Re: Dens Fracture case study

March 9, 2004

Dr. Mike, could you fill us in on how you

obtained these images. Do you have a digital x-ray machine or did you

scan them in and then mark them?

Larry Lubcke, DC, DABCO

Dens Fracture

case study

This is a case study from our own Dr.

Underhill. Great case -

interesting findings.

D Freeman

Mailing address: 1165 Union St NE, #300

Salem, OR 97301

503 586-0127

fax 503 763-3581

cell 503 871-0715

drmfreeman@...

A 57 year old male presents to my office with

complaints of upper neck

ache which he describes as annoying. No

particular accident or incident

triggers the visit but rather an off and on

chronic condition. He

reports a treatment history of going to two different

chiropractors in

Oregon and getting his “neck cracked”

which provides relief – sometimes

long lasting for months or years. The last

such treatment was just under

one year ago. He also stated that he had a

fracture in his neck from a

motorcycle accident 30 years ago and that it was

not treated. He reported

that in the same accident, he fractured his

hip/leg and it required

surgery which took all the attention of his

doctors. The last spinal

x-rays he remembers were taken approximately 30

years ago.

This man works in construction both as a

supervisor and a laborer. He is

quite muscular and appears very fit. He is

on no medications. His

examination turned up very little. Normal

neurological findings, no

reflex abnormalities, no sensory changes and no

weakness. He did have

some limited motion upon CROM evaluation.

This patient has no insurance

and pays for his care out of pocket. Even

so, based on the history he

gave me, I felt that a brief cervical x-ray study

was appropriate.

Patient agreed and I took an AP and lateral

cervical.

The lateral cervical looked unusual at the C1-2

junction and the APOM

revealed what I believe to be a non-union fracture

of the dens. In order

to see if it was stable, I took flexion and

extension films. The flexion

and neutral lateral showed no change in the

position of the atlas, axis

or dens (by templating). The extension film

showed fairly dramatic

movement of the atlas and dens on the axis with

what appears to be 12-14

mm excursion of the rather large posterior

osteophyte into the spinal

canal. I also found what appears to be an

old avulsion type fracture of

the tip of C-7 spinous process.

I am sending digitized x-rays with dots placed on

the superior posterior

body of C2 and inferior posterior lateral mass of

C1/osteophyte to help

you visualize the movement.

So, what do I make of this?

I believe that the C-7 avulsion was discovered

right after the accident

and this was the fracture the patient was talking

about. I also think

that the dens fracture was missed and yes, some

have said to me this

could be congenital but based on the appearance, I

don’t think so. What

frightens me is that the patient still wanted me

to “crack” his neck and

of course I told him in detail why it was a bad

idea and in fact tried to

get him to talk to a neurosurgeon. The patient

does not want me to call

his previous chiropractors and in fact, I

don’t have their names so I am

unable to do so. Based on our

conversation, I think the patient will

return to his previous chiropractor for treatment

and I hope the results

are not disastrous.

Thanks!

Underhill, DC

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March 10, 2004

Thanks

I was over at Dr. Underhill's office Last Friday and saw the x-rays.

I was hoping to get copies of the pictures. for educational purposes.

So thanks

Carl Bonofiglio

-- Dens Fracture case study

This is a case study from our own Dr. Underhill. Great case -

interesting findings.

D Freeman

Mailing address: 1165 Union St NE, #300

Salem, OR 97301

503 586-0127

fax 503 763-3581

cell 503 871-0715

drmfreeman@...

A 57 year old male presents to my office with complaints of upper neck

ache which he describes as annoying. No particular accident or incident

triggers the visit but rather an off and on chronic condition. He

reports a treatment history of going to two different chiropractors in

Oregon and getting his “neck cracked” which provides relief – sometimes

long lasting for months or years. The last such treatment was just under

one year ago. He also stated that he had a fracture in his neck from a

motorcycle accident 30 years ago and that it was not treated. He reported

that in the same accident, he fractured his hip/leg and it required

surgery which took all the attention of his doctors. The last spinal

x-rays he remembers were taken approximately 30 years ago.

This man works in construction both as a supervisor and a laborer. He is

quite muscular and appears very fit. He is on no medications. His

examination turned up very little. Normal neurological findings, no

reflex abnormalities, no sensory changes and no weakness. He did have

some limited motion upon CROM evaluation. This patient has no insurance

and pays for his care out of pocket. Even so, based on the history he

gave me, I felt that a brief cervical x-ray study was appropriate.

Patient agreed and I took an AP and lateral cervical.

The lateral cervical looked unusual at the C1-2 junction and the APOM

revealed what I believe to be a non-union fracture of the dens. In order

to see if it was stable, I took flexion and extension films. The flexion

and neutral lateral showed no change in the position of the atlas, axis

or dens (by templating). The extension film showed fairly dramatic

movement of the atlas and dens on the axis with what appears to be 12-14

mm excursion of the rather large posterior osteophyte into the spinal

canal. I also found what appears to be an old avulsion type fracture of

the tip of C-7 spinous process.

I am sending digitized x-rays with dots placed on the superior posterior

body of C2 and inferior posterior lateral mass of C1/osteophyte to help

you visualize the movement.

So, what do I make of this?

I believe that the C-7 avulsion was discovered right after the accident

and this was the fracture the patient was talking about. I also think

that the dens fracture was missed and yes, some have said to me this

could be congenital but based on the appearance, I don’t think so. What

frightens me is that the patient still wanted me to “crack” his neck and

of course I told him in detail why it was a bad idea and in fact tried to

get him to talk to a neurosurgeon. The patient does not want me to call

his previous chiropractors and in fact, I don’t have their names so I am

unable to do so. Based on our conversation, I think the patient will

return to his previous chiropractor for treatment and I hope the results

are not disastrous.

Thanks!

Underhill, DC

March 10, 2004

I read this case yesterday. I understand Dr. Underhills concern and would only add one thing...Dr. should send a letter to the patient both by regular mail and certified mail stating his concerns and recommendation to consult a neurosurgeon immediately. This is a legal issue waiting to happen and although it sounds that Dr. Underhill did everything correctly this added effort will leave no doubt in anyone's mind (like mine) that he informed the patient of his concerns and the risks.

sharron fuchs dc

Dens Fracture case study

This is a case study from our own Dr. Underhill. Great case -

interesting findings.

D Freeman

Mailing address: 1165 Union St NE, #300

Salem, OR 97301

503 586-0127

fax 503 763-3581

cell 503 871-0715

drmfreeman@...

A 57 year old male presents to my office with complaints of upper neck

ache which he describes as annoying. No particular accident or incident

triggers the visit but rather an off and on chronic condition. He

reports a treatment history of going to two different chiropractors in

Oregon and getting his "neck cracked" which provides relief - sometimes