More on Types of Intervertebral Disc Injuries Following Baltimore Car Accidents

More on Types of Intervertebral Disc Injuries Following Baltimore Car Accidents

In my last blog post I discussed disc protrusions as a form of disc injury following acute spinal trauma such as that which occurs in Baltimore auto accidents. In this blog post I would like to discuss another type of disc herniation called disc extrusions.

Disc extrusions are types of disc herniations in which disc material extends beyond the normal disc space, similar to disc bulges and disc protrusions. By definition the depth of the extruded disc material is longer than the width of the extruded disc segment. Whereas if you remember in disc protrusions the wideth of the protuded segment is wider than the depth of the lesion.

Generally speaking disc extrusions are usually more clinically significant than disc bulges and disc protrusions. That is because there is a longer piece of disc material extending outside of its normal boundaries. This can lead to compression within the neural canal (central canal stenosis) and/or compression in the neural foramen, leading to true nerve compression as the disc materials contacts the dorsal root ganglion or spinal nerve any level. Patients with disc extrusions sometimes respond well to chiropractic therapy in my office, but sometimes they do not.

It is important to note that due to the sensitive nature of disc extrusion type injuries, often traditional rotatory spinal manipulation is relatively contra-indicated. That is, there is a concern that manual manipulation of the spine can lead to a worsening of the condition. With these patients I generally take a “less is more approach” and begin with mobilization techniques to their spines rather than full on chiropractic spinal manipulation.

Again, the best way to characterize a disc injury with patients following Baltimore whiplash or Baltimore auto accident injuries is via MRI. The MRI will help the treating provider and patient understand which neurological structures may be compressed. In these instances it may be important to refer the patient to an orthopedist or to a pain management specialist to consider either surgical or non surgical approaches towards pain relief.

While patients with disc bulges and even some disc protrusion may or may not have symptoms, a patient with a disc extrusion is not that hard to spot clinically. They usually have intense lower back pain with concurrent radiating pain down their arm or leg, past their elbows or knees, that does not abate regardless of position. Sometimes there are lower motor neuron findings of numbness, tingling, or weakness also associated with these injuries. If left for too long of a period patients with these complaints run the risk of long term nerve damage and pain.

With any disease process or injury, the most important step is getting access to care quickly and making an appropriate diagnosis. All to often I have seen patients that have found me after treating with other physical therapists or chiropractors that have not improved after months of treatment. I typically recommend MRIs in these challenging cases and then refer the clients for pain management or surgical intervention if clinically indicated. While I am a chiropractor and spend the majority of my day utilizing chiropractic spinal manipulation it is important to recognize that a patient’s needs come before my own. I will always make an appropriate recommendation for care, especially if it is for a condition that I can not treat myself.

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

Dr. Gulitz

More on Types of Intervertebral Disc Injuries Following Baltimore Car Accidents

In my last blog post we discussed disc bulges and their clinical significance. As we discussed these are pretty common findings that often do not cause a patient’s presenting symptoms. The next classification of disc injuries that I would like to discuss is what is called a disc protrusion. Technically, a disc protrusion is a type of disc herniation. By specifying the difference between a disc protrusion and a disc extrusion (more on this to come in the next blog post) a provider and radiologist can better understand the type of injury and the treatment that might best suit that particular injury.

A disc protrusion is a type of herniated disc that involves tearing of the outer annular fibers of an intervertebral disc. This is important to note because even without disc protrusion, torn annular fibers are known to be pain-sensitive fibers that can be the source of a patient’s pain. Once the outer tissue of a disc is torn it allows for migration of disc nuclear material to migrate and extend beyond the limits of the normal disc space. Typically this migration is a backwards movement. By definition, a disc protrusion is a type of herniation where the protruded material is wider than it is long. That is, the base of the lesion is broader than the depth of the lesion. You can see a picture of a disc protrusion here.

Discs can protrude in many different directions, and as a result, they can cause various different symptoms. There can be central protrusions, where there is some spinal canal stenosis and inflammation. There can also be paracentral or paramedian protrusions where the swelling and protrusion occurrs off of the mid line, with a bias towards either the left or side side.

Clinically speaking paramedian disc protrusions can cause symptoms of back or neck pain with concurrent numbness, tingling, and/or weakness down the affected arm or leg. That is, they can present with these symptoms but that is not always the case.

The most clinically significant types of disc protrusions are called lateral disc protrusions. These protrusions move disc material into that lateral recesses, or the lateral canals. The reason that these are so clinically significant is because they either directly touch or chemically alter the dorsal root ganglia at this level and as a result are more likely to cause the numbness, tingling, or weakness that we classically suspect when dealing with disc protrusions.

It is important to note that not all disc protrusions are the same. That is, some can cause pain in the absence of numbness, tingling, and weakness. And some can cause numbness, tingling, or weakness in the absence of pain. Additionally, some will respond well to chiropractic care, spinal manipulation, and soft tissue modalities, and some fill have no response at all.

This is why it is extremely important that when treating for injuries sustained in Baltimore car accidents that involve headaches, neck pain, and back pain with numbness, tingling or weakness, that you work with providers that understand the difference of these types of injuries. That is, classifying the morphology (shape) of an injured disc not only impacts care in the moment, but may well impact how much a patient can recover. The best way to image a disc protrusion is by way of an MRI of the neck or back. I routinely refer out for these tests on my injured clients.

In my next blog post I will write about another type of herniated disc, known as a disc extrusion.

For now, if you or someone you know is suffering from a disc protrusion that has resulted in back pain, neck pain, or numbness, tingling or weakness, please contact Mid-Atlantic Spinal Rehab & Chiropractic. We would be happy to help!

Dr. Gulitz

Types of Intervertebral Disc Injuries Following Baltimore Car Accidents

As a Baltimore chiropractor that spends a significant amount of my time treating patients in Baltimore auto accidents, it is very common for patients to present for care that have injuries to their intervertebral discs. The discs are the “shock absorbers” that exist between the bones of the spine that function to help in not only decreasing compressive forces of the spine but also in allowing for smooth segmental motion at every level of the spine. This enables the spine to rotate, bend and twist in complex manners which would not otherwise be possible in the absence of all the vertebral segments.

There are a myriad of terms to describe altered disc morphology (shape) that have made their way into our everyday lexicon. Some of these terms include “slipped disc”, “blown disc”, “shredded disc”, “inflamed disc”, “prolapsed disc”, “hot disc”, etc.

The problem with these terms is that they are not universal; that is, they might mean one thing to one person and another thing to another person. Following recommendations of the Combined Task Forces of the North American Spine Society, American Society of Spine Radiology, and American Society of Neuroradiology the nomenclature of disc pathology has been simplifed as follows:

• Disc Bulge
• Disc Herniation (Protrusion, Extrusion)
• Sequestered Disc

In this and the next several blog posts I will discuss the different type of disc injuries and their clinical implications. For now, let’s start with “Disc Bulge.”

Out of all of the different types of disc pathology, the least clinically significant is the “Disc Bulge.” It refers to an extension of disc material beyond the edge of the vertebrae. In many people this is considered “normal” and it can exist with or without pain at a given spinal level. For a disc to be considered a disc bulge, more than 50 percent of disc material needs to extended over the vertebrae. While it is common for disc bulges to extend posteriorly (backwards) into the neural canal, there can also be anterior (ventral) disc bulges.

Most people with disc bulges usually are not even aware that they have them. That is, the disc inflammation or compression is usually a result of repetitive microtraumas over a lifetime rather than one acute injury. Additionally, since the compression and or inflammation is relatively small there is usually little or no neural compression in the spinal canal or the lateral canals. This means that most patients do not usually have associated numbness, tingling, or weaknesses associated with these findings.

While it is true that many patients live their lives with undiagnosed disc bulges in their neck, it is also important to note that these injuries, while not usually caused directly by traumas such as motor vehicle collisions, work-related injuries, or slips and falls, can actually predispose an injured patient to worse pain than had they never had a disc bulge to begin with. That is, the presence of disc bulges renders a patient “pre-weakened” and more likely to be seriously injured following resultant trauma to their spine.

The treatment for disc bulges is conservative management: A patient will undergo a series of treatments that include stretching, moist heat, electric muscle stimulation, and when appropriate, spinal manipulation and/or traction. Some patients with low pain tolerance levels may elect to take medications such as tylenol or advil in addition to muscle relaxers. A diagnosis of disc bulging does not contraindicate spinal manipulative therapy and in fact many patients with these injuries respond well to conservative chiropractic therapy.

In the next several blog posts I will discuss the other different types of disc injuries and their clinical presentations and treatment.

If you, or someone you know has been experiencing neck pain with or without disc bulges, please contact Mid-Atlantic Spinal Rehab & Chiropractic at (443) 842-5500. We would be happy to help!

Dr. Gulitz

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