Acute Proximal Deep Vein Thrombosis: Presentation in a Chiropractic Office1

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Acute Proximal Deep Vein Thrombosis
Presentation in a Chiropractic Office1

• Kopansky-Giles DR, Grod JP, Crowther ER. JCCA
  1995 39(4)205-209.

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Defintion

• Deep venous thrombosis (DVT) is the presence of
  coagulated blood, a thrombus, in one of the deep
  venous conduits that return blood to the heart
• The clinical conundrum is that symptoms (pain and
  swelling) are often nonspecific or absent
• If untreated, the thrombus may become fragmented
  or dislodged and migrate to obstruct the arterial
  supply to the lung, causing a potentially
  life-threatening pulmonary embolus (PE)

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Epidemiology

• DVT and PE are the manifestations of a single
  disease entity, namely, venous thromboembolism
  (VTE)
• Lower-extremity DVT is the most common venous
  thrombosis, with a prevalence of 1 case per 1000
  population2

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Epidemiology

• The incidence of deep vein thrombosis (DVT) has
  been reported to be as high as 2.5 million cases
  per year in the U.S.1
• DVT is the underlying source of 90 of acute
  PEs, which cause 25,000 deaths per year in the
  United States2

Deadly DVT????
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Anatomy

• DVT is often divided into proximal and distal
  thromboses
• Proximal veins are the popliteal, femoral (also
  known as superficial femoral), deep femoral,
  common femoral, and iliac veins and the inferior
  vena cava (IVC)
• Calf-vein DVT involves at least 1 of the paired
  deep calf veins anterior tibial, posterior
  tibial, peroneal, or deep muscular veins

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Anatomy

• Calf-vein DVT is rarely a cause of symptomatic
  PE2
• Proximal DVT is reported to produce relatively
  severe symptoms and consequences related both to
  the congestion of collateral veins and to the
  risk of PE2

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Risk Factors

• Numerous factors, often in combination,
  contribute to DVT
• These may be categorized as acquired (i.e.,
  medication) or congenital (i.e., mutation)

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Risk Factors

• Most common risk factors are obesity, previous
  VTE, malignancy, surgery, and immobility
• Each is found in 20-30 of patients2
• Hospitalized and nursing home patients often have
  several risk factors and account for 50 of all
  DVTs (with an incidence of 1 case per 100
  population)

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Morbidity/Mortality

• It is estimated that 95 of all pulmonary emboli
  occur as a result of DVT with 30 being fatal1
• As many as 50 of patients with DVT have been
  shown to have experienced asymptomatic silent
  embolism on subsequent ventilation perfusion
  scanning of the lungs

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Clinical Presentation

• Diagnosis of DVT can be difficult to make on the
  basis of clinical signs and symptoms alone
• In early stages patients can present with
  symptoms of calf, thigh, groin and buttock pain

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Clinical Presentation

• Often patients present with leg pain,
  edema/swelling, erythema, heat and a positive
  Homan s sign
• 50 of these patients who present with these
  signs and symptoms fail to demonstrate DVT on
  further imaging1
• Alternatively, patients who fail to show evidence
  of DVT on further imaging, following the
  development of PE, are frequently entirely
  asymptomatic

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Clinical Presentation

• Classic finding of pain on dorsiflexion of the
  calf (Homans sign) is specific but insensitive
  and present in one half of patients with DVT2
• Symptoms often resolve with symptomatic treatment
  because collateral flow develops symptoms may be
  most persistent with iliac involvement

Should you do this to a DVT?????
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Clinical Presentation
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Complications PE

• Cough
• Begins suddenly
• May produce bloody sputum (significant amounts of
  visible blood or lightly blood streaked sputum)
• Sudden onset of shortness of breath at rest or
  with exertion

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Complications PE

• Chest pain
• Under the breastbone or on one side
• Especially sharp or stabbing also may be
  burning, aching or dull, heavy sensation
• May be worsened by breathing deeply, coughing,
  eating, bending, or stooping
• Rapid breathing
• Rapid heart rate (tachycardia)

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Complications PE

• Swelling in the lower extremities
• Lump associated with a vein near the surface of
  the body (superficial vein), may be painful
• Low blood pressure
• Weak or absent pulse

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3-D Pulmonary Embolism
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Diagnosis

• If chiropractors are to detect those patients who
  may be in the process of DVT formation, a
  thorough history and physical examination must be
  performed
• Practitioners should be alert to the clinical
  risk factors for DVTs
• Specific questioning regarding transient chest
  pain and dyspnea, which may be suggestive of
  subclinical or silent pulmonary embolism, should
  be conducted

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Diagnosis

• In addition to a complete neurological and
  orthopaedic workup, special emphasis should be
  directed towards peripheral vascular examination
  of lower limb
• Femoral, popliteal, posterior tibia and dorsalis
  pedis pulses should be palpated bilaterally1
• Circumference of the lower limbs should be
  measured bilaterally and compared to detect any
  swelling1

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Diagnosis

• When DVT is suspected, further diagnostic imaging
  is necessary to confirm the presence and location
  of the thrombus
• Ultrasonography, because of its accuracy, cost
  effectiveness and lack of invasiveness1
• MRI and CT scans have also been shown to provide
  excellent images1

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Diagnosis

• The superficial femoral vein (lateral vein) has
  the appearance of 2 parallel veins, when in fact,
  it is 1 lumen containing a chronic linear
  thrombus

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Differential Diagnosis

• Neurogenic claudication (NC)
• Lumbar spinal stenosis (LSS) implies spinal canal
  narrowing (either canal stenosis or lateral canal
  stenosis) with possible subsequent neural
  compression
• LSS classically presents as bilateral NC
• Unilateral radicular symptoms may result from
  severe foraminal or lateral recess stenosis

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Differential Diagnosis

• NC
• Patients, typically aged more than 50 years,
  report insidious-onset NC manifesting as
  intermittent, crampy, diffuse radiating thigh or
  leg pain with associated paresthesias
• Leg pain affects 90 of patients with LSS

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Differential Diagnosis

• NC
• In a retrospective review of 75 patients with
  radiographically confirmed LSS, reports of
  weakness, numbness or tingling, radicular pain,
  and NC were in almost equal proportions3
• Most common symptom was numbness or tingling of
  the legs

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Differential Diagnosis

• NC
• NC pain is exacerbated by standing erect and
  downhill ambulation
• Alleviated with lying supine more than prone,
  sitting, squatting, and lumbar flexion

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Differential Diagnosis

• Vascular claudication (VC)
• Single or multiple arterial stenoses produce
  impaired hemodynamics at the tissue level in
  patients with peripheral arterial occlusive
  disease (PAOD)
• Intermittent claudication typically causes pain
  that occurs with physical activity

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Differential Diagnosis

• VC
• Pain is reproducible within the same muscle
  groups and that it ceases with a resting period
  of 2-5 minutes
• Risk factors for PAOD are the same as those for
  coronary artery disease or cerebrovascular
  disease diabetes, hypertension, hyperlipidemia,
  family history, sedentary lifestyle, and tobacco
  use
• Smoking is the greatest of all the cardiovascular
  risk factors

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Management

• If a DVT is remotely suspected in a chiropractic
  office/clinic, patient should be referred for
  further assessment and treatment1
• Once the diagnosis of DVT has been established,
  medical treatment is directed toward reducing the
  development of emboli
• To reduce the risk of dislodging emboli,
  intravenous anticoagulant therapy is recommended1
• Initial therapeutic approach is followed by oral
  anticoagulants for up to six months1

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Interventional Radiology
Coumadin
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Management

• Prognosis for most patients is good
• Risk of PE decreases from 50 within the first
  week to 30 within fourteen days1
• Because the organization process destroys the
  patency of the venous valves, resulting in venous
  stasis and scarring of the vein surfaces, 1020
  of patients will develop a second DVT within one
  year1

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Conclusions

• Patients presenting with lower extremity signs
  and symptoms atypical of biomechanical or
  musculoskeletal disorders should be carefully
  evaluated for peripheral vascular disease
• DCs should be aware of clinical findings and
  risk factors associated with diagnosis and
  development of DVT and understand that
  anti-coagulant therapy in the post-thrombolytic
  patient is a contra-indication to spinal
  manipulation

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References

• Kopansky-Giles DR, Grod JP, Crowther ER. Acute
  proximal deep vein thrombosis presentation in a
  chiropractic office. JCCA 1995 39(4)205-209.
• Feied C. Deep vein thrombosis. e-Medicine
  (http//www.emedicine.com).
• Furman MB. Spinal stenosis and neurogenic
  claudication. e-Medicine (http//www.emedicine.com
  ).