More on Spondylolisthesis in Baltimore, MD

More on Spondylolisthesis in Baltimore, MD

In my last blog post I discussed a lower back condition called spondylolytic spondylolisthesis. If you recall, it was a condition that resulted from an bilateral acute bony fracture and a resultant slippage of one vertebral body on another.

As a Chiropractor that uses X-rays to help me determine the structure of a patient’s lower back prior to spinal manipulation I see these pretty regularly. One of the questions that I get a lot is how I know whether to have a patient see an orthopedist/consider bracing or to undergo spinal manipulative therapy in my office and return to activities.

The first thing I consider is the mechanism of injury. If a patient comes in with an acute injury (they were weightlifting, playing sports, etc) I am more inclined to consider the injury (if present on standard x-ray) to be acute, or “hot.” In cases like these I tend to air on the cautious side and refer patients out for STIR MRIs to look for acute spondylolytic spondylolisthesis. If positive, these patients are referred for orthopedic evaluation and bracing. Bracing typically includes the fitting of a boston brace which allows for patients to spend over 23 hours a day not loading the posterior elements of the spine, and giving their bones time to heal. Research has shown that appropriately used bracing in these instances can “cure” the spondylolisthesis.

If, on the other hand, a patient presents with a spondylolisthesis and their physical examination does not seem to indicate that it is the cause of their pain I will begin treatment to include spinal manipulation of the joints above and below the effected segment. Much of the time spondylolistheses are “red herring” diagnoses- in that they are present but are not the cause of a patient’s lower back pain.

As a provider I have two concerns with these patients. The first is the pain that they are experiencing. As mentioned, most people present due to pain and want to be out of pain as quickly as possible. I will generally perform lesser invasive techniques and then progress to more aggressive techniques as tolerated. The second concern I have is the stability of the segment. If the patient has had a STIR MRI and there is evidence of an acute spondylolisthesis, I will refer the patient for orthopedic evaluation and have them discontinue provocative activity. Generally speaking, non-acute spondylolistheses are stable structures and will not continue to slip, whereas acute spondylolistheses that are active on STIR imaging are considered unstable and should be referred out to orthopedists and braced.

In summary, spondylolisthesis are one cause of lower back pain seen in my chiropractic office. X-rays are a good starting point to determine what MAY be the cause of lower back pain. In some cases it is safe to proceed with spinal manipulation of the lower back and in some cases it is not. I am trained to know when it can be handled in my office and when I should refer it out and I work with several orthopedists who are equipped to handle these conditions if they are outside of the scope of my practice.

If you, or someone you know, thinks they may have a spondylolisthesis please contact Mid-Atlantic Spinal Rehab & Chiropractic at (443) 842-5500. We would be happy to help!

Dr. Gulitz

Spondylolisthesis in Baltimore, MD

As I have spoken about in several other blog posts, there are many causes of lower back pain. Part of the challenge (but fun!) of being a chiropractor is trying to determine which structure or structures in any given patient are responsible for their presenting lower back pain.

One form of lower back pain that is not given much attention but is never the less important is spondylolisthesis. Though it is hard to pronounce, it is easy to describe. It is a condition where one bone slides forward on another bone. There are several types of spondylolisthesis, but the type that I come across most clinically and are the most challenging to treat clinically are spondylolytic spondylolistheses.  These are mainly seen in the lower back (lumbar spine) at the L5/S1 level, although not exclusively.

In spondylolytic spondylolisthesis the posterior aspect of a bone undergoes a systematic overload of force that leads to an eventual acute bony fracture. If this occurs on both sides of the posterior aspect of a bone the vertebral body can actually slide forward on the bone below it, causing not only back spasms and pain, but in some cases, instability. These are generally developed in youth with hyperextension loading mechanisms such as those seen in baseball pitches, wrestlers, and young dancers.

While high velocity low amplitude chiropractic spinal manipulation (what patients refer to as “back cracking”) is used on many patients with acute and chronic lower back pain in my office, it is not the only tool that I use to treat lower back pain. Though not an absolute contraindication to spinal manipulation, chiropractors and PTs need to exercise caution when handling spondylolisthesis patients.

The question that comes to mind is how to best help with the symptoms of pain and whether or not the spondylolisthesis is stable (not going to slide) or unstable (active and able to keep sliding).

Traditionally, SPECT bone scans have been used to determine clinically active sites of nuclear uptake which correlate with active acute spondylolistheses. While this has helped to determine the cause of active and unstable spondylolisthesis, it has recently come to light that the degree of exposure to patients to radioactive material has made these tests less desirable.

Fortunately a more readily available less deleterious test exists that is highly specific in detecting active spondylolisthesis in Baltimore, MD. The test is referred to as a STIR imaged MRI. STIR stands for short tau inversion recovery. It is a “fat suppression technique” that looks for signs of edema and fluid changes in and around the pars interarticularis- the location of spondylolytic spondylolistheses.

As a Baltimore Chiropractor that treats patients with acute and chronic lower back pain including active and inactive spondylolytic spondylolisthesis it is important to understand the use of STIR MRI imaging and what it means for patient outcome and treatment recommendations. I will discuss management of these conditions in a future blog post and how to determine whether it is appropriate to avoid activity, continue activity, undergo chiropractic care, or undergo bracing and/or surgical fusion.

For now, if you, or someone you know is suffering from lower back pain including spondylolisthesis please contact Mid-Atlantic Spinal Rehab & Chiropractic at (443) 842-5500. We would be glad to help!

Dr. Gulitz

Digital vs. Analog X-rays

In previous blog posts I wrote about the importance of obtaining x-rays following Baltimore auto accidents. I wrote about how often clinically important diagnoses went unnoticed either because a hospital did not think a patient’s symptoms were severe enough to warrant x-rays or because a given Chiropractor treating the patient for whiplash, headaches, neck pain or back pain did not have x-rays on site for their patients.

Technology is ever changing and the technology of x-rays is no different. The machinery and chemicals that used to require dark rooms and expensive, smelly chemicals is long since behind us. Today’s x-rays look the same once developed but they are digital (on a CD) rather than analog (think the old big floppy x-rays).

There are several advantages to using new digital x-ray technology in a chiropractic office:

1. Radiation exposure to patients is decreased. This makes x-rays safer for patients.

2. Diagnostic imaging quality is improved. The radiologist or chiropractor can read the films with more clarity, make appropriate diagnoses, and direct care with more confidence than ever before.

3. Decreased development and storage/copy costs. There are no more smelly chemicals to process the films and no more necessity for dark rooms in small offices. A modern digital x-ray can be stored on a flash drive, hard drive, or CD in a matter of seconds and can be archived in a matter of seconds for little cost.

4. Faster interpretation: In a matter of 15 seconds digital x-rays can be transmitted securely to a teleradiology group that can read, interpret, and report their findings. It is not unusual for me to get x-ray interpretations back within 15 minutes of taking x-rays in my office.

The x-ray technology used at Mid-Atlantic Spinal Rehab & Chiropractic is state of the art. Patients involved in Baltimore auto accidents that have neck pain or back pain that require x-rays can have them taken quickly in the office. They can be viewed nearly instantly and interpreted in minutes. This allows patients to get on the road to recovery on the first visit rather then being sent down the street to wait in another office.

If you, or someone you know, has been involved in a Baltimore auto accident and require digital x-rays, please contact Mid-Atlantic Spinal Rehab & Chiropractic at (443) 842-5500. We would be happy to help!

Dr. Gulitz

Sleepy Monday Is Upon Us

Spring is right around the corner and we finally got a break from the frigid cold temperatures that have been plaguing us all winter long. Combine warmer weather with daylight savings time and it seems like long sunny days are right around the corner. So what could be so bad about that?

Believe it or not the effects of daylight can dramatically impact our sleep patterns. Most people take a few more days to accommodate to the new sunrise and sun set schedule. Sometimes this manifests as a few later nights and earlier mornings than we would like. This may lead to general sluggishness in the morning. Scientists have developed a term for this condition referred to as “Sleepy Monday.” Most of us will be waking up what feels like one hour earlier (assuming we fall asleep at the time our body usually tells us to). The results of this relative hour shift of awake time can actually cause injury during our morning commute. By some accounts there is expected to be a 6-10% increase in auto accidents across the country on the first Monday following daylight savings time.

Unfortunately, folks, that’s this Monday. With a 6-10% increase in auto accidents, there should be an increase in Baltimore auto accidents, neck pain, back pain, and whiplash. While that is not necessarily a bad thing for me and my practice, I do not wish harm on anyone and want you to take any necessary precautions that you can to avoid becoming a patient.

Generally speaking this is a short term adjustment that we all must make and generally takes most people only 1-2 days to adjust back to a normal circadian rhythm. Besides drinking an extra cup of coffee in the morning on Monday, make sure to go to bed a little bit earlier the night before. Turn off the television as you drift off to sleep to make sure that you are rested the fully recommended 8 hours of sleep the night before.

So that’s it for now- enjoy your warmer weekend and have as much fun as you can with the one hour less of weekend that we have. Remember- there will be a lot of sleepy drivers on the road on Monday, so make sure you are extra rested to avoid being involved in a Baltimore auto accident and getting baltimore whiplash.

If you are unlucky enough to be involved in a Baltimore auto accident and require Baltimore auto accident treatment please contact Mid-Atlantic Spinal Rehab & Chiropractic at (443) 842-5500. We would be glad to help!

Dr. Gulitz

X-rays in a Chiropractic Office?

As a Chiropractor with a busy practice in Baltimore I see a lot of patients. Mainly they have headaches, neck pain, and back pain or some combination of the above. Most are referred to me by friends, family, doctors, previous patients, etc. Regardless of how patients find me one of the most common questions I get asked is “do I need an x-ray?”. Like most questions in clinical practice, there is no simple yes or no, but rather a series of guidelines that can be followed which, when combined with clinical intuition, can lead to an answer.

The first thing you should think about is why a patient might need an x-ray. Simply put, x-rays look at bones. They give me a picture at a moment in time as to the underlying spinal structures so that I can determine if it is safe to perform physical therapy with or without chiropractic manipulation. Essentially, I am looking to rule out contraindications to chiropractic care and physical therapy. If there is any indication of fracture, dislocation, cancer, infection, or instability found on x-ray then I know how best to proceed with care. I will not take an x-ray simply because you “want to see what you look like.” That is irresponsible care.

The good news is that generally speaking, most new patients do not require x-rays. If a patient has an acute case of non-radiating, reproduceable spinal pain then chances are a short course of conservative chiropractic therapy and physical therapy modalities will help and the patient will respond quickly. I tell most patients that if the therapy I am going to provide will help they should expect to see some form of improvement (be it better range of motion, decreased pain frequency and/or severity, less radiation of pain, etc) within 2-4 weeks. If at that point they are not improving or if they are getting worse, we can either take an x-ray at that point or consider referral for other advanced imaging (MRI, CT, ultrasound, etc) at that time. By some accounts 80-90 percent of new chiropractic patients with neck and back pain fall into that category and do not require an x-ray on their first visit.

The last 10-20 percent of patients typically do require x-rays on their first visit. These are patients who have a history of metabolic diseases (think decreased bone density), history of spinal fractures, history of spinal surgery, new onset of radiation of pain past the elbows (upper extremity) or past the knees (lower extremity), pain that wakes you up at night, new onset of pain over age 50, and acute trauma (think motor vehicle collisions, whiplash injuries, auto accidents, slip and fall injuries, worker’s compensation injury, etc).

Fortunately for me and my patients I purchased and installed a new digital x-ray developer. This allows me to take any necessary x-rays and have them developed and read in about 60 seconds. Patients that require x-rays do not need to reschedule or be referred off-site prior to getting the care that they need. I will always give patients a copy of their x-rays on a CD so that they can archive them for their records and/or bring them to any other medical provider should they need to do so. I transmit all of my x-rays digitally to a teleradiology group to make sure that board certified radiologists confirm my findings and protect the health of any new patient. A second set of eyes is always better than just one.

If you are not sure that you require an x-ray on your first visit we can discuss the pros and cons given your specific circumstance and make an appropriate choice at that time. If you, or anyone you know requires chiropractic care that may include the need for an x-ray, please contact Mid-Atlantic Spinal Rehab & Chiropractic at (443) 842-5500. We would be glad to help!

Dr. Gulitz