More on Spondylolysis and Spondylolisthesis in Baltimore

More on Spondylolysis and Spondylolisthesis in Baltimore

I spend a fair amount of time blogging about acute trauma associated with Baltimore whiplash injuries, as it is a major part of my practice. One of the more interesting lower back conditions that I treat from time to time is spondylolisthesis with or without spondylolysis. These conditions are generally present prior to whiplash injuries from Baltimore auto accidents. While they do involve small bony ring fractures, they are rarely caused by the forces involved in Baltimore auto accidents.

If you recall, spondylolisthesis is a condition where one vertebrae slides forward on the one below it. In some instances, these condition is “stable” or not moving, and it is safe to undergo chiropractic manipulation and/or therapeutic rehabilitation. In other cases, these conditions are “unstable” and can get worse and continue slipping over time. Up until recently it was difficult to determine which situation a patient was in when they presented for an evaluation in my office, or for that matter, in anyone else’s office.

Spondylolistheses with spondylosis has been difficult to treat up until recently. That is, once present on standard x-rays, it is hard to know whether the patient requires bracing, surgical fusion, or whether traditional chiropractic spinal manipulation and a return to normal activities is appropriate.

A leading educator and author in the profession Dr. Terry Yochum DC DACBR has focused much of his attention to spondylolytic spondylolistheses. He has found a way to predict what he has termed “pending spondylolysis.” He can tell by looking at MRIs which patients are at the risk of developing these problems before they happen! Additionally, on patients with already existing spondylolytic spondylolistheses, he has helped to determine via MRI which patients would benefit from treatment and which ones need to be braced.

Simply put, Dr. Yochum utilizes a special MRI sequence called STIR. It stands for short tau inversion recovery. It is a sequence that suppresses the signals of fat and will demonstrate a bright white signal in the presence of marrow edema. Dr. Yochum will evaluate vertebrae on MRI using STIR imaging and he can predict with great success those patients that are at risk of developing spondylolysis by evaluating for marrow edema within the pars interarticularis of the vertebrae. If the bone marrow edema (BME) is present on STIR imaging, then the patient is at risk for developing spondylolysis. These patients should be shut down from activities and braced using a Boston Overlap Brace to reduce biomechanical stress on the pars interarticularis and to allow the body to heal. After about 90 days in the brace these patients experience complete or near complete resolution of lower back pain, with a healed bone that is stronger than before. These patients (which are usually highly motivated athletes) can resume their training without fear of worsening their original complaints.

This use of STIR imaging to assess for pending spondylolysis is also beneficial for patient who already have unilateral or bilateral spondylolysis. If a patient has an x-ray which reveals spondylolysis the question becomes is that the cause of their lower back pain? And if it is, should we be bracing them, or performing spinal manipulation? The problem with x-rays is that they are static and only show anatomy, whereas STIR MRIs reveal pathology by way of bone marrow edema. This patient that already displays spondylolysis would also undergo STIR imaging. If there is bone marrow edema and swelling the patient’s spondylolisthesis is considered “active” and they are to be braced as described above. If, on the other hand, there is no presence of edema or swelling then the lesion is considered to be inactive. In inactive spondylolytic spondylolisthesis it is safe to proceed with a course of conservative chiropractic care including spinal manipulation.

The brilliance of this discovery from Dr. Yochum is that now we don’t have to guess or practice in fear of the spondylolyltic spondylolisthesis patient. We have a way to determine if the slippage is acute and active or whether or not it is stable. This helps us to not only determine the best course of treatment for a patient, but it also helps us to prognosticate healing times.

If you, or someone you know, has experienced spondylolytic spondylolisthesis you should be evaluated by a Chiropractor such as myself who understands how to determine if these conditions are active or inactive. Please contact Mid-Atlantic Spinal Rehab & Chiropractic at (443) 842-5500. We would be happy to help!

Important Tips to Avoid Back Pain While Shoveling Snow

I wrote this blog post last year regarding how to appropriately shovel snow so as to avoid injury. With the impending winter weather it bears repeating.

First tip: Make sure you are physically capable of a work out. A recent article by the Baltimore Sun found here details the death of several men in Howard County who died of apparent heart attacks while shoveling. No one really ever plans on having a heart attack, but it speaks to the bigger issue that shoveling is really a work out. With any work out, make sure you are physically fit enough to do it before you begin. Consult your physician if you are not sure.

Second Tip: Warm up. As with any other work out you want to make sure that you are ready for exertion. Make sure to stretch your back before beginning any work out so you do not strain a muscle. Even a few jumping jacks will get you appropriately warmed up quickly.

Third Tip: Use the right tool. For light dustings of snow I prefer a push broom which avoids repetitive bending or lifting. If you need to use a shovel to pick up snow, make sure you have a sturdy but light weight shovel. Often the big, heavy, industrial shovels are way more than is necessary to clear snow, resulting in increased weight to carry and often times increased back pain as a result.

Fourth Tip: Use Proper Biomechanics. As with any dreaded tasks there is a desire to rush through it and “just get it done.” The problem with taking this approach while shoveling is that it is often the cause of increased back pain and visits to my chiropractic office. As with all heavy lifting, make sure to bend your knees and lift with your legs, not your back. If you have to move snow to one location make sure that you turn your entire body (avoid twisting at the waist). Typically, if you throw the snow over your shoulder the increased twisting at your waist while carrying a heavy load will cause an increase in lower back pain.

Fifth Tip: Find a friend with a Snow Blower. In the best case scenario you may have a friend or relative with a snow blower. This will allow a machine to do all the heavy lifting and help save your back. If you are a friend that has a snow blower, please remember to help out the elderly and less fortunate by clearing their sidewalks and driveways.

While most of these tips are straightforward and probably pretty obvious, you might be surprised how often my phone rings with patients who did not take proper precautions and now have acute lower back or neck pain from shoveling.

If you, or anyone you know has suffered from back pain or neck pain while shoveling, please contact Mid-Atlantic Spinal Rehab & Chiropractic at (443) 842-5500. We would be happy to help!

Dr. Gulitz

Baltimore Car Accidents and Peripheral Nerve Injuries

As a Baltimore chiropractor that spends a lot of time treating patients involved in Baltimore car accidents with Baltimore whiplash injuries, I see many “non traditional” presentations of injuries. That is, I will treat patients for several weeks and they may fail to improve as expected. They continue to have arm or leg symptoms such as numbness, tingling, or weakness in an extremity. In these instance I will typically refer my patient for advanced imaging such as MRIs or CT scans to better characterize their injuries. I would typically expect to see disc inflammation, disc protrusion/extrusion/herniation, and or ligament or tendon tears. Once in a while these expected findings do not appear on imaging. In these instances I typically refer my patients to a neurologist for a second opinion.

Neurologists are able to perform a series of studies such as NCVs and EMGs. These are tests where needles are placed near the spine and down the arms and legs where the spinal nerves travel. These tests attempt to determine where along the pathway of a nerve there is a decrease in nerve impulses that correlate with a patient’s symptoms.

Whiplash injuries can cause injuries to peripheral nerves. A tractioning of the brachial plexus (the collection of nerves that exit the neck and innervate the arms) or the lumbosacral plexus (the collection of nerves that exit the lower back and innervate the legs) can lead to arm or leg symptoms following whiplash injuries due to the rapid acceleration and deceleration forces involved in these crashes.

Research out of the Journal of Bone and Joint Surgery in 2001 state that “symptoms and signs attributable to stretching of the brachial plexus do occur in a significant proportion of patients after a whiplash injury. Their presence and persistence are associated with a poor outcome…”

When treating patients involved in whiplash injuries in Baltimore, it is important that patients treat with providers that not only know how to help them feel better, but how to appropriately document the full extent of these injuries. Depending upon the normal ADLs that a patient has to perform in their lives and/or their jobs, peripheral nerve injuries can cause permanent impairment and in some cases may require an injured individual to find another vocation.

If you, or someone you know, has suffered a peripheral nerve injury as a result of a Baltimore car accident and have suffered Baltimore whiplash, please contact Mid-Atlantic Spinal Rehab & Chiropractic at (443) 842-5500. We would be happy to help!

Dr. Gulitz

Baltimore Whiplash Injuries Worsened Due to Cervical Spine Stenosis

Whiplash injuries in Baltimore, MD are very common injuries due to the sheer number of rear-end motor vehicle collisions in Baltimore. Most of the time these injuries are self limiting and patients respond well to several weeks of chiropractic manipulation, electric muscle stimulation, passive modalities, intersegmental traction, and active therapeutic exercises. Sometimes some patients do not respond as well to care even in instances where the impact to a vehicle is not very severe.

Most patients that present for whiplash treatment in Baltimore have some form of prior injury or pre-existing condition. They have either had prior crashes that resulted in cervical spine (neck) trauma or they have some form of pre-existing injury in their neck that makes them more susceptible to injury even in response to minimal acceleration forces in minor crashes.

One condition that I see frequently is cervical spine stenosis. This is a condition where the sagittal neural canal diameter (where the spinal cord and its surrounding connective tissues normally sit) is already smaller than usual. Patients can have cervical spine stenosis and have no symptoms of it in the absence of trauma. Generally speaking cervical spine stenosis is largely a result of aging and of having advanced arthritis of the neck and is present in elderly patients (middle age and beyond). In these patients even minimal amounts of cervical disc bulging and/or inflammation in the neck following Baltimore whiplash injuries can result in severe neck pain, and in some cases, neurological symptoms such as numbness, tingling, and/or weakness down either one or both arms.

Research from Debois, Herz, Berghmans, Hermans, and Herregods in 1999 demonstrated that “a small diameter of the bony cervical spinal canal predisposes [a patient] to an adverse clinical outcome after whiplash injury.”

Clearly no two patients are the same. Property damage to a vehicle and forces involved in a Baltimore whiplash injury are not always great predictive indicators of the injury suffered in a whiplash injury. Human metrics, such as the presence or absence of pre-existing conditions, are important indicators when determining the injury severity of a whiplash patient.

If you, or someone you know, has recently suffered from whiplash from a Baltimore car accident, please contact Mid-Atlantic Spinal Rehab & Chiropractic at (443) 842-5500. We would be happy to help!

Dr. Gulitz

Baltimore Whiplash Injury at 2.5 MPH

As a Baltimore chiropractor that spends the majority of my time treating patients involved in whiplash injuries in Baltimore, I see a lot of headaches, neck pain, and back pain associated with Baltimore car accidents. Some of the injuries I see are severe and require referrals outside of my office to other specialists. Some are not so severe and only require a few weeks of treatment in my office for a patient to have complete resolution of their complaints.

One of the most challenging aspects of clinical practice occurs when patients are involved in “minor fender benders” or “no property damage crashes”. That is, the patient’s car is only minimally damaged (just a few scrapes) or not damaged at all. Third party insurance companies that are responsible for paying for injuries caused by their insured are often quick to point out the lack of damage to my patient’s vehicle, and as a result, the near impossibility that my patient could have been injured in any given crash.

In past blog posts I mentioned that there is no scientifically proven correlation between property damage and relative injury likelihood. That is, it is possible to be injured in non-property damage crashes and there is no way to tell just by looking at a bumper whether or not an occupant was injured.

In one research article by Brault, Wheeler, Siegmund, and Brault, in 1998, the authors were able to determine that “analysis of the effect of 4km/h (2.5 mph) impact severity on ROM measurements over time revealed that, at both post-impact examinations, subject with and without symptoms had a significant decrease in cervical flexion, extension, retraction, and right lateral flexion, with left lateral felxion ROM approaching statistical significance.”  It is important to note that many of today’s rear bumpers are built to withstand forces of 2.5 mph and thus do not deform even with enough force to cause injury to an occupant.

As a Baltimore Chiropractor who cares about the musculoskeletal health of his patients, it is often frustrating when injured clients are handled as if they are fakers or malingerers by the insurance companies that they trust to make sure that they get the care they need.  In these instances my patients typically choose to speak to a local personal injury attorney to help fight for their rights to get the care they need while they are under my care for their injuries.

If you, or someone you know, has been injured in a Baltimore car accident and have suffered from whiplash and require treatment, please contact Mid-Atlantic Spinal Rehab & Chiropractic at (443) 842-5500. We would be happy to help!

Dr. Gulitz

Often Overlooked Cause of Lower Back Pain Following Baltimore Auto Accidents

When the general public think of me as a Baltimore chiropractor by in large they think of me for two reasons; the first is “back pain doctor” and the second is “the guy you see when you’ve been in a Baltimore auto accident.”

Both of these statements are true and while I like to think that I do more than just treat patients with whiplash, headaches, neck pain, and back pain, these injuries do constitute the majority of the injuries that I see day to day. One of the areas that often gets overlooked as a cause of lower back pain following Baltimore auto accidents are the sacroiliac joints, or SI joints. These are joints that serve to attach the pelvis to the sacrum. As viewed from behind, these are often noted as the “low back dimples” and you can see them on yourself if you look in a mirror. I was trying to find some pictures to post on this blog but the vast majority of them are NSFW (not safe for work).

Rear end automobile crashes of only 15 mph can subject the sacroiliac joints (SI joints) to over 7000 N of force (nearly 1600 pounds of force). Despite being relatively stable joints with a lot of ligaments to hold them in place, there can be enough force with only a moderate impact to sprain these joints or even to tear a ligament entirely. (See page 118 of Dr. Croft’s Book: “Whiplash and Mild Traumatic Injuries, A Guide for Patients and Practitioners”).

Typically speaking these injuries are not that hard to diagnose. Patients who are able to point directly to one or both of their SI joints as a site of pain are usually good at describing the type of discomfort they are experiencing. Where these injuries usually go undiagnosed is in ER or Urgent Care facilities where “nothing is wrong on x-ray” and where the patient is able to ambulate into and out of the facility. A thorough history as well as a proper understanding of the forces resulting from a rear-end auto accident can usually lead the treating provider to an appropriate diagnosis.

In future blog posts I will talk about the other signs and symptoms of SI joint dysfunction as well as the appropriate treatment of such a condition.

In the meantime, if you, or someone you know, has lower back pain from a Baltimore auto accident and you want to get an opinion as to the best way to care for it, please contact Mid-Atlantic Spinal Rehab & Chiropractic at (443) 842-5500. We would be glad to help!

Dr. Gulitz

Types of Vertebral Fractures Following Whiplash Injuries

As a Baltimore Chiropractor that spends the majority of my time treating patients with whiplash presenting with headaches, neck pain, and back pain following Baltimore auto accidents (Baltimore car accidents), I spend a lot of time assessing acute injuries, particularly in the neck. One of the tools that I use to grade the severity of an injury is an x-ray. Often patients appear frustrated when I tell them that I need to take x-ray films because they like to say “there’s no way anything is broken.” In some cases, these patients have been to a hospital and a doctor tells them that they don’t need x-rays. While it is true that the vast majority of x-rays do not reveal fractures or dislocations (or any other abnormalities that would otherwise contra-indicate chiropractic spinal manipulation), there are some instances where fractures can be seen on x-ray following a Baltimore auto accident in a patient presenting with whiplash.

The first type of vertebral fracture is called a clay shoveler’s fracture. Usually this occurs at the base of the neck, around C6 or C7. This is a small fracture of the tip of the spinous process when the head “whips” back suddenly and smashes into the vertebrae below it. It was originally named for (as you might have guessed) people who shoveled clay for a living who developed these lesions while working. Needless to say these spinal levels should not undergo chiropractic manipulation, but instead, referred to an orthopedist for treatment recommendations.

The second type of vertebral fracture is called an end plate fracture. These are typically harder to find on an x-ray, and often require other forms of advanced imaging such as MRI to properly diagnose. These type of fracture is important for two reasons. Firstly, the fracture itself can be painful and can be the main cause of a patients neck pain. Secondly, the end plate is a structure that serves to help supply blood and nutrients to the intervertebral discs. Once fractured, the endplate has been shown to decrease its blood supply to a given disc due to scar tissue formation, and thus accelerate the degenerative process of the disc. In addition to pain, these types of injuries cause a vertical height decrease in that spinal level, and the neck as a whole, which can lead to a myriad of problems above and below the level of the lesion.

While it is true that cervical spine fractures are rare following Baltimore auto accidents and are not commonly seen in Baltimore whiplash patients, it is prudent of the health care provider to make sure that it is safe to proceed with treatment prior to beginning therapy. Often hospitals do not see the need to take x-rays, but by not taking films, they miss important diagnoses and patients can suffer longer than needed with undiagnosed neck fractures.

If you, or someone you know, has been injured in a Baltimore auto accident and have neck pain following whiplash, please contact Mid-Atlantic Spinal Rehab & Chiropractic at (443) 842-5500. We would be happy to help!

Dr. Gulitz

Medications Can Be Deadly- Try Chiropractic First

As a Baltimore Chiropractor that treats patients with headaches, neck pain, back pain and muscle pain, usually stemming from Baltimore auto accidents and Baltimore worker’s compensation injuries I see many patients who are taking too many medications. While there is certainly a time and place for medications, I find that many patients are either knowingly or unknowingly taking too much medicine to treat their pain and this can have serious adverse health effects.

The two most common forms of medications that I see being over used are opioid medications and acetaminophen.

Opioid medications are drugs such as oxycontin, hydrocodone, percocet, and vicodin. These are prescription narcotics that can help with pain. Originally these drugs were designed to treat patients recovering from surgeries or who suffer from debilitating pain such as cancer patients. Now, many of my Baltimore auto accident and Baltimore whiplash patients with acute injuries are taking these pain medications, as prescribed to them by local emergency rooms and family doctors. While it is not my place to say which medications a patient should or should not be taking when they are under appropriate medical care, it is startling to me how many of these patients assume that these medications are “safe” just because they have been prescribed by a doctor. Many of these opioid medications are highly addictive (in some cases, more so than heroin!) and patients generally have to continue to up their doses just to get the desired level of pain relief.

Opioid use has skyrocketed in the past decade and now hydrocodone based opioids are among the most commonly precribed medications in the U.S.  Some 46 people per day (approximately 17,000 per year) die from complications associated with these medications. Nearly 30 people a day are admitted to the emergency room or local hospitals for complications associated with opioid usage.

Unfortunately opioids are not the only dangerous type of medication. Acetaminophen (Tylenol) is largely overused in this country as well. Due to its ubiquity in every drug store and medicine cabinet across the country many people believe that acetaminophen use is safe. In small doses it absolutely is. However, there is such a wide variety in terms of the dose per pill and the recommended daily allowance that it is hard to know how much acetaminophen is “too much”, leading to surprise overdoses.

Depending on the bottle that you read, some bottles of acetaminophen recommend not exceeding 4000 mg per day. Others recommend no more than 2400 mg/day. While you may think that the FDA would streamline what the maximum allowable dose should be, it is astonishing how many different guidelines are out there.  Additionally, some pills offer 200 mg per pill, others 325 mg, and others 800 mg. With all of these different dosages it is hard to remember how much has been taken and how many should be taken maximally in a 24 hour period.

Patients who knowingly or unknowingly take too much acetaminophen can develop liver damage, liver failure, dark urine, pale stools, abdominal pain, and jaundice (a yellowing of the sclera of the eye).

To further complicate matters some of the opioid based medications are actually coated with acetaminophen to help with pain. Therefore patients who are taking opioids and acetaminophen for pain can easily exceed the maximum daily dosage of acetaminophen and can be feeling better from their pain but poisoning their livers unknowingly.

No matter the cause of a patients neck pain, back pain, or muscle soreness, the key to feeling better is staying physically active. Yoga, physical therapy, massage, acupuncture and chiropractic care have all been shown to demonstrate improvement in these conditions without the use of drugs. Again, while I am by no means against the appropriate use of drugs, I just wanted to point out how dangerous inappropriate use of these drugs can be.

If you, or someone you know, is consuming opioid medications or acetaminophen in excess to deal with headaches, neck pain, back pain, or muscle soreness please have them contact their primary care provider so that they can make sure that they are not accidentally taking too much medication. Then, please contact Mid-Atlantic Spinal Rehab & Chiropractic at (443) 842-5500 to schedule an appointment for chiropractic treatment. We would be glad to help!

Dr. Gulitz

Consider Chiropractic Care Before Steroid Injections For Back Pain

As a Baltimore Chiropractor that treats a lot of patients with neck and back pain, typically following auto accidents or work related injuries, I often see patients who have had a history of chronic recurrent neck and back pain. In many instances they have gone to their primary care providers, been given pain medications, tried physical therapy and STILL they have back pain. In these instances their primary care providers will usually refer them to a pain management clinic. These clinics are becoming more and more popular. The typical form of treatment in these clinics are “injections” into the spine. They will inject the affected areas with corticosteroids to try and help with inflammation and decrease a patient’s level of pain.

A recent warning was issued by the Food and Drug Administration (FDA) on April 23, 2014 that warns of the use of these injections for neck and back pain. They stated that the injections may cause rare but serious adverse effects, such as loss of vision, stroke, paralysis, nerve damage, and even death.  You can click on the link to read the warning here: http://www.fda.gov/Drugs/DrugSafety/ucm394280.htm.

While the use of these epidural corticosteroid injections is very common, the FDA has not approved the use of corticosteroids for injection into the epidural space (the space surrounding the spinal cord within the spinal canal) to help with neck and back pain. Because of the FDA’s recent report the Public Citizen’s Health Research Group now designates steroid injections as “do not use” drugs for neck and back pain.

This group suggests that the use of over the counter medications such as aspirin, ibuprofen, and naproxen along with exercise, physical therapy, and spinal manipulation by a chiropractor may provide more effective relief of pain with less adverse reactions.

Simply put exercises, physical therapy, and spinal manipulation are at the core of our offerings at Mid-Atlantic Spinal Rehab & Chiropractic. If you were considering epidural steroid injections for neck and back pain and would like to try conservative care before more invasive care, please contact us at (443) 842-5500. We would be glad to help!

Maintained Spinal Manipulation Therapy for Chronic Nonspecific Low Back Pain

As a Baltimore Chiropractor who spends a lot of time treating acute injuries such as those commonly experienced in auto accidents, slips and falls, and work-related injuries, one thing I do not spend a lot of time addressing is the benefits of chiropractic care in cases of chronic pain. That is, typically I talk about new injuries and the importance of restoring normal spinal motion to help patients get relief from acute pain. Unfortunately not every patient that I treat related to these acute injuries is able to return to pre-injury status and to become pain free. Rather, a small percentage of these patients become chronic pain patients that I will either refer to other specialists (neurologist, orthopedist, pain management specialist, etc) or that choose to live with their chronic pain.

When it comes to chiropractic care there is often a concern from prospective new patients that once they begin a course of treatment that they will have to continue care indefinitely. I can assure you that that is not the case. Like any good book there is a beginning, a middle and an end. I make sure to let patients know that care will not be forever. Typically they will have an initial evaluation, a course of treatment over the next several weeks, a re-evaluation to assess their improvement (if any), a new course of treatment, and soon thereafter a final evaluation.

A recent article set out to address whether or not maintained spinal manipulation (that is, continued lower back spinal manipulation after the acute phase of care has ended) would lead to better clinical outcomes such as reduced recurrences of lower back pain and decreased pain levels. The article can be found here: http://www.ncbi.nlm.nih.gov/pubmed/21245790. For those who may be reading this article in print you can click the link to the article on my blog at www.midatlanticspinalrehab.com.

In the study a total of 60 patients were enrolled. Each had a history of nonspecific chronic lower back pain lasting at least six months or longer. During the study the participants were divided into three treatment groups.

Group 1: Participants were subjected to 12 “sham” manipulations within one month
Group 2: Participants were subjected to 12 “true” chiropractic manipulations within one month
Group 3: Participants were subjected to 12 “true” chiropractic manipulations within one month plus “maintenance” manipulations once every two weeks for the next 9 months.

Each of the categories of patients were followed up with at one, four, seven, and ten month intervals to assess their subjective pain levels and to perform self reporting guidelines regarding their degrees of disability, if any.

The results of the study concluded that patients in the third group that received “true” chiropractic manipulations as well as “maintenance” manipulations biweekly for several months showed the most improvement in their pain levels and disability.

The conclusions from this study are important. Firstly, they demonstrate that spinal manipulation is an effective tool for managing chronic lower back pain. Additionally, it demonstrates the importance of continued chiropractic spinal manipulation even after the first month of therapy to help “maintain” progress.

While I can empathize with patients who might be concerned about needing to follow up with treatments forever, it is important to know that research supports the need for periodic “tune-ups.” Even patients that I have treated for acute neck and lower back pain would benefit from periodic adjustments to help maintain the improvements that they received while under my care. It is not uncommon to have patients that were once under my care for acute auto accident or work-related injury care to return to my office for periodic adjustments just to maintain their levels of improvement.

If you or someone you know are suffering from chronic lower back pain and need some help to get out of pain please contact Mid-Atlantic Spinal Rehab & Chiropractic at (443) 842-5500. We are conveniently located at 2001 Eastern Avenue in Fells Point, Baltimore. We would be glad to help!

Dr. Gulitz