This article is the eighth of a series relating to Sacro Occipital Technique and Cranial Manipulation. Please use this for educating insurance companies, the judiciary, the legislature, the colleges and the interested public.
The focus of this edition was an article which can be found in the Journal of Bone Joint Surgery . Over the last few years I have had a couple of patients that defied the usual and customary findings associated with Category Three patient presentations. What I hope to share is that there are cases in which a finding might be present one in a hundred, one in a thousand or even at greater odds. If you or a loved one is that “one” in however many, you don’t care about what were the chances, but that you have the condition 100%.
Before I present the article in the Journal of Bone Joint Surgery I want to share a couple of case histories of two patients I have had over the past few years.
Case History #1: He was a male in his mid-fifties, who slipped and fell while playing soccer and felt marked pain and discomfort in his lower back. The following day when he arrived at my office he was in acute pain with right sided sciatica, antalgic gait, splinting paravertebral lumbosacral musculature, and had classic symptoms of discopathy. He needed aid to walk into the office and would cry out from pain as he moved. He had severe pain along the sciatic nerve, especially at the sciatic notch and point tenderness at the spinous processes of L3 through L5. Neurological, orthopedic and chiropractic examinations were difficult to perform due to his significant pain, but they appeared consistent with a herniated lumbar disc at multiple levels, L3/L4, L4/L5 and L5/S1.
He was treated using Category Three pain control and using R + C Factors for orthopedic block placement. Due to the severity of the spinous process tenderness, placement of the orthopedic blocks without pressure to the vertebra. Though greater time was needed than usual the cervical and styloid indicator resolved during treatment. By the third visit he could walk a little easier and his sciatic pain had resolved, however he still was having significant pain in the L3/L4 region. He was sent out for an MRI which showed what appeared to be an infection in the body of L3 crossing the disc to L4. I informed him to immediately see his allopathic physician, which he did and was given 5 weeks of antibiotics with bed rest. I treated him at home with orthopedic blocking and Category Three procedures. Following the 5 weeks of medication he recovered his ability to move pain free without residual vertebral sequelae.
Case History #2: This patient was a forty year old male who fell from a chair and injured his sacroiliac and lumbosacral region. The pain presentation according to the patient was “exactly” like the times he had injured his back in the past. He noted that this would happen almost one time a year, and chiropractic care would relieve his pain. He also noted that due to the pain, he was unable to lay down without moving. This was an issue for him because he needed to have a PET scan for a “minor” skin cancer that was found on his head that was malignant.
His presentation was consistent with a Category Three illustrated by an antalgic gait with and anterior lean characteristic, consistent with iliopsoas spasms. He responded well to two visits of Category Three treatment and had lessening of his R + C Factors regarding sensitivity at styloid processes, and cervical vertebra. His ability to move though improved was still limited and he would report that at times in bed his pain would wake him up. He assured me that he was feeling better and because he had no insurance did not want to have x-rays or an MRI. I informed him that I was concerned that his pain was still present and his history of a malignant skin cancer while finding that his Category Three indicators had cleared. I was concerned about alarming him, but the inconsistency regarding his SOT findings was alarming to me.
I called an MRI facility that would offer him a rate reduction and he had an MRI which revealed, according to the radiologist, a disc herniation at L2/L3 creating pressure on the thecal sac. I spoke with the radiologist and asked if the “disc herniation” could be a metastasis. He said that we would need to have a bone scan to determine the patient’s condition clearly. The bone scan was performed and there appeared that the patient’s cancer had spread to his spine. He was told by his oncologist that he only had months to live, and that most likely would not survive any surgery.
An article in the Journal of Bone Joint Surgery discussed the insidious and nonspecific nature of primary bone sarcoma of the pelvis. See:
Wurtz LD, Peabody TD, Simon MA Delay in the diagnosis and treatment of primary bone sarcoma of the pelvis J Bone Joint Sutg (Am) 1999;81(3):317-25.
The authors in this study noted that symptoms arising form primary bone sarcoma of the pelvic girdle are often insidious in onset and nonspecific in nature. To make the subtle initial signs and symptoms of these tumors more apparent to clinicians, they studied a cohort of patients who had a primary bone sarcoma of the pelvic girdle. The purpose was to describe the initial clinical findings and to evaluate the duration, frequency, and implications of delays in the treatment of these tumors. A retrospective study utilizing data analyzed from 68 patients who had primary bone sarcoma of the pelvic girdle, was performed.
The average duration of symptoms before an accurate diagnosis was made was ten months, with the median – six months and the range from one month to four years. In 20 (44 per cent) of the 68 patients the pelvic sarcoma was not recognized initially and an inaccurate diagnosis was made.
Common symptoms and findings on physical examination included pain in the gluteal region (23 patients; 35 per cent), a mass (20 patients; 30 per cent), sciatica (19 patients; 29 per cent), pain in the hip ( 17 patients; 26 per cent), pain in the groin (13 patients; 26 per cent), and low back pain (14 patients; 21 per cent).
Misdiagnoses included a herniated lumbar disc, spinal stenosis, spondylolisthesis, tendinitis, bursitis, an inguinal hernia, a stress fracture, a pilonidal cyst, a recurrent urinary-tract infection, and degenerative arthritis of the spine, hip, and knee.
Inappropriate treatment for these misdiagnoses included seven operative procedures (two laminectomies, two debridements, one hip arthrotomy, one total knee replacement and one inguinal herniorrhaphy), six courses of non steroidal anti-inflammatory medications, five chiropractic adjustments, four trials of physical therapy, and three local injections of steroids.
The authors found that with the numbers available, no significant association between the duration of symptoms before an accurate diagnosis was made and the grade or the stage of the tumor could be detected. In addition, no association between the duration of symptoms and the survival of the patient (p=0.54) could be determined, with univariant analysis. The grade and the stage of the tumor were strongly associated with the outcome, with a low tumor grade proving to a favorable prognostic indicator for survival (p=0.006). They concluded that when a patient has symptoms that appear to be out of the ordinary, particularly refractory pain or pain at rest, physicians should include the pelvic girdle in the evaluation and should carefully examine a high-quality radiograph of the entire pelvis.
Primary bone sarcoma of the pelvis is not a common finding. In 20 years of practice I have never had one case. However we all need to be cautioned regarding conditions which may present themselves at our office or clinic at any time. I have found my SOT indicators to be extremely valuable in diagnosing the seriousness of the patients I treat. Usually there is consistency between pain relief or health with reduction of SOT indicators and when there is not this congruency my alarms sound off.