Question
QUESTION: Dear Sir,
Please give your opinion of chiropractic adjustment using a dropping bench(pelvis)where spinabifida occulta has been noted as well as presence of a spur.Should multiple downward thrusts with simultaneous bench drop (pelvic area)be employed?What is your view that spondylolysis and spondylolythesis may result,due to this treatment.2)Should this treatment be employed if slip is present already?
Thank you for your valued input.

ANSWER: spina bifida occulta , back pain , spondylolyis , spondylolisthesis ,
thompson technique

Hello Jonathan,

My home computer is down, sorry it has taken a few days for my reply.

Sorry for your back pain.

Spina Bifida Occulta.  Welcome to the club.  I also have a Spina Bifida Occulta.  Various estimates exist, up to 2% of the population may have this Spina Bifida OCCULTA (SBO).  I capitalize OCCULTA because Spina Bifida has many degrees of severity, many variations, and occulta is the LEAST severe.

Waaaaaaay back in chiropractic school we learned Spina Bifida Occulta was clinically insignificant.  It should not cause discomfort, contribute to pain, complications or degeneration.  Adjustment technique is usually not altered by presence of SBOcculta.

Multiple downward thrusts WITH simultaneous bench drop is the trademark of Thompson Technique Chiropractors.  An SBO should not prohibit a Thompson Drop move, , ,  a spur- depending upon it's placement may or may not prohibit certain maneuvers.  Usually, most chiropractic manipulative maneuvers are not contra-indicated.  If a person is mobile, ambulatory, walks into the office and participates in most of the activities of daily living, that person can receive most chiropractic adjustment techniques.


In my opinion, Spondylolysis is not likely to result from this maneuver.

In my opinion, SpondyloListhesis (if spondylolysis is already present)
could possibly occur, however this is also unlikely.

IF spondylolisthesis already exists, a thompson drop move P- A direction would not be my choice of technique.  However, I rarely utilize thompson drop work in my Staten Island Chiropractic office.

If spondylolysis, or spondylolisthesis is present, and should be seen upon Xray, MRI, CT imaging, then the area is a more complicated area, with more conservative treatment.  A thompson drop move would not be my choice with spondylosis/ spondylolisthesis present.  Perhaps practitioners of the Thompson Technique would differ with me, but in my opinion, I would prefer SOT blocking, distraction, side posture, or A- P maneuvers over the  P- A  drop maneuvers.  (P- A  drop maneuvers seem to be what you have described- patient on stomach, doctor pushes from above down (P- A) with the table dropping as well; an A- P approach would be where the patient is on their back, and the doctor works from above (stomach side) and pushes  A- P, perhaps with legs bent; side posture would mean the patient is on their side)

Patients, lay people,  tend to think of Chiropractic as monolithic- that we all work the same.  Just as medicine has different specialties, and those different specialties have many different practitioners with many different preferred medicines and/or surgical approaches-- the same with Chiropractic.  Some medical doctors like tylenol, some like exedrin, some like aspirin, some like motrin.  Chiropractic is similar, we have different techniques, and different doctors like different techniques.

I think I answered this part of your question-  "....Should this treatment be employed if slip is present already?...." -
In my opinion no.  I would use a different approach.

Xrays should have been taken Pre-treatment.  Xrays could be taken post-treatment.  Comparison could be made.  If not happy with this Doctor or not happy with this technique,,,, get a different doctor with a different technique.  There are many DC's out there, and many different techniques.

Re-reading your question;  the SBO and spur are relatively minor considerations (of course depending upon size and placement of spur); the spondylolysis or spondylolisthesis are larger considerations in deciding treatment.  SBO / spur,,, probably would not alter my technique choices.  'Spondylo' - definitely does alter my treatment technique preferences.

If further is needed, please re-contact me here at AllExperts.com  
( http://allexperts.com/ep/965-100794/Chiropractors/Victor-Dolan-DC-DACBSP.htm ).

I hope this helps.

Good Luck, and I wish you Good Health Naturally,
your Staten Island Chiropractor friend,

Dr. Victor Dolan, DC
http://drvictordolan.chiroweb.com      (Email newsletter)



---------- FOLLOW-UP ----------

QUESTION: Dear Dr.Dolan,
Thank you for your detailed response.
It is a relief to know that I am not alone with my disturbing symptoms,although God willing you do not have to suffer any vertebral slip.
In your opinion, could it be considered negligent if insufficient x-rays are taken?
Could slip (spondylolithesis)be exacerbated by the bench drop technique?
There seems to have been no reference to any lateral view x-rays,and the treatment was carried out by a final year intern,without supervision at the time.
I feel that inadequate "before and after x-rays" have clouded the situation as regards the "cause and effect" aspects and feel that a certain amount of responsibility,however,should be born by the practitioner(s)involved.Would you agree with this point?Thanks sincerely once again for your valued input Dr.Dolan.

Answer
Hello Jonathan,

Some of these questions I would refer you to a Lawyer in your locale, with chiropractic expert also from your locale.  Different states, different areas have different customs and standards of care.

Answering 'in general' (and I have never testified in any malpractice case), here is my opinion.

"....negligent if insufficient Xrays are taken...", In my opinion, yes.  Xray exam has to include at least two views of an area, an A-P and a lateral film.  These films have to visualize the structures intended to be visualized in a clear manner.  The world is FULL of experts now-a-days, I am not a chiropractic radiologist.  The specialty of Chiropractic Radiology exists (as does medical radiology)
---to fully evaluate if a film(s) are proper, a Radiological expert may be necessary.  I do not take Xrays in my Staten Island Chiropractic office.  I utilize Xray facilities and rely upon the Radiologist expertise, as well as my own- after theirs-  in viewing the films.  I like to hear other people's opinions. I 'try' to be sure.

I do not Xray EVERYone ALL the time.  I do not feel EVERYone ALL the time needs to be xrayed.  Some have been Xrayed in the past- and present without anatomical abnormality, and currently present with a similar ache or pain without intervening trauma or a long period since the prior Xrays.   Some people I am going to treat super-conservatively with little force or movement (ie:  SOT chiropractic blocking technique), with no indications as to a NEED for Xray,,, I may not Xray and treat conservatively.  But if there is a need for Xrays, enough investigation (films) should be taken, of the best quality.

Could Spondylolisthesis be aggravated by the 'drop' technique.
In my opinion, a P- A move as described by you previously could exacerbate a spondylolisthesis.  I would not do it in my office.  I would prefer a side posture roll, or a A- P type move.

I am not sure how the chiro school intern system works, I do not think a supervisory licensed doctor has to be present IN THE ROOM at the time of the adjustment.  However, I do think a supervisory clinic doctor has to have reviewed the Xrays and appropriate treatment plan approaches with the student doctor.

I do not think that the P- A move was the best type of care for your condition.  Other techniques should have been considered and utilized.
I only have your side of the situation, and given that, I do agree with you that 'responsibility' should be borne by the practitioner(s) involved.  But, when 'legalities' get involved, everything gets confused.  You probably went to the chiropractor (apparently a student) with back pain.  Unfortunately you left with (more (?) ) back pain.  This is difficult to 'prove'.  I am not trying to sidestep your question, I am trying to give answers in a 'legal' way---  very frustrating indeed to a person in pain, and perhaps at this (early) stage show you what may await you.

Lateral Xrays , are of course, the best films to view this spondylolisthesis type problem.  MRI is excellent also.  Positioning is of paramount importance; curves, positions, malpositions, can be altered by patient positioning.  Pre/ post films will be important, but not exact.  "Post" films can even be taken at this date- perhaps at the same facility,,, perhaps at a different facility.  Comparison can still be made with older (prior) films to look for changes.

Questions:
Was this spondylolisthesis KNOWN prior to treatment?  Had Xrays, MRI shown 'spondylo' either in the past or with current treatment?  Were Xrays taken this time?? a previous time??   Did the intern discuss the spondylo with you in consultation/ examination?  Was this your symptoms- pain in the low back, perhaps into legs?  Had you been treated with chiropractic in the past?  Was this area asymptomatic prior to treatment (no pain prior)?

I hope I am answering your questions.  Although this is AllExperts.com, I am answering from the viewpoint of a practitioner, I think well-informed practitioner.  I am NOT an academician (professor, instructor)or researcher in chiropractic.  If I am not answering your questions directly, I hope I am engendering a thought process in your mind.  Do not hesitate to re-contact me if needed;
 http://allexperts.com/ep/965-100794/Chiropractors/Victor-Dolan-DC-DACBSP.htm  .

There are few yes / no answers.  I think I answered your questions, although detailed. If not, re-contact, re-connect.  


Thanks, I wish you good luck and Good Health Naturally.

Dr. Victor Dolan, DC
http://drvictordolan.chiroweb.com      (email newsletter)