Katz, DC5)Journal of whiplash & related Disorders Volume 4,Number 2,2005 Hawthorn medical press. Assessing Changes in the Cervical Curve Before and After a Car Crash using before and after digitized X-rays. Evan Katz Dc, Seana Katz Dc et al.6)Paul Ivancic Phd et al Effect of Active head restraint on residual neck instability due to rear impact. Spine volume 35 number 23 pp 2071-2018. Year 2010 7) Harrison D, Harrison D et al: Modeling of the sagittal cervical spine as a method to discriminate hypolordodis: Results of elliptical and circular modeling in 72 asymptomatic subjects, 52 acute neck pain subjects, and 70 chronic neck pain subjects. Spine 29(22):2485-2492 Nov 15, 20048)Keller TS, Colloca CJ et al. Inflence of spine morphology on intervertebral disc loads and stresses in asymptomatic adults: implications for the ideal spine. The spine J;5:297-3099)Hohl, Journal of bone and joint surgery. 1974 “when left untreated the likely consequences of cervical kyphosis are future pain and degeneration.”10)McAviney J, et al. Determining the relationship between cervical lordosis and neck complaints. JMPT march-april 2005; Vol.28, No.3 11)Ozer, Ercan MD et al Kyphosis one level above the cervical disc disease: Is kyphosis cause or effect? Journal of spinal disorders & techniques 2007, Vol 20, issue 1 pp 14-19 12)Uchida K, Nakajima H, et al, Cervial spondyolotic myelopathy associated with kyphosis or sagittal sigmoid alignment: Outcome after A-P decompression; Journal of Neurosurgery: spine 2009; Vol,11, pp. 521-528 13)Australas Phys Eng Sci Med. 2013 Jan 25. Straightened cervical lordosis causes stress concentration: a finite element model study.Wei W, Liao S, Shi S, Fei J, Wang Y, Chen C.Hangzhou Red Cross Hospital, 208 Huancheng East Road, Hangzhou, 310003, Zhejiang, China.(14)Med Sci Monit. 2016; 22: 495–500. Decreased Vertebral Artery Hemodynamics in Patients with Loss of Cervical Lordosis(15)SPINE Volume 41, Number 5, pp 371–377 2016 Impact of Cervical Sagittal Alignment Parameters on Neck Disability Sravisht Iyer, MD, Venu M. Nemani, MD, PhD, Joseph Nguyen, MPH, Jonathan Elysee, Aonnicha Burapachaisri, Christopher P. Ames, MD,y and Han Jo Kim, MD,z Stud(16)J Neurosurg Spine May 6, 2016 Cervical radiographic parameters in 1- and 2-level anterior cervical discectomy and fusion(17)Clinical Biomechanics 13 (1998) 239-249 Mechanism of whiplash injury Manohar M. Panjabi,“” Jacek Cholewicki,” Kimio Nibu,ab Jonathan N. Grauer,” Lawrence B. Babat,” Jiri Dvorakd “Biomechanics Laboratory, Depurtment of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, C?: USA(18)journal of the mechanical behavior of biomedical materials 53 (2016) Injury mechanisms of the ligamentous cervical C2–C3 Functional Spinal Unit to complex loading modes: Finite Element study(19) 14) Upper cervical spine anatomy: 15) ................
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