An orthopedic surgeon specializes in the surgical management of musculoskeletal disorders ranging from fractures to deformities. Since their primary income comes from surgical intervention they prefer cases which will ultimately require surgery. I am frequently asked by general practice orthopedic surgeons to limit my “back and neck” referrals. This is because the great majority do not require surgical intervention and, if they did, more than likely an orthopedic spine specialist or neurosurgeon would be more appropriate. I have been told by several orthopedists that they limit the number of back and neck cases to less than 5% of the patient load.
From a personal injury perspective the role of the orthopedist is clear. They should receive all referrals from the primary attending physician which involve extremity complaints which may require surgery (knee, shoulder, hand, wrist, foot. etc.). If a spine related referral is requested, it should be expected to be given low priority due to the probable non-surgical nature and referred out for a short course in chiropractic intervention or physical therapy. If spine surgical indications are present, the patient should be sent directly to the surgical spine specialists which are orthopedic spine surgeons and neurosurgeons, both of which are fellowship trained in spine surgery.
The insurance industry has deemed orthopedic surgeons as the gold standard for any orthopedic injury, even if non-surgical in nature. This works towards the advantage of insurance carriers since many orthopedic surgical specialists perceive non-surgical injuries as “insignificant and self-limiting”. This perception diminishes the magnatude of a connective tissue injury which, while non-surgical, can be severely disabling. Therefore, when orthopedic referral is made by the primary attending physician the referral should be for the purpose of determining whether orthopedic surgical intervention will be indicated or if continued conservative efforts are appropriate.
Neurology is the specialty which deals with diseases of the neurologic system. Many neurologists consider themselves the “cerebral” doctors when compared to the neurosurgeon. Right or wrong they have no inclination to recommend surgery unless absolutely necessary and this benefits the patient. Neurologists spend much of their time working with neurologic diseases like Parkinsons, Multiple Sclerosis, Amyotrophic Lateral Sclerosis, Myasthenia Gravis, etc. They are excellent in identifying the neurologic components of traumatic injuries such as radiculopathies, neuropathies and post concussion syndromes. However, when referring to a neurologist, the primary care provider should ask the neurologist to limit their recommendations to their specific area of expertise. If the neurologist feels compelled to comment on other connective tissue components he should suggest that other musculoskeletal components exist and require intervention. The primary care provider should make the decision which methods of intervention are most appropriate.
The medical specialty of physical medicine and rehabilitation (PM&R) is the emphasis of the physiatrist. Many physiatrists in institutional settings have areas of specialization such as respiratory rehabilitation, stroke rehabilitation, brain injury, spinal cord injury, cardiac rehabilitation, amputation or burn management. Most physiatrists, like chiropractors, have great appreciation of the soft tissue / connective tissue injury. They make accurate assessments based upon thorough examinations. They also regularly perform electrodiagnostic procedures such as electromyography, nerve conduction studies and somatosensory evoked potentials. Recently, many physiatrists have become actively involved in pain management procedures ranging from muscular injections to narcotic management to introperative placement of neurostimulation devices. Their recommendations are directed towards the optimal resolution of the soft tissue complaints. The physiatrist is extremely valuable when documenting injuries and can offer the primary physician valuable insight. They should be used regularly with soft tissue injury patients. However, the care recommendations should be referred back to the primary physician so that the appropriateness of the treatment can be considered in conjunction with the medical data and the specific case requirements.
The neuropsychologist is a PhD and the specialist who can best assess the cognitive functioning of the patient. Many high energy traumatic injuries can result in mild traumatic brain injuries which are not demonstrable on imaging or neurphysiologic testing. It is also quite common for a patient to suffer psychological consequences secondary to physical trauma. Memory problems, post traumatic stress disorders, sexual dysfunction, attention deficits and other documentable psychological problems must be identified and correlated to the injury. Post traumatic marital, social and professional relationships may be subtly changed and only a specialist with the neuropsychologists education is qualified to objectify these complaints. Of course, organic disease must be ruled out by a neurologist but after medical clearance is obtained, the neuropsychologist is the professional of choice.
Neurosurgeons perform surgery on many parts of the body including the brain and spinal cord. The neurosurgeon can be of great value with cases of documented disc herniation. Herniated discs may or may not require surgical intervention. Any neurosurgeon worth his weight has enough scheduled surgery that only the most severe cases will undergo immediate surgery. The neurosurgeon will generally evaluate the patient and refer back for appropriate conservative care. If unsuccessful, he may recommend more aggressive treatment but surgical intervention is reserved for those patients who meet strict criteria. In many sugical disc cases, both the orthopedic spine surgeon and neurosurgeon are appropriate. These days, they often team up and work togeather to complement each others skills
Neurosurgeons are beneficial for the soft tissue injury case because they appreciate that soft tissue injuries can have serious complications which may not benefit from surgery. They usually are conservative in nature and will write supportive reports. Their role is limited in the management of the non-surgical case but their input is well respected in the insurance industry.
The craniomandibular specialist is usually a dentist who is comfortable in the management of the temporomandibular joint (TMJ) disorders. Not all dentists manage TMJ and not all should. Like any subspecialty it requires additional training and is not for the general dental practitioner. Management of TMJ may involve physical therapy, chiropractic, surgery or the use of prosthetic devices,
The benefit of this specialist is that TMJ disorders are a common result of cervical acceleration/deceleration injuries. While the exact mechanism of injury is not clear, the TMJ specialist has the knowledge and expertise to manage this common disorder. When they are familiar with the medicolegal relationship the reports can be of great value in your settlement efforts.
Physical therapist can play a vital role in the management of the soft tissue case and in pre and post surgical rehabilitation. By coordinating care with the gatekeeeper physician they can offer much needed treatment and documentation in the form of treatment notes. They are valuable in optimizing the results achieved by chiropractors when used towards the end of care with an emphasis towards the re-conditioning of deconditioned musculature. This deconditioning is a common sequelae to trauma as patients often undergo extended periods without physical exertion.
In many states physical therapists have direct access to patients in varying degrees. This reflects a legislative recognition of the improved and more comprehensive education of of physical therapists. As more and more states recognize the autonomy of physical therapists and their ability to self direct care we will see greater solo management by these qualified specialists. At this time, the majority of physical therapy providers acknowledge that direct access is a move in the right direction. They also acknowledge that not all therapists have the education and skills to differentially diagnose patients and rule-out conditions that are not within their diagnostic scope. Until that skill has matured, and it has been with new PTs earning doctorate level dgrees (DPT), it is best to have physical therapy care coordinated between the gatekeeper physician and the specific therapy provider.