Low Back Pain: Where Is My Pain Coming From?

Low Back Pain: Where Is My Pain Coming From?

Low back pain can emanate from many anatomical locations (as well as a combination of locations), which always makes it interesting when a patient asks, “…doc, where in my back is my pain coming from?”  In context of an office visit, we take an accurate history and perform our physical exam to try to reproduce symptoms to give us clues as to what tissue(s) may be the primary pain generators. In spite of our strong intent to be accurate, did you know, regardless of the doctor type, there is only about a 45% accuracy rate when making a low back pain diagnosis?  This is partially because there are many tissues that can be damaged or injured that are innervated by the same nerve fibers and hence, clinically they look very similar to each other. In order to improve this rather sad statistic, in 1995 the Quebec Task Force published research reporting that accuracy could be improved to over 90% if we utilize a classification approach where low back conditions are divided into 1 of 3 broad categories:

1.    Red flags – These include dangerous conditions such as cancer, infection, fracture, cauda equina syndrome (which is a severe neurological condition where bowel and bladder function is impaired). These conditions generally require emergency care due to the life threatening and/or surgical potential.
2.    Mechanical back pain – These diagnoses include facet syndromes, ligament and joint capsule sprains, muscle strains, degenerative joint disease (also called osteoarthritis), and spondylolisthesis.
3.    Nerve Root compression – These conditions include pinching of the nerve roots, most frequently from herniated disks. This category can include spinal stenosis (SS) or, combinations of both, but if severe enough where the spinal cord is compromised (more commonly in the neck), SS might then be placed in the 1st of the 3 categories described above.

The most common category is mechanical back pain of which “facet syndrome” is the most common condition. This is the classic patient who over did it (“The Weekend Warrior”) and can hardly get out of bed the next day. These conditions can include tearing or stretching of the capsule surrounding the facet joint due to performing too many bending, lifting, or twisting related activities. The back pain is usually localized to the area of injury but can radiate down into the buttocks or back of the thigh and can be mild to very severe.

Clearly determining why a patient is having back pain is no easy task. It takes the training and evaluation by a licensed professional such as Dr. Gulitz at Mid-Atlantic Spinal Rehab & Chiropractic to determine which tissues are injured and how to best bring about relief of your condition. If you, or anyone you know, is suffering from back pain in Baltimore please contact Mid-Atlantic Spinal Rehab & Chiropractic at (443) 842-5500. We would be happy to help!

Dr. Gulitz

This article was reproduced with permission from Dr. Ben Altadonna and “The Practice Building Alliance.”

The Importance of X-rays following Auto Accidents in Baltimore

We’ve all heard stories of people being involved in roll-over auto accidents and being taken away on stretchers to the hospital. When they get to the ER they are given X-rays and/or CT scans to rule out fractures. You may be surprised to realize that in most cases of rear-end auto accidents or in cases where ambulances do not take automobile occupants to the hospital, most ERs/Urgent Care facilities do not take X-rays of the patients.

On one hand, that may seem reasonable. You might think that it is unlikely that these occupants would have suffered fractures. While this may or may not be the case, it is important to recognize that X-rays following auto accidents in Baltimore need to be administered to monitor the stability of spinal segments following trauma, and not just the presence/absence of fractures.

I often joke with patients that I do not have X-ray vision. Following sudden trauma to the spine it is important to rule out not only fractures (which are admittedly rare), but more importantly, any other relative or absolute contraindications to chiropractic therapy. I’ve seen plenty of examples where hospitals/ERs did not X-ray a patient and then when I did in my office I found evidence of ligamentous laxity that would put them at risk of receiving chiropractic manipulation.

Dr. Arthur Croft in his book “Whiplash and Mild Traumatic Brain Injuries: A Guide for Patients and Practitioners”, Dr. Croft notes “…fractures may be missed simply because the ER doctor did not feel the type of injury warranted radiographs. In a report from a group of 32,117 trauma patients here in San Diego, the single most common error identified in missed cases of pathology was failure to obtain an adequate cervical spine radiographic series.” (page 221).

In my nearly 5 years as a practicing Chiropractor in both Las Vegas, Nevada and Baltimore, Maryland I have seen several cases where a patient either did not get an X-ray at the hospital, or was told that they did not need an X-ray. When I insisted we take some films “just to be safe” we discovered subtle fractures and/or aberrant motion that warranted immediate orthopedic referral. Had I not taken the films, I could have put the patient’s health at risk.

In my office not every patient gets an X-ray. My clinical decision making process depends on the patient’s age, presenting symptoms, history, and my physical examination findings. Patients involved in automobile accidents in Baltimore seeking auto accident therapy will always have an X-ray prior to beginning therapy. There’s an old saying in Chiropractic “to see is to know and not to know is to guess…I don’t want to guess about your spinal condition.”

If you, or anyone you know, has been involved in an auto accident in Baltimore and are in need of auto accident treatment in Baltimore, please contact Mid-Atlantic Spinal Rehab & Chiropractic at (443) 842-5500. We would be glad to take X-rays and render the appropriate course of rehabilitation.

Dr. Gulitz

Cervicogenic Headaches and Neck Pain

Patients with headaches also commonly complain of neck pain.  This relationship is the rule, not the exception. Therefore, treatment for headaches must include treatment of the neck to achieve optimum results.  The term, “cervicogenic headaches” has been an accepted term because of the intimate connection between the neck and head for many years.  There are many anatomical reasons why neck problems result in headaches.  Some of these include:

•    The first 3 nerves exiting the spine in the upper neck go directly into the head.  They penetrate the muscles at the top of the neck near the attachments to the skull and therefore, any excess pressure on these nerves by the muscles or spinal joints will result in irritation and subsequent pain.
•    The origin or nucleus of the 5th cranial nerve called the Trigeminal, innervates the sensation to the face and is located in the upper cervical region near the origin of the 2nd cervical spinal nerve, which innervates sensation to the back of the head up to the top.  Therefore, problems located in the upper neck will often result in pain radiating up from the base of the skull/upper neck over the top of the skull to the eyes and /or face.
•    The 11th cranial nerve that innervates the upper shoulders and muscles in the front of the neck arises from the top 5 to 7 spinal cord levels in the neck.  Injury anywhere in the neck can result in spasm and pain in these large muscle groups.
•    Other interconnections between the 2nd cervical nerve and trigeminal/5th cranial nerve include communication with the 7th cranial / facial nerve, the 9th cranial / glossopharyngeal nerve, and the 10th cranial / vagus nerve.  These connections can affect facial muscle strength/movements, taste, tongue and throat movements, and stomach complaints such as nausea from these three cranial nerve interconnections, respectively.

When patients seek treatment for their headaches, a thorough examination of the neck, upper back, and cranial nerves is routinely performed for the above reasons.  It is common to find upper cervical movement and vertebral alignment problems present in patients complaining of headaches. Tender points located between the shoulder blades, along the upper shoulders, on the sides of the neck and particularly, at the base of the skull are commonly found.  Pain often radiates from the tender point over the top of the skull when pressure is applied in the upper neck/base of the skull area. Tenderness on the sides of the head, in the temples, over the eyes, and near the jaw joint are also common. Traction or pulling the head to stretch the neck is often quite pain relieving and this is often performed as part of the chiropractic visit and can also be applied at home with the use of a home cervical traction unit. Chiropractic adjustments applied to the fixated vertebra in the upper neck often brings very satisfying relief to the headache sufferer.  Exercises that promote movement in the neck, as well as strengthening exercises are also helpful in both reducing headache pain and in preventing occurrences, especially with stress or tension headaches.

As a Chiropractor that routinely treats patients with headaches and neck pain as a result of auto accidents in Baltimore, I see patients with headaches and neck pain every day. If you, or someone you know, can use the help of a Baltimore Chiropractor for headaches and neck pain, please contact Mid-Atlantic Spinal Rehab & Chiropractic at (443) 842-5500. We would be happy to help!

The above information was reproduced with permission from Dr. Ben Altadonna and “The Practice Building Alliance”.

How Important is a Good History and Physical Examination?

If you are reading the title of the blog post you probably already know where I am going with this. A good history and physical examination is the cornerstone to an accurate diagnosis and an appropriate treatment plan. Without a problem-focused examination and history a patient’s complaints will be missed and the healing process will be protracted.

Sure, this seems obvious enough. When you get injured in a Baltimore auto accident and present to your doctor, ER, or urgent care facility, you expect that the doctor examining you is giving you an appropriate evaluation with appropriate radiographs (x-rays). Believe it or not, this may not always be the case. In this day in age with longer wait times and more patients being seen per day, most providers (whether they be doctors, PAs, nurse practitioners, chiropractors etc) are under more pressure than ever to “treat and street” patients to make room for more patients. In doing so they often go through a history and physical examination in a cursory manner, sometimes missing key injuries sustained by patients. You would be surprised how often the time of day or day of the week dictates how thorough a history and examination is given to any given patient. As you might expect, it has been my experience that more diagnoses are missed on Friday nights when the ERs are busy than are on Monday nights. In my nearly 5 years as a Chiropractor treating acutely injured patients involved in Baltimore auto accidents and baltimore worker’s compensation injuries, I am shocked at how often diagnoses are missed by portal of entry providers.

Dr. Arthur Croft in his book “Whiplash and Mild Traumatic Brain Injuries: A Guide for Patients and Practitioners” (page 211) notes that “…medical school training is woefully inadequate to prepare doctors to examine and understand musculoskeletal disorders, despite the fact that this very class of disorder constitutes the leading causes of disability in the U.S. In a recent study published in the Journal of Bone and Joint Surgery, a validated musculoskeletal cognitive examination was given to medical students, residents, and staff physicians in multiple disciplines of medicine to assess the adequacy of their musculoskeletal medicine training. Only 21% received a passing score.”

In news closer to my area of practice treating patients involved in Baltimore auto accidents, “…fourth year medical students from the University of Chicago were presented with a fictitious whiplash patient to evaluate how they would assess him if he were a real patient. He was a 21-year-old male who gave a history of being a passenger in a car that was struck from the rear…Shortly after the crash, he began to experience neck pain and was transported by ambulance to the ER…Only 21% palpated (touched) the neck, and only 17% asked the patient to turn his head from side to side.”

I am in no way trying to be negative towards portal-of-entry providers who must handle tons of new injured patients every day. All I am trying to do is point out that doctors are busy and sometimes rush through the history and physical examination. By doing so, they put a patient’s health at risk by missing diagnoses and not ordering appropriate diagnostic tests. It is important that you, as the patient, speak up and direct a doctor to your chief complaints to ensure that no appropriate diagnoses are missed.

As a Baltimore Chiropractor who routinely treats patients involved in Baltimore auto accidents, I have been trained to ask the right questions and take an appropriate history so that nothing is missed. I routinely work with other specialists such as orthopedists, pain management physicians, and neurologists who can perform special diagnostic testing if necessary. Rest assured that no matter how complex the motor vehicle collision I will take as much time as necessary to diagnose your condition and to establish an appropriate patient-focused treatment plan.

If you, or anyone you know, has suffered injuries as a result of an auto accident in Baltimore and are in need of auto accident treatment in Baltimore, please contact Mid-Atlantic Spinal Rehab & Chiropractic at (443) 842-5500. We would be glad to help!

Dr. Gulitz

Cervical Radiculopathy following Baltimore Auto Accidents

In many of my past blog posts I have touched on topics of injuries associated with Baltimore Auto Accidents. One area that I have not spent much time on is the idea of cervical radiculopathy. In simple terms, radiculopathy is inflammation of a nerve root. Anytime the spine is stressed or compressed, such as in a Baltimore auto accident, there can be irritation to nerve roots. This is the case for the entire spine, but for the sake of this discussion, we will only be considering cervical, or neck, radiculopathy.

The nerve roots in the neck comprise all of the motor and sensory fibers that innervate the upper extremity. Incidentally, they also innervate some muscles in the neck and upper back. The motor fibers control motion in the upper extremity (which I activate as I type this blog post) while the sensory fibers convey sensation from the environment (such as heat, cold, pain, light tough vibration, pressure) to the brain.

Following trauma to the spine, such as that often experienced in Baltimore auto accidents, the nerve roots may become injured, manifesting as a myriad of symptoms. Most commonly patients present with neck pain along with numbness and/or tingling and/or weakness into the upper extremity on the affected side. Often times radiculopathy can be confirmed on physical examination and if need be, advanced imaging studies such as MRIs.

As part of the therapy for Baltimore auto accidents that I provide in my office, therapy usually involves heat, electric muscle stimulation, traction therapy, and if appropriate, chiropractic spinal manipulation. Most patients respond favorably within 6-12 weeks to conservative chiropractic therapy. Those that don’t are referred to specialists for additional intervention. The key to recovery is quick intervention. That is, the longer a patient experiences radiculopathy the longer it takes for the symptoms to resolve.

If you, or anyone you know, has suffered a cervical radiculopathy as a result of 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!