When they use a phrase, "Something like or close to, this pain is unlike any- thing I've ever had in my life, or this is unlike any kind of headache I've ever had before, or this is unlike any kind of neck pain I've ever had before or it's the worst neck pain I've ever had before." Pay very close attention to that. You know in your offices on Monday morning that you'll have patients that have come in and say, "Oh, doc. I had one of my headaches over the weekend. I need an adjustment." They know their pain. They know their headaches. They know their routine. When they come in and talk about it being unlike anything they've ever had before, they don't routinely dissect their arteries. When they do dissect an artery, it produces a very unique pain that they very rarely experi- ence. When they come in and tell you about that unique pain, pay very close atten- tion to that. The second category of information we wanted to keep an eye on is, is there a family history of aneurysm or dissection in this patient's immedi- ate family? If there is, there's a 5% likelihood that that person may be moving in the direction of aneurysm or dissection themselves. The third in the area is there is a group of patients and a group of conditions that are collagen disor- ders that will lend themselves to dissection phenomena. For example, Marfan's disease. Marfan's disease is most commonly associated with dissection of the abdominal aorta but again, collagen disorder resulting in dissection. Can be di- verted most as much as the aorta. Osteogenesis imperfecta 1 increases the fra- gility in arteries. Ehler-Danlos syndrome 3 and 6, same thing. Fibromuscular degeneration also increases the fragility. Fibromuscular degeneration for example, has the ten- dency to appear more in the renal arteries than the vertebral arteries but it sets the stage for dissection in any artery of the body. Then also, we want to pay attention to clotting disorders. Patients with clotting disorders that have hypercoagulable states that have a far greater risk of coagulation than the nor- mal population. Obviously, they form thrombi and emboli easier and faster than the regular population. We need to be alert to those kinds of cases. In the history, explore the pain, explore the family history, explore the presence of the collagen disorders that I talked about in that individual and their immediate family. Next slide, please. Relative to physical examination, we were all taught George's test in school. I may have taught hundreds of thousands of the use of that test along the way. The bottom line is, the test has too many false positive, too many false nega- tives. It really isn't worth the time to do it. Now what I would suggest you do is take the opportunity to listen for bruits at the base of the neck. If you hear a bruit, consider a referral immediately. If you don't hear a bruit, that's good but it doesn't mean everything's free and clear. Continue to look what's going on. Be on the lookout for neurological changes in general, Number 1. Number 2, neurological changes with cervical motion, whether that's active motion or passive motion.
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