Blog, Chirosecure Live Event January 28, 2024

Chiropractic Malpractice Insurance – The Basics of MRI Interpretation

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Disclaimer: The following is an actual transcript. We do our best to make sure the transcript is as accurate as possible, however, it may contain spelling or grammatical errors.  We suggest you watch the video while reading the transcript.

Hi, I am Dr. Mark Studin, and first I’d thank to thank ChiroSecure for the opportunity to be able to share this information with you Today. I wanted to be a little bit more didactic and share information that you could use in your office every day that’s critical to your patients. It’s critical to your relationships with lawyers and medical doctors in emergency rooms.

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But let’s go back to the beginning. It’s critical to your patients. Let’s go to the slides right now and let’s dig in. Now, the first thing I want to share with you is this is a two part presentation. There’s too much to do in the time allotted, and ChiroSecure has been very gracious enough to allow me to do this in two parts so that you could watch it and get a little bit more.

And it’s gonna be at MRI, spine Interpretation and DISC morphology, which is really disc shape. So when we look at disc morphology, we’re gonna have to understand. What the disc is from a, and by the way, you’re gonna see me turning my head every now and then. I’ve got a bunch of slides in front of me. So when I’m looking at you in the camera, I’m here.

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When I’m looking at my notes, it’s here. I’m gonna go back and forth system that’s not a little bit disoriented. This is just a normal disc. And we’re gonna dig into this. This is a focal herniation, a broad base herniation. Okay. Then we’ve got a protrusion and an extrusion and a fragmentation, which are all extrusions by the way.

And we’re actually the extrusion and fragmentation, whether it’s connected or not, that’s an extrusion also. We’re gonna go into all of those things in intimate detail. I. Now I do not want to delude you and think that this presentation, even though it’s in two full parts, is going to give you the knowledge to interpret MRI images of spine.

If you want a real academic education taught by Harvard trained neuroradiologist State University of New York, it’s Stonybrook trained neuroradiologist. Take your phone out, click this QR code, and you will actually bring you to a landing page so you can find places to take a to take these courses and get real academics where you’re gonna go through thousands of images and dozens or hundreds of hours, depending upon how far you want to go down the rabbit hole.

But here’s the problem. There is a 43.6% error rate. General Radiologist interpreting Mr. And you imagine that you’re delivering a high velocity thrust with your patient’s health on the line, your practice on the line, your family on the line, your malpractice company on the line, all the way down the line.

All the way down the road, based upon almost a 50% error rate in interpreting these images. I’m not asking you to be a radiologist. But I am begging you to understand the basics of MRI, so you can read the report and see if it makes sense, because once I train a doctor, it jumps off the screen at them and said, oh my, or the paper, and they say, oh my God, this isn’t right.

Something is wrong. And I want you to be a real expert, not a BS artist. Most chiropractors historically. It’s changed a lot since when I went to school and I’m in the game 43 years now. Okay. It’s changed and through the years it’s changing more doctors of chiropractic know 5%, but they profess to know 500 Whoa profess to know 500% and that’s a problem.

You’ve gotta be a real expert. And in this doctor, in the, in Georgia, in the state of Georgia. An attorney when he went to court, tried to get him knocked out of the box because he is only a chiropractor. All he’s qualified to do is exam X-rays and adjustment. That’s it. That’s it. And he actually prevailed on this mo on this motion.

It was denied and they allowed him based upon a motion order denying motion to exclude. This is Dr. Don Capri’s put up here with this permission. Can you imagine if it was approved? If the judge allowed that, that would knock every chiropractor out of the state of Georgia, and that was the bellwether state at the time, because the carriers wanted to knock every chiropractor out.

That’s their goal, and they want us to fly blindly. And we’re gonna talk about when to order MRIs because insurance carriers want you to wait, actually want you to wait six weeks doing conservative care and treat your patient before you order the M mri. You know what that’s like. I know what’s wrong with the patient.

I know what’s wrong. You put your blinders on and you’re guessing if a patient’s got pain radiating down the arms or legs. What’s causing that pain? Don’t tell me subluxation. Don’t tell me bonnar nerve. ’cause it can’t happen at the root. It’s not physiologically possible. What’s causing that? Is there a space occupying lesion?

And you need to know. And if you don’t know, you don’t guess your patient’s worth you not guess it. So if there’s a radiculopathy or myelopathic component, then myelopathy is. Issues with the spinal cord, with ensuing neurological deficit, distal to that level of lesion. You need to do an immediate MRI before you touch the patient.

You want to treat them palliatively, heat stim, ice, et cetera. Hey, knock yourself out, but you’re not helping them. You want to deliver a high velocity, low amplitude thrust, what we call a chiropractic spinal adjustment, and it’s not a manipulation, it’s a chiropractic spinal adjustment manipulations. Have an 86, I believe this.

I don’t have the number at my fingertips, but I believe it’s an 86% decrease outcome versus a chiropractic high velocity, low amplitude thrust. So we’re not manipulating, we’re adjusting, and it’s not a philosophical issue. It’s based upon the evidence and the literature, and that’s extremely important Now.

The most important reason for an MRI in a contemporary chiropractic practice folks, is to do it right. It’s the gold standard to evaluate intervertebral disc pathologies, and that’s according to Kim in 2022. And by the way, everything I’m sharing with you today is based on either the evidence in the literature or from the American College of Radiology.

This is the standard. This is the standard. It’s not a chiropractic standard. It’s not a medical standard. It’s a standard of which we use when we want to diagnose what’s going on in the spine. I am a spine specialist. I want to know, I don’t wanna treat blindly, and I tell you, when I was practicing back in the eighties.

We didn’t have MRI and we guessed, and I remember back a long time ago, so many patients, I wish I had this tool available so I wouldn’t have to guess on my patients. A lot of ’em got well without it, and a lot of them, frankly, I really delayed necessary care or surgery and I heard a few, and I’m being honest with you because I didn’t know this tool was not available to us.

It’s available to us now. So when we look at this and we look at referrals, the common roadblock for lawyers and medical providers, a common roadblock to lawyers and MDs is MRIs. We have to understand what’s going on. If you want that referral, you at best when clinically indicated, order an image. Now the fact that the patient’s in a car crash, or they fell.

Is that an indication for an m? They have a lawyer. Oh, I have a lawyer. I have an MRI. If you do that, prepare to hand your license over. That is not a standard. It’s not a standard that is taught in any level of academia. I teach in both chiropractic, academia in the classroom. I teach in medical academia.

I’m a professor in a medical school as well. It’s not a standard, you order an MRI based upon clinical presentation and we’re gonna talk about that in just. Moment, and that’s really important. So what you want to do is start with patient history, clinical findings, and if you see alopathic or myelopathic sign or symptom, you order an immediate MRI.

You have weakness in an extremity, you have motor loss in an extremity. You want an immediate MRI if you’re looking at a myelopathic problem. Cord issues, whether it’s compressed or not, and ensuing neurological deficit distal to the level of lesion. You have to worry about myomalacia, which is right here, by the way.

This is just one way that we report what’s going on in each level. We’re letting the person reading the report know what our findings are. Is there a spinal cord issue? Is there a spinal nerve root issue? Is there a fecal sac, which is the covering of the spinal corded nerve roots? Is there a disc problem in the recurrent meningeal nerve?

Those nerves reside in the outer one third of the disc, and if you have a problem at any disc problem, you’re gonna have discogenic pain from the recurrent NAL nerve, which used to be called the sinu vertebral nerve. Is there cord edema? In other words, when there’s pressure on that spinal cord, it’s like stepping on that garden hose and the water backs up, so you’re gonna get cord edema.

But when the water or blood in this case backs up, it can’t get to the cord and the nutrients can’t get there, and you start getting death of the neurons and the spinal cord and you’ll start seeing a shrinkage of that cord, and that’s myelomalacia and that’s a biggie. You worried about chemical radiculitis?

As a result of an annular fissure, when that inner nucleus osis material leaks out that nucleus papus material is neurotoxic, it’s toxic to the nerves either in the nerve root coming out of the neuro canal or the nerve root in the central canal when you’ve got the cauda aquina and you’ve gotta understand your anatomy.

If a nerve, if a if a piece of nucleus osis material. Which is made up of proteoglycans and collagen type one and type two. And Proteoglycans binds it all together and it leaks out from a herniation or even an Ann Fisure, which is a pore or little tiny opening in the Anns with a nucleus goes goes inside that canal.

It’s brutally painful, brutally. When you have a. Sequestration or fragmentation, and we’re gonna talk about that as well. And that goes into the canal. It’s exquisite pain. Immediate surgery. So when you’ve got any of these signs or symptoms, it is, do not pass, go immediately in that tube. And guess what?

Don’t touch your patient. Here’s a hard mark rule. If you don’t know, don’t touch. I don’t know. I’m gonna guess. I’m gonna go. My philosophy says I could grow, hair in a cue ball. I don’t care what your philosophy says. You have to know what your diagnosis is for your patient. I want a conclusive diagnosis, period.

There’s no such thing as lac diagnoses. That’s a topic for a different conversation. You’ve gotta have a definitive diagnosis of what you’re treating. That patient might need immediate medical care, might need immediate surgical care. Oh, I don’t wanna work with a surgeon. Oh, my decompression can do everything.

That’s nonsense. If that spinal cord is compressed, you’re spinning the dice. If there’s no space for that cord to go. You’re spinning the dice, especially if you see signs of cord edema. Myomalacia is soon thereafter, cord’s gonna start to die, and that die is die. It don’t come, it doesn’t come back.

It’ll have to reroute itself, but it won’t come back. So you’ve gotta determine clinically, if you can decompress that independently, that patient might need bedrest. The definition of bedrest, two additional recumbent hours per day. They might need red bed rest, they might have to stop working.

But you need a conclusive diagnoses. ’cause if you don’t know, you don’t guess. And also when you’re treating your patient, despite the irresponsible actions of the. Of the people telling you not to say the Choose Wisely program, not to take x-rays immediately. How do you know it’s there? How do you know if there’s a fracture?

You, hopefully, you’ll know there’s a lot of pain. How do you know if there’s a connective tissue pathology? How do you know if there’s bone on nerve? And bone on nerve is not at the nerve root. It’s at the facet level. And by the way, that’s really important to understand these concepts of what’s going on.

And these are all for different conversations by the way. But how do you know what you’re treating? Is it spinous left? Is it spinous? Is it two times PIEX? Palpation and motion palpation have failed intra and interrater reliability where X-rays correct? A hundred percent of the time. Guess what?

When I went to school back in the seventies. When you went to school in the seventies, eighties, nineties, 2000, 2000 tens when you went to school, we all learned X-ray. There’s a reason for that. We wanna rule out pathology despite the absence of flags. This past year we saw two, a genesis of the two, a genesis of the posterior arch at C one.

We see a tremendous amount of spina bifida. Your palpation can’t possibly figure that out. We’ve seen a myriad of other things going on. We’ve picked up tumors and on ’cause we’ve seen, but you will always get a biomechanical diagnoses and we know that you need to take 56 lumbar x-rays and 500 cervical x-rays to have less than one in 100,000 negative sequela.

No one’s taking 56 lumbar X-rays and radiation is not cumulative. No one’s taking 500 cervical X-rays in one sitting. No one’s taking 56 lumbar X-rays in one sitting. It doesn’t happen. It just doesn’t happen. So if you have a radiculopathy or myelopathic sinus symptoms. Or biomechanical compromise.

We’re gonna be looking for angular deviation or translation on X-ray. If you see both angular deviation and translation, you could take an MRI to determine if there’s a ligament pathology, which is a huge pain generator, and we’ll call premature degeneration. That’s called wolf’s law. It’ll cause premature degeneration of the spine.

So you need to know these things. You need to see and look, you need to, you can’t function blindly. I just sat with some people who were talking about the vitality of life, of the adjustment. Hey, listen, I got no qualms with how you choose to practice, but I do have a qualm. If you’re delivering a high velocity thrust into someone and you’re gonna hurt them, first thing, doctor, do no harm.

Don’t hurt them. Know what you know, what’s going on. Get that definitive diagnosis. Now, let’s go into DISC anatomical pathology. And we’re gonna look at the disc, bone disc. Your facets are over here. Here’s your sp, this is a spinal cord because it’s solid. We know all those things. So now what we’re gonna do, I’ve actually got, here we go.

Here’s yours. Spinal cord is solid. Sorry, I move my mouse in the wrong wrong image. Here’s your facets lining up. This is your bone, your disc, your bone, and this is the nucleus pulposus on the inside. And the annulus fibrosis on the outside. And these are your lateral horns in the spinal cord, and that’s the facet.

Now, when we look at terminology, there’s very much outdated terminology, and I’ll know if you’re a dinosaur, if you’re using words like prolapse, slip, disc protrusion, bulge protrusion, that’s like looking at these telephones, TVs and typewriters. You’re dating yourself. An MRI was actually invented one mile from where I’m sitting at the State University of New York at Stony Brook.

Dr. Paul Lauder, who’s a chemistry teacher, won the Nobel Prize for inventing MRI and the professors and the doctors who taught me to interpret, worked with Dr. Lauder. So I feel honored about that. But when we look at this definitions, this research article right here, take your phone out and take a picture of it.

Faran 2014, lumbar disc nomenclature Version two is still the industry standard on nomenclature. It’s still the industry standard. It doesn’t give you everything, but it comes awfully close. It sure doesn’t give you everything, but you’re getting close to where you need to be. Now, if we look at a typical spinal nerve, here’s the bone, the body of the vert, of the discs on top.

Here’s the spinal cord. Here’s the anterior horn. This is the posterior horn. This is the nerve root. This is the recurrent meningeal nerve used to be called the so vertebral nerve. Now in, in disc issues, there’s different zones. This is the central zone. This is the lateral recess, and this is not a foramina.

Foramina means whole stop thinking like X-rays. This is a neural canal, like a tunnel with a nerve goes through. Now we’re gonna start looking at a little it bit of anatomy. And when we look at this, here’s your disc. How do I know that? I’ve outlined it for you. Here’s the disc. Here’s the spinal cord.

Here’s the spinal cord. Here’s a neural canal. The nerve root comes off and goes in the neuro canal, and it goes in the canals, which is right over here. Now we’ve got the spinous process, which comes in the back. And by the way, this image is a wee bit off and I’m not gonna reset it when I moved it over, it’s set off.

So let’s just come here. Here’s your disc, here’s your spinal cord. Here’s your cerebral spinal fluid. Here is the neural canal is right here. And right here, your facets line up here. This is your ligamentum flava, and this is a good basic place to start. That’s where we look at everything and see what’s going on.

So as you, and this is called the axial view. You’ve got the side view called sagittal and the top down view here. This is the side view or sagittal, and this is the top down view called the axial, like the guillotine shot. And you’re looking straight down. Now, it’s an educational standard. In every state in the United States and every country in the world to need a minimum of two views, two views.

So you’ve gotta have both views to conclude an accurate diagnosis. And that holds true for any image, any with the exception of bone scans. And we’re not gonna talk about bone scans today. That’s a topic for a different day. But bone scans are really important when you’re looking for fracture tumors, degeneration.

But MRI is best for visualizing spine, not x-ray, not CAT scan, MRI in. In our world, we’re never going to use contrast. Let me rephrase it. We’re rarely going to use contrast. Contrast is for post-surgical MRIs. Contrast is when you’re defining tumors and other issues in our world, you need an appropriate number of sequences.

And slice thicknesses, that’s critical. And we’re not gonna really have an opportunity to talk about sequencing in either today or the next conversation, which is gonna, which we’re gonna jump out in just a moment. But sequencing is critical. You need a T one image, you need a T two image, and you need a start image.

At the very least, you need proton density images. In many issues. There’s water suppressed. There’s fat suppressed. There’s so many different things, and it’s really not that difficult, but you need at least two clean slices through the disc, not catching the bone. And that’s important, and that’s really important.

So what we’re gonna do right now is we’re going to jump out and we’re gonna pick up this conversation in our next session. We’re going to define herniation, bulge, protrusion, extrusion, and sequestration, which is the very bare basics.



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