Rebuttal to insurance docs

Published July 12, 2015

This is a report that a patient was treated by some insurance docs for about 2 years and they just said he had “migraines and sprain/strain”. No full evaluation was done and one of the docs happened to be a IME doctor who would usually “cut off patients for too much care and no real injuries”. Now, here he is treating for 2 years with no diagnosis and no improvement. The patient decided to come to my office and pay out of pocket as he just wanted to get better, which we helped him achieve that goal as well as coming up with an appropriate diagnosis. I took this opportunity to give my “opinion” on a IME doc.

KATZ CHIROPRACTIC AND REHABILITATION CLINIC

FRONT RANGE DIGITAL MOTION X-RAY

2727 Pine Street, Unit 1, Boulder, Colorado  80302

Office:  303-938-9070  ~  Fax:  303-938-9170

 

 

April 6, 2015

 

Patient :  Nick PAtient

 

I am taking it upon myself to answer some questions that I have discussed with Nick pertaining to his crash, his pathologies, as well as his treatment.   Hopefully his providers and myself can work together to do all we can to help Nick heal.  I have posted these questions that Nick has asked as well as what we have discussed as follows:

 

  • Are these injuries from this the 1st crash or the 2nd crash?

 

I believe these are from the 2nd crash for a few reasons. You were not complaining of these symptoms before this crash, and you were not previously diagnosed with the diagnosis you now have.

 

  • What is my diagnosis?

 

So far I have not fully evaluated your lumbar spine as I feel you need some weight bearing and flex/extension images to rule in/out further pathologies. I will, however, discuss your cervical spine. I have diagnosed you with loss of the cervical lordosis, facet damage, and cervical instability and IVF narrowing. All of these pathologies have been shown in the research to be associated with a crash similar to what you have experienced; which causes pain and symptoms similar to what you are complaining of since this most recent crash (1-10).

 

Interestingly enough, in one of your MRI reports it does mention IVF narrowing.  Yet, I do not see it mentioned in any of your treatment notes by any of your providers, except in your radiology report.  This level of IVF narrowing clearly correlates with some of your symptoms.

 

Dr. Insrance has been treating you for approximately two (2) years; which clearly shows this is not a “self-resolving” injury and clearly more than a “sprain/strain”.  Dr. Insurance mentions in his notes that you have pain in your upper cervical spine and change of ROM.  Dr.Insurance  also mentions in his initial report that you have signs demonstrating facet injuries.  However, it does not appear that Dr. Insurance followed up with further imaging to confirm, such as flex/ext. x-rays and/ or a digital motion X-ray; which has been shown  to be one of the most specific tests.  You have had MRIs but you can clearly see the radiologist started the read at C2/3 and could not access C0, C1, and C2.

 

  • How did I come up with a diagnosis for your cervical spine?

 

I looked and reviewed your records from your providers, which did not seem detailed, as it pertained to your injuries.  The majority of your “diagnosis” was “migraines” which seems more of a symptom than a diagnosis.  I like to determine if we can establish a pathology that can be causing the headaches.

 

Based on the mechanism of your crash, your subjective complaints of headaches, pain with turning his head (C1 is responsible for 50% of rotation), jarring motions hurting (may be a sign of instability) as well as Dr. Insurance first DOS mentioning you have upper cervical spine pain, and pain with lateral flexion, I performed a digital motion X-ray (DMX).  The DMX was measured using x-ray computerized mensuration analysis (CRMA) which has been shown to be the most specific and accurate way to measure.  Dr. Oppenheimer, MD, Radiologist at Boulder Community Hospital read the DMX video (11-18).  These finding are also based on guidelines and research, as well as my clinical experience.

 

  • What about the chiropractic care and treatment I have had so far?

 

I have reviewed Dr. Insurance notes and they are not very detailed in my opinion. He does document that you have “pelvic unleveling” on multiple dates.  However, it seems to all be subjective.  I do not see any lumbar x-rays to determine if this is from a short leg or from trauma.  Dr. Cahn does mention that you have a facet injury but no flex/ext imaging was performed.  Nor did he mention that you have a loss of the cervical lordosis which can also effect the facets and no treatment was applied to help with the biomechanics. Dr. Insurance mentions that you have upper cervical pain and dysfunction which seemed to be subjective up to this point, but now we can see why you have these complaints based on the DMX, two years later.

 

If you have any questions please feel free to call.

 

Sincerely,

 

 

 

Dr. Evan Katz DC

 

C:

 

 

 

 

References:

 

 

1)         Whiplash produces an S shape curve. Panjabi et al,. 1997 spine 22(21): 2489-94.

 

2)         Journal of whiplash & related Disorders Volume 4,Number 2,2005 Hawthorn medicalpress. 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.

 

3)         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

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  • 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, 2004

 

  • 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

 

  • Apoptosis of endplate chondrocytes in post-laminectomy cervical kyphosis defor Eur Spine J 2013 May 5. Kong D et al

 

  • Straightened Cervical Lordosis causes stress concentration: A finite element model study. Australa phy Eng Sci Med 2013 Jan 25. Wei W et al

 

 

  • Panjabi, M.M., et al., Capsular ligament stretches during in vitro whiplash simulations. J spinal disord, 1998. 11(3): p. 227-32

 

  • Head-Turned Postures Increase the Risk of Cervical Facet Capsule Injury During Whiplash. 33(15):1643-1649, July 1, 2008.
    Siegmund, Gunter P. PhD *+; Davis, Martin B. MS ++; Quinn, Kyle P. BS [S]; Hines, Elizabeth [S]; Myers, Barry S. PhD [P]; Ejima, Susumu PhD [//]; Ono, Kishiri PhD [//]; Kamiji, Koichi BS **; Yasuki, Tsuyoshi MS **; Winkelstein, Beth A. PhD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Nicks Imaging:

 

 

 

 

  • Derrick LJ, Chesworth BM: Post motor vehicle accident alar ligament laxity. J Orth Sports Phys Ther 16(1):6-11, 1992

 

  • Reich C, Dvorak J: The functional evaluation of cranocervical ligaments in side bending

      xrays. Manual medicine (1986) 2:108-113

 

  • Buonocore E, Hartman JT, Nelson CL: Cineradiograms of cervical spine in diagnosis of

     soft-tissue injuries.  JAMA 198(1):143-147, 1966

  • Ruey-mo Lin MD, Kuen-horng tsai, PhD. Characteristics of sagittal alignment in flexion determined by dynamic radiographs of the cervical spine. SPINE may 2001, volume 36, number 1 pp 236-261

 

  • Hino MD, Abumi MD, Digital motion analysis of normal and unstable cervical spines

using cineradiography. SPINE jan 15,1999 vo 24,number 2, pp 163-168

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