This case demonstrates a patient with chronic wrist pain, with progression to carpal instability, which ultimately manifested as SLAC. We demonstrate, utilizing multiple imaging modalities, both preoperative and postoperative findings. To our knowledge, this is the first case to describe the use of diagnostic ultrasonography in the evaluation of the proximal row carpectomy procedure.

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To the Editor:We read the retrospective series by Prasad et al 1 titled "Traumatic and Spontaneous Vertebral Artery Dissections: An Analysis of Tertiary-Center 310 Patient Cohort" with interest. In this study, patients with vertebral artery dissection (VAD) were dichotomized according to traumatic VAD (tVAD) or spontaneous VAD (sVAD) etiology to compare pathoanatomic and clinical characteristics. We agree that VAD is a devastating event, and chiropractors hope to contribute to improved understanding of this condition. We point out incongruities with current epidemiologic research pertaining to VAD, potential misclassifications, and suggest a sensitivity analysis to strengthen the authors' results.The authors 1 classify VAD as traumatic based on the clinical record indicating a preceding major or minor traumatic event. This strategy seems subjective considering it depends on the authors' interpretation of patient-provider communication reflected in the chart notes. Conversely, we recognize that the use of an objective measure of cerebrovascular injury, such as the Denver screening criteria, 2 would be impracticable based on the retrospective nature of this study.The authors 1 describe spinal manipulative therapy (SMT) as a traumatic etiology of VAD, labeling SMT as one of its "most common" and "well-known" risk factors. The provided references do not support the authors assertion 3,4 or represent a low level of evidence (case report and series), unsuitable for determining causation. 5,6 In addition, a systematic review in 2016 authored by a team of neurosurgeons identified no evidence that chiropractic SMT caused cervical artery dissection (CeAD). 7 The largest study in this synthesis, a case-control design including over 100 million person-years of observation, found no evidence of increased risk of vertebrobasilar stroke in those visiting a chiropractor, as compared with a primary care physician. 8 This high-level evidence does not support the authors' assertion of SMT being a traumatic etiology of VAD.Considering the lack of evidence of a causal relationship between chiropractic SMT and CeAD, researchers have proposed that reports of CeAD temporally linked to SMT could be explained by protopathic bias or confounding by indication. 7,[9][10][11][12] According to this hypothesis, patients with evolving CeAD seek chiropractic care for neck pain and/or headache, which represent early, nonspecific CeAD symptoms. This model is supported by reports of patients with VAD in progress seeking chiropractic care and instead being referred for medical care, [13][14][15][16][17][18] which is plausible considering neck pain is the second most common reason patients seek chiropractic care. 19 CORRESPONDENCE

Sciatica as a clinical diagnosis is nonspecific. A diagnosis of sciatica is typically used as a synonym for lumbosacral radiculopathy. However, the differential for combined low back and leg pain is broad, and the etiology can be one several different conditions. The lifetime prevalence of sciatica ranges from 12.2% to 43%, and nonsuccessful outcomes of treatment are prevalent. Nurse practitioners and other primary care clinicians often have minimal training in differential diagnosis of the complex causes of lower back and leg pain, and many lack adequate time per patient encounter to work up these conditions. Differentiating causes of low back and leg pain proves challenging, and inadequate or incomplete diagnoses result in suboptimal outcomes. Chiropractic care availability may lessen demands of primary care with respect to spinal complaints, while simultaneously improving patient outcomes. The authors describe three patients referred from primary care with a clinical diagnosis of sciatica despite differing underlying pathologies. More precise clinical terminology should be used when diagnosing patients with combined low back and leg pain. Nurse practitioners and other clinicians' triage, treat, and determine appropriate referrals for low back and leg pain. Multidisciplinary care including chiropractic may add value in settings where patients with lower back and leg pain are treated.