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