MD Referral Program
from the desk of William J Owens Jr DC DAAMLP CPC
Clincial Consulting – MRI and Others – Consultation #9
MRI Case Study #1 – Central Stenosis
This was a 67-year-old male that presented to the upper status post MVA. This accident was on June 3, 2014, he went to the emergency room on that day for evaluation. Imaging studies included a CT of the cervical spine. I’m going to dictate the findings in the impressions of this report. I only had the actual paper report we didn’t actually have the images themselves so I was going off the report only. This is why it’s critical to make sure that if you don’t have the images that you do your property evaluation before you jump into treating somebody.
CT findings on June 3, 2014-cervical spine-the images obtained demonstrate marked narrowing of the disc spaces with endplates sclerosis and osteophytosis from the C4-C5 level through the C7-T-1 levels. The spinal alignment appears adequate. The neural canal is abnormal size except for some mild spinal stenosis at the C6-C7 level due to osteophytes effacing the thecal sac which arise from the vertebral bodies. The odontoid appears normal. The ring of C1 is intact. There is degenerative facet joint arthropathy noted bilaterally from the C3-C4 level through the C7-T-1 levels resulting in moderate to marked degrees of bilateral foraminal stenosis. The final impressions for this exam were as follows:
1: No acute fracture or dislocation
2: Degenerative disc disease and cervical spondylosis of the C4-C5 level through the C7-T-1 level
When I examined the patient the only neurological findings was decreased sensation over the left C7 dermatome. His past medical history as indicated his hypertension and diabetes. Now we talk a lot about when you should order advanced imaging outpatient. This case is interesting because he already had a CT scan of the cervical spine so conventional wisdom, although this is generally incorrect, would dictate 46 weeks of conservative treatment and without improvement then we would order the MRI. In my office, any neurological deficit must be evaluated with advanced imaging. That could be sensory, motor or pathological findings.
So what we have here is actually a CT scan that was misread by the emergency room radiologist. Some single upper extremity subtle neurological findings. And a patient that is over the age of 65 with a diabetic comorbidity which is certainly a complication to his health and for me, is a red flag for detailed clinical evaluation. Now this is also a medical legal issue as well but I’m going to read to you what I read on the MRI confirmed by the radiologist read. This MRI facility is a great facility and I’ve known these radiologist for very long time 90% of the time we agree on the findings on the MRI scan. This was a case where we are in total agreement. But what I want you to pay attention to is the difference between the opinion of the CT scan radiologist and the truths regarding the central canal stenosis.
So the read on the MRI is as follows.
C2-3-hypertrophy of the right uncovertebral joint and left facet joint resulting in right foraminal stenosis.
C3-4-bilateral facet arthropathy and minimal anterolisthesis with posterior disc extrusion measuring 6 mm into the spinal canal with impingement and compression of the spinal cord with severe central spinal stenosis. Hypertrophy of the uncovertebral joint in bilateral foraminal stenosis.
C4-5-disc space narrowing and spondylosis with minimal posterior ridging and retrolisthesis with anterior spurring and bulge and diffuse posterior ridging with superimposed disc herniation extending approximately 2.5 mm into the spinal canal with effacement of the thecal sac. There is mild lateral recess stenosis bilaterally at this level.
C5-6-moderate disc space narrowing and spondylosis with anterior spurring and disc osteophyte complex slightly asymmetric to the left. There is mild to moderate central stenosis and bilateral lateral recess stenosis.
C7-T1-subligamentous disc herniation minimally defacing the subarachnoid space.
T1-T2-4 mm central disc herniation effacing the anterior subarachnoid space and mild bilateral facet arthropathy.
Learning Issue #1
The 1st learning issue in regards this case is always make sure you read your own films in that MRI trumps CT scan for cervical spine imaging at every level. Having a detailed neurological exam but also taking into consideration comorbidities and patient history is critical. If this patient were ever adjusted there be catastrophic consequences.
Learning Issue #2
Relationships matter. This was the patient’s 2nd visit and I was going to review the MRI with them and start treatment. Obviously that didn’t happen, my office called to the spine surgeons office and they made an immediate opening for the patient to go right down for my office. The orthopedic surgeon did comment it have a phone consult with them quickly to review whether or not the patient should actually come to their officer go to the emergency room. Since there were no hard neurological deficits, the patient ambulated without a pathological gait and there were no changes in bowel or bladder habits he could be seen an ambulatory medical office. If any of those other issues were present I would’ve sent into the emergency room at the local, hospital for evaluation.
Learning Issue #3
The last learning issue has to do with building a relationship with the primary care physician as well as the patient. I did give the patient my cell phone number and told him when he’s done to comment on that number. I told him that there’s any issues over the weekend that I would be more than happy to take his call. He was extremely satisfied and thinking over and over again for being so thorough. I will be calling the primary care physician and faxing over my report as well as the CT and MRI studies. I will keep the PCP updated and look to build a relationship.
If you want to position yourself in your community is a true spine specialist you need to understand the entire continuity of care relating to spine injuries and or pathological findings. Just because I am a chiropractor in my main focus is the correction of subluxation does not mean that I can ignore all the other issues that go on with the spine. This is why postgraduate training in MRI, biomechanics and most importantly the Fellowship and spinal trauma be critical to her your continued growth and marketing plan for your practice.
Before the patient arrived at the orthopedic’s office I had my staff fax over the MRI (the surgeon can review the MRI on the PACs system – that is the electronic computer based system that allows you to access films) and my intitial report. That is how you show your diagnostic abilities, your ability and desire to communicate and your ability to handle complex cases. To review the Initial Report so that you can see what one looks like click here.