Evaluation of the patient
Candidates are selected for manipulation under anesthesia after obtaining an adequate history, thorough physical examination, and the appropriate diagnostic imaging and laboratory procedures necessary for an accurate diagnosis of the underlying condition.
History and physical
The burden of proof for medical necessity rests with the treating doctor. It should be substantially documented in the patient’s history and physical, with specific emphasis on: the failure to respond to conservative means in the history; indication of fibrosis and/or myofibrosis in the physical examination; and any supportive diagnostic testing as indicated and warranted by medical necessity of the patient’s condition.
A complete physical examination is performed paying special attention to motion palpation of the spine and a visual inspection and palpation of the skin (manifestation of sympathetic nervous system changes including edema, tissue texture, increase or decrease of moisture, temperature changes, etc). Additionally, digital palpation identifies increased or decreased changes in muscle and fascia tone which lead to altered biomechanics.
Laboratory exam
Laboratory examinations should be performed to further evaluate patient health. They not only contribute to differential diagnosis, but they also help the medical staff assess patient health prior to going under anesthesia. Females of child bearing years should be evaluated for pregnancy.
Females of child bearing years should be evaluated for pregnancy. A male past 40 years of age should also have the following test done: serum alkaline and acid phosphatase. After completion of the preliminary work, other laboratory procedures may be indicated.
Radiographic examination
Anterior-posterior (front/back) and lateral (side) radiographs of the joints involved should be taken. Additionally, extension and lateral bending views may be of benefit in visualizing loss of function. Many times one may want a detailed view of the joints which are to be manipulated under anesthesia. Motion studies on fluoroscopy may be helpful.
Studies should be repeated after serial manipulation under anesthesia to see what changes have been affected by the procedure. When warranted, CT Scan and/or MRI scan of the spine should be employed to rule out or confirm suspected pathology.
Electrodiagnostic tests
Electrodiagnostic studies of the appropriate spinal outflows should be performed to rule out specific neurological dysfunction. These tests confirm or differentiate diagnosis of neuropathy, radiculopathy or plexopathy. They show the presence or lack of nerve compression and localize and assess the degree of injury along the course of a nerve.
Ultrasound studies
Musculoskeletal diagnostic ultrasound is a test used to visualize soft tissue structures and identify signs of inflammation and scar tissue (adhesions) around joints, nerve roots, tendons, ligaments and muscle. This test is important because it confirms the presence of adhesions and medical need for maniuplation under anesthesia.
