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Orientation for Non-Spine Specialists
CURRENT DIAGNOSIS
1. Annulus Tear
What the usual thing that people refer to as back sprain is in fact a
tear in the annulus. That is the most common problem in the back. The central
nuclear material loses its normal properties and abnormal stresses gradual
breakdown the outer anulus. Usually the disc wears out first, then the rest
of the spinal joint wears out. You can recognize it because at its onset
it is typically associated with position of flexion. So people who have
been on a long driving trip or have bent over to tie their shoes or fall
on their butt experience this and sometimes it can be associated with sciatica
because where the tear is there is some inflammatory reaction which is next
to the nerve root and then they get the nerve root irritated. So sometimes
you cannot differentiate it from a disc herniation but it does not matter
because a disc herniation without a neurologic deficit you treat the same
way anyway. Basically, you reverse the mechanism of injury so you have the
patient do press-up exercises. You have them lie on their stomach like doing
push-ups and that drives the nucleus anteriorly into the disc and either
seals off the area that is torn or gets the pressure off it and usually
symptoms will be better right away when they do that. A famous Physical
Therapist from New Zealand, Robin Mckenzie discovered this type of very
useful treatrment.
Q: Does the annulus actually heal?
It can heal, especially if you have a peripheral tear where there is
blood supply to the tissue it can heal but it slowly heals. In the classic
simple cases of this the patient is better within 72 hours if they do the
press-up exercises and manage their body mechanics. They have to avoid
sitting because when you sit you are bending your back forward.and if you
straighten your knees and put your feet on the floor and keep your back
in the sitting position, this is where you are-- bent over. So you are
in flexion when you sit which is partly why there is so many with back
disease. That flexion position drives the disc out of the anulus like squeezing a tube of tooth paste. And the tighter the hamstrings the the worse sitting is because they pull the lower back into even more flexion.
2. Segmental Instability
This just refers to people who have a generally painful spinal segment.
The segment is the two vertebra the facet joint and the disc. Frequently
in the back when the disc is already degenerated it gets narrow and also
causes the facet joints to shift from their normal alignment and may make
them iritable. The facet joints are irritated and if they increase their
lordosis (extension) which is usually good for the disc they can't because
the facet joints are worn out and they get facet symptoms from the increase
mechanical stress on the joints. If they go forward the disc acts up. So
they have symptoms in both directions. So we just say the segment is bad
and call it clinical segmental instability. Usually segmental instability
means there is x-ray hypermobility but this is a radiological finding and
may or may not be associated with clinical symptoms. We just use this term
because you treat it a little bit different; you have to maintain a neutral
position in stabilization exercizes and surgery usually requires fusion.
3. Facet arthropathy
Facet arthropathy is the opposite pattern as the annulous tear and bulging
disc syndrome. Here the patients are comfortable sitting but they cannot
walk because when you walk your back arches (more lumbar extension)which
puts more load on the facet joints. For the treatment of facet arthropathy,
you teach pelvic tilting and try to get them to unload the facets and load
the discs; so it is the opposite of the annulus tear. The best way to identify
facet arthropathy is they have tenderness over the facet joints because
you can usually push on the facet joints of the back over the skin.
Patients are worse when they walk than when they sit. Whereas discogenic
pain is worse when you sit because in flexion the back transfers the load
to the anterior column which is the disc and extension transfers the load
to the posterior column facet joints. The other hallmark of facet arthropathy
is there is a delayed onset of symptoms from the activity so if they go
out and walk they do not feel too bad but a couple of hours later or the
next day they will be very sore. That is typical of facet arthopathy because
it is a complete synnovial joint like the knee and is subject to delayed
synnovitis after excesss mechanical loading.
Q: Do you ever see patients who are symptomatic when they extend?
They have pain but you are unable to reproduce it just by pressing on the
facets?
Yes. Then you need to think of another reason besides the facet joint
for the pain and so other reasons are spinal stenosis which is common.
When you stand up straight, arch the back, the spinal canal gets smaller.
And rarely you can have an annulus tear in the front of the disc and you
can have an opposite pattern. That is unusual.
4. Bulging disc syndrome
This refers to an annulus tear where the disc pressure starts to built
up and there is a limited time they can sit. It is a chronic version of
#1 (Annulus Tear). It's an anular tear that doesn't heal.
These four #1-4 (annulus tear/segmental instability/facet arthropathy/bulging disc syndrome) comprise about 90% of the people who see physicians for their back problems.
5. Sprains
Most of the things that people call sprains are annulus tears but you
can get a muscle sprain and can differentiate it because it is a high velocity
injury, usually an athletic type injury. There is no particular position
of comfort. They are just sore and tender because they have torn muscle.
It is not as commom as you would think.. An annulus tear is much more common.
6. Dysfunction
This is a general term referring to soft tissue abnormaliies and secondary
joint dearrangemnts related to soft tisue abnormaliites that are treated
by manual therapy directed at correcting these imbalances. Hard facts about
these common entities are hard to come by. Some of the things are clearly
recognizeable and respond to treatment. For instance, if you put your hands
on the upper anterior ribs on a patient who has neck or shoulder pain take
a deep breath, normally the ribs come up together. If they have rib dysfunction,
only one will come up and they will have tenderness i=on the side of their
pain. If you see that and especially if there is tenderness in the front
of the ribs, about two-thirds of those people will get remarkably better
with just manual treatment of the rib. The same thing is true of the sacroiliac
joint and pelvis. You can put your thumbs on the posterior superior iliac
spines, have the patient bend forward and normally they go together and
if one goes out up and the other one sticks there, there is imbalance. In
both the rib and pelvic dysfunction, it may be that those are secondary
sources of pain from damaged segments in the neck. In the pelvis you have
your psoas muscles overlying on the spine. In the neck, you have the scalene
muscles that are overlying the neck and if there is a damaged disc, it is
right under those muscles and the segmental nerves that come out from that
disc anulous. If you are getting stimulation from the discs all the time,
it may well be causing the scalenes or the psoas to splint that part of
the spine and so the muscles get fatigued from constant stimulation and
it becomes chronically painful. If the psoas is in spasm all the time because
it is over-stimulated, it pulls the hemipelvis up on one side and strains
the sacro-iliac joint. The same thing occurs with the upper rib costovertebral
joints because the scalenes are attached to them too. It is just impossible
to precisely know what is the primary cause and what is secondary because
there are so many interrelated structures involved simultaneously and you
can't really study it in a lab.
7. Herniated disc and herniated disc with radiculopathy
If a herniated disc has no nerve root damage, you treat it like anything
else (#1-4). You find out what position is most comfortable for the patient
and you send the patient to therapy to be trained in how to stay in that
position and to teach him good body mechanics. You teach them what the neutral
position is. The neutral position is whatever position they can get into
that does not hurt. They strengthen them in that position. So if they have
#1, an annulus tear, they can do extension stabilization, which means they
do press-ups and arches to strengthen their gluteus maximus muscles and
the extensor muscles of the spine to loosen the hips so that the patient
can lie in a little bit of extension all the time and sit with extension
all the time and that will protect the posterior disc. If they have segmental
instability which means pain in flexion and extension, they can be stabilized
in a neutral position and taught to limit the range of motion of the back
and use the hips instead of the back.
So with the herniated disc, like I said, you treat them like an annulus
tear. Imagine if you have a little bulge like this and you do press-ups,
the vertebra are going to push it back in. If it is a big knuckle sticking
out far and you do press-ups, you may pinch it off and make it worse. So
when you give them exercise, you have to be careful and not increase the
pain. The exercise should be associated with decreased pain. If there is
radiculopathy, then that brings on the issue of whether the patient should
have surgery quickly or not and the only issue that would clearly need surgery
is if the radiculopathy is getting worse under aggressive conservative care.
Aggressive conservative care to us means not only rest for several days
and anti-inflammatory agents but also especially with radiculopathy, we
like to inject cortisone right on top of the nerve as soon as possible.
I think that that blocks the swelling in the nerve. The problem with these
things is that the blood supply is cut off to the nerve and the nerve dies.
That is because of swelling. So if you can block the swelling, most of the
people recover and if you can buy about a month of time without damaging
the nerve, then the inflammation resolves. Traditionally, these people are
operated on and we actually get 90% of them better without surgery. So if
there is a foot drop or something like that, you want to get them blocked
and then if they do not respond they should have surgery but most of them
do respond.
Q: What kind of time response are you looking at?
Usually within a couple of days and usually it is the next day for that
situation. Once they have their block and the inflammation is down, they
can work with a physical therapist and you can watch how they do. They
will either get better or get better to a certain point and will not get
that much better or their symptoms will come back. So there are people
who clearly do not get well and have to be referred to the surgeon to be
watched. Probably if you are practicing around here in internal medicine,
all these patients should see a spine surgeon consultant for their protection
and then it is that surgeon's problem. Some patients would prefer to take
the risk of having permanent muscle loss to avoid the issue of surgery.
It is the minority people who really have to have surgery for radiculopathy.
Most of them can reverse with injections and it is true of the neck too.
Q: Do you put people in corsets?
Yes. The corset is like a substitute for what they could do with body
mechanics. It is helpful in the beginning but you try to take them out
of it eventually. This idea that corsets weaken the muscles and all that
stuff, I do not believe. A person is better off being active in a corset
than he is lying around out of the corset. So, if a corset is helpful then
a person can wear it until they can get strong enough to wean out of it.
8. Spinal stenosis
There are two types. There is central stenosis and lateral stenosis.
Central stenosis is kind of more dangerous because you can get cauda equina
syndromes down below L2 and myelomalacia in the upper areas of the spine.
You have to have a real high index of suspicion always for these cauda equina
syndromes because they may not recover unless they are corrected right away
and then sometimes even when corrected right away they do not return. Sometimes
you can have no leg symptoms and just some back pain and lose control of
bowel and bladder. So it can be subtle sometimes. If it is not a neurological
emergency, then you can block the patient. They usually do well with central
stenosis, at least for awhile. You try to hold their spine in a way that
the spine is open which is in flexion. You teach them flexion stabilization
and you can give them a body jacket. At some point, however, it usually
will get worse and the patient will have to be decompressed. Most people
who get stenosis are elderly and their spines are kind of stiff. They usually
do not need a fusion so it usually is just a decompression. In big herniated
discs that are central and in spinal stenosis which is central when this
spector of possible damage to the nerves of the bowel and bladder is there
you have to make sure that you have documented a rectal exam and if there
is any question about it then the patient needs to see a surgeon and be
tested the same day. A lot of that is a medical/legal issue. Actually, there
is some research that says you have to do it within 48 hours but the documentation is quite poor for them to conclude that and newer studies show that you can do it late and sometimes get better and you can do it early and sometimes not get better. The standard of care, at least right now, is that it needs to be done immediately and you are always at fault if you hesitate. These
things are rare. We see maybe three a year in my practice with my partners.
I bet being an internist not seeing a lot of those problems you are more
vulnerable to missing it so when someone walks into the office...like I
had a patient come in here and he denied any urinary symptoms or anything
and then when he left the secretary came in and said, "There is urine
all over the place." So we got the patient back in and he was incontinent
but he would not admit it. The other type of stenosis aside from the central
is lateral canal stenosis which is when just the nerve gets entrapped as
it is leaving the spinal canal. The pain pattern with both stypes of stenosis
is neurogenic claudication which you have to differentiate from vascular
claudication. You do that by examining the pulses and if there is any question,
get Doppler studies of the arterial supply to the lower extremities.. Sometimes, they may have both. EMGs are good to show if there is spinal stenosis,or peripheral neuropathy or not but sometimes everything can be normal in spinal stenosis and the only thing is that they cannot walk because the symptoms come on when they walk. When they sit, the symptoms go away. Spinal stenosis is a little more variable than vascular. Vascular is pretty predictable. They can go about 100 feet every time. With the spine if they have a good day they may be able to go a couple of blocks. On a bad day it is 100 feet.
9. Spondylolysis and spondylolisthesis
Spondylolysis is the defect in the pars interarticularis which is the
piece of bone that attaches the superior to the inferior facet. So when
that is not connected, the restrain to slippage is gone. The facet joints
are no longer connected to the spine. Actually 3% of the population has
spondylolisthesis or spondylolysis. So it is common and obviously most people
do not have to have surgery. We treat it just like the other things. A percentage of the time in people who have spondylolisthesis the symptoms are coming from the level above and not from the spondylolisthesis. So you might even have them do press-up exercises, if that seems to work. You are treating
the upper area. If they do have trouble, it is from lateral canal stenosis
because at the area of the crack of the bone there is constant motion and
either build up a fibrous tissue plus the vertebra slip which distorts the
size of the nerve hole resulting in nerve entrapment. And so for radiculopathies with spondylolishtesis, you treat it just like the other things, you try to block the patient right away and if you can control it, you set them up for stabilization training and try to hold the vertebra as straight as possible. When it is operated on, it usually has to be fused however not
always. Sometimes you can just decompress them. So those are the three most
common surgical issues; herniated disc, spinal stenosis and spondylolisthesis
with or without radiculopathy.
10. Internal disc disruption
Internal disc disruption occurs when the nucleus tears its way through
the annulus inside but does not cause a herniation. So the MRI scan and
CT scan and myelogram look normal because there is no protrusion but since
the outer third of the disc has nerves in it, if you get a tear it goes
to the outer area and can function to be a chronic source of pain because
the jelly in the middle is constantly being driven outward against the annulus
as some of the newer chemical studies show. There are studies on phospholipase
in discs that cause an inflammatory reaction. Phospholipase is the highest
content in the body in the disc and the problem could be that the chemical
is coming into contact with the nerve endings. So this is kind of a rare
thing but it is important to know about the people who have it. They are
usually between 20 and 40, active people and extremely frustrated because
they are being told there is nothing wrong with them yet they are totally
disabled and can't even get up as this increases the load on the disc increases
their pain.
About half of them can get better with training and conservative treatment
and about half do not get better. About half of those who do not get better
end up being fused. in the group that are fused, about 70% get better.
Q: If you fuse them, you are going to take out the disc anyway, right? So if you take out the disc, you take out the problem.
First of all, you cannot completely take the disc out because the disc
is the ligament that attaches the vertebra together. So you have to leave
some. if you do a fusion, you may not get a solid fusion which is probably
the most common cause of a patient not getting better. The other reasons
surgery may not work are because the only way we can make the diagnosis
is based on the discogram which means you inject several discs and see
if they hurt, so that is not a very good test because it is subjective
in part. The accuracy of the test is not that great. Then they have other
levels that also are internally disrupted or they may be chronic pain patients with psychological reasons to hold onto the pain. So it is a mixed, complicated bag of people. We are probably still not that good at picking out the ones that are purely structural problems. The success rate is not as hig as
we would like.
Q: How accurate is it when you do discograms and then you do CT?
That is the most sensitive test for disc herniations. So if I had to
pick one test to rely on, it is the best test. Doing a discogram and a
CT afterwards.
Originally, discograms were done and they did some studies on prisoners
about 20 years ago without fluoroscopic control, just x-rays. They put
the needles in through the thecal sac, whereas we come in from the side
to do it now. They decided the pattern of the discs were abnormal in almost
everybody whether they had symptoms or not so it was concluded this was
a useless test. They were doing prisoners. The prisoners got to get out
of prison to have the test done so they were probably not being truthful
about whether they had symptoms or not. The techniques they were using
were primative. They had no CT scan to see actually what was going on with
this. Sometimes the x-ray would look normal but the CT scan shows fissures.
So with the modern techniques, those old biased studies which led everyone
to be anti-discogram have been seen for what they were; it has now turned
around in about the last five or six years. Surgeons who are spine specialists,
I would say the majority of them, find discograms really useful. In our
practice we cancel as many cases because of the discogram results as we
do schedule them.
Q: Is there any problem with the water content in the disc itself,
as far as the discograms go and putting the dye in? Does that make a difference?
The key issue is whether the disc is painful or not. So like other people
if most of the discs leak and look very abnormal, that is not abnormal
unless they hurt.. They are not supposed to hurt when injected. So usually
we do not do discograms in people under 60 because they are just going
to leak out everywhere. But we have had some internal disc disruption in
60 year olds occasionally and they have done well with surgery., When I
started in orthopaedics, everybody who had back problems was another crock
and very few of them had something on the myelogram which showed a recognizabler
treatable lesion; the vast majority of them were just achy, complaining
people with back pain and there was nothing to do for them. Then the CT
scan came in and we could see in detail the shape of the spinal canal and
so for a lot of the patients had stenosis that we could not see on the
myelogram because it was too lateral. So there were less crocks around.
Then we had been doing discograms and selective blocks and now with the
MRI scans the diagnostic sensitivity has gone up another level Now there
are less and less crocks around. It is more and more unusual that somebody
with a bad problem does not have a specific diagnosis and can be specifically
treated for. So it is a lot easier and efficient to treat the problem.
11. Fractures
Fractures is too big of a topic for this discussion. The most common
thing you see are these osteoporotic flexion/compression fractures which
are most common at the thoracolumbar junction. That is where the stress
riser from the end of the rib cage to the beginning of the lumbar spine
is. There is a lot of stress transfer because the thoracic spine is rigid.
If you have a rigid stick and then a loose rope and you whip it, the stress
is greatest right at the beginning of the rope. Now as you know, osteoporosis
can be treated and diagnosed pretty well. Treating it prevents people from
getting hip fractures and collapse of their bones later and so forth and
should be looked for.
12. Infections
Infections in the spine, as you know, can occur spontaneously sometimes.
Usually, they are associated with trauma and it might not even be direct
trauma. If there is not trauma of the spine they might just have an abrasion
someplace and have it seed to the back. Obviously, IV drug users get spine
infections frequently. In people who have had surgery before, we notice
there is a kind of indolent infection syndrome where they get anerobic organisms in the surgical wound. There is a very indolent infection that does not really make them sick enough for us to detect it, even their sed rates can
be normal. But they just kind of smolder along and we never make a diagnosis
until we actually operate on them and see some kind of tissue edema and
the cultures come back usually with diphtheroids or other slow growing organisms. Some of these things are not even accepted as pathogens by the lab. We have done controlled studies on patients who have not had surgery before and
so forth and I am pretty sure that it a real entity. So it is one of the
common explanations for failed surgery in our experience.
13. Neoplasm
The most common neoplasm, as you know, is metastatic and for primary
bone tumors are encondromas.
Q: Do you see much bone tumors, I know it is so rare.
Primary bone tumors are very rare. We probably see one a year in a general
spine practice. We see a fair amount of metastatic tumors.
14. Functional
You could say that almost everybody has a functional overlay, it is just
a matter of the degree. It is very frustrating to have a back problem because
you cannot do anything. You cannot stand. You cannot walk. Everything has
to be transferred from the upper to lower extremities through the back.
If there is a functional overlay that you can identify it by pain behavior
on examination, you know unphysiologic responses and so forth, it does not
mean there is not a significant spine problem, it just means they have central
nervous system augmentation conscious or unconscioious. A few of them do
not have any problem, but it is unusual. You only see maybe two of those
a year. So it is always kind of a mixed bag. If they have a functional problem,
it just means that it has to be delt with. If you just deal with them only
structurally and do not recognize the other, your treatment outcomes are
not going to be that good.
15. Metabolic
Metabolic mainly is gout and osteoporosis. Gout can cause almost any type
of joint symptom anywhere in the body, you just have to keep it in mind.
The systemic arthritis that attacks the spine is mainly ankylosing spondylitis
which there really is no treatment for. Reiter's syndrome frequently involves
SI joints and rheumatoid arthritis which can attack the spine, especially
the C1-2 articulation where the transverse ligament of the odontoid joint
can become lax. This can pith the medulla. So anytime those patients have
surgery, they have to have flexion/extension views first. Any patient who
has rheumatoid arthritis, to make sure they are not unstable in the cervical
spine should have bending lateral neck x-rays.
Osteoporosis is very common and now it is very treatable. Not enough
physicians diagnose and treat it. It is responsible for many health problems-
fractures,degenerative arthritis, spinal stenosis are probably caused in
part by oteoporosis in many cases.
16. Costovertebral Joint Syndrome
Costovertebral joint syndrome is fairly common and has to do with the
rib spine junction. There are a lot of little ligaments in there and a couple
of joints. Twisting injuries or blows to the chest can sometimes result
in damage to the joint. The rib actually becomes unstable and wobbles back
and forth and irritates the nerve root which is running right under it.
Symptoms may be from a spur on the rib head which pokes in the nerve root.
It is a very difficult area to visualize on imaging and so frequently you
just rely on injections. If the patient does not get better with exercises
and injections and we block them several times and it is always the same
site that makes them temporarily better, we will occasionally operate. Now
that we can perform the operation through tiny incisions using a thoracoscope
there is less down side to the operation The classic operation is removing
the end of the rib which is called a costotransversectomy.
Q: What are the classic symptoms?
The classic findings are pain at the joint where the rib comes into
the spine. The pain is increased by rotation of the thoracic spine. That
is what it does. The thoracic spine rotates.
Q: I saw a lot of patients who seem to have pain in their rhomboid
region. I was wondering if that is referred pain from that type of injury.
It could be from that but that is most commonly referred from the neck.
Pain between the shoulder blade. So in those cases what you want to do
is have them put their head down like that. If that increases their pain,
that is probably from discogenic pain from a anulous tear or central herniation
in the neck. That is the most common cause. Usually these costovertebral
joint patients are worse with flexion. They cannot sit too long. So the
exercise program for them is hyperextension exercises and try to increase
those muscles around the site of the spine in the back. Try to mobilize
the thoracic spine which is intrinsically a very stiff structure. So it
is not easy. Most of those people gradually get better with conservative
care. We maybe operate on one or two a year out of about maybe 50 that
we see.
17. Degenerative Disc Disease
This is just the overall term for all the problems that go along with
the degenerative cascade. In the degenerative cascade the disc nucleus loses
its water imbibing capacity and therefore looses the height because it no
longer can suck water into it so it actually gets smaller. It cannot hold
the water but if you lie down during the night, it gets the water in it.
When you load it, it squeezes it right out. The stress applied to the disc
changes form tension to compression. When the disc is working right the
walls of the annulus are pulled up tight and it changes the compression
forces in the vertebra on the spine into tension forces along the wall of
the disc. When you lose the disc integrity, the nucleus integrity, so that
it no longer retains water well, then the forces changes to the compressive
forces on the anulus and you start to grind the annulus down and the anulus
starts to deteriorate. Then the vertebra can be even more close together.
When they come closer together, the facet joints which are attached in the
back come closer together, then they do not fit like they used to anymore
and the cartilaginous surface aren't opposed anymore and then you start
to get degenerative changes on them and the load on them increases because
they are closer together. So they can get spur formation at the facet, spur
formation of the vertebra in which the disc is too wobbly and as the vertebra
starts to stabilize itself it forms traction spurs. The end result is spinal
stenosis. Before the spinal stenosis, there is a period of instability the
disc is incompetent and the facet joints are worn out. The ultimate result
is that the patient will fuse himself eventually via the spurs growing together.
Although some people do that, most people do not get enough bone formed
and usually die before it happens.
18. Pseudoarthrosis
Since there are a lot of spine fusions done, this is a common problem.
It is difficult to detect a pseudoarthreosis unless it is grossly loose
and you can see motion on bending x-rays which aren't very accurate. CT
scans are not reliable; nothing is totally reliable. We have found the best
way to detct it is single plane lateral midline flexion extension tomograms.
It is a simple test. It is very reliable. It is accurate down to a mm or
two of motion. We know that is true from exploring people from the anterior
approach after they have the studies done.
If the patient has pseudoarthrosis, the treatment is either a pulse electromagnetic
field stimulator where you put these coils around them and it makes a magnetic
field which increases bone formation or you have to go in and fix them surgically.
BMP: Bone morphogenic protein. This is the protein that is in bone which
tells the body that it is supposed to be bone. When we do a fusion procedure,
we take bone from one part of the body and put it into the area we want
bone to form. Basically, we are just doing that because it has BMP in it.
The bone is dead as soon as you remove it. When the body has to eat up that
piece of bone and replace it with new living bone, that is why it takes
a long time.
BMP before could be extracted from bone but it would take 500 pounds
of cow bones to get a gram of BMP. Now it is being cloned from a hamster
ovary cell from a hamster who lived in 1952. It is just now being released
for clinical trials. It is unclear who well it would work. It might work
so well that you do not have to operate on anything anymore, you know, broken
bones. Just inject them with BMP. We will probably know in a few years.
It may be that for a pseudoarthrosis, all we have to do is inject some BMP
into the crack.
19. Scoliosis
This is a whole field in and of itself. Most scoliosis is idiopathic
and if it is more than 20 degrees it is treated with a brace. If it is more
than 40 degrees, it is usually operated on. This is in an immature individual.
In an adult, once a person has stopped growing, the scoliosis progression
usually stops unless it is over 40 degrees. if it is progressing with a
lot of pain or if there is neurological deficit associated with deformity,
those would be indications to operate on. Most adults with scoliosis do
not have to be operated on. Most children do not have to have surgery either
because usually braces will control it if you catch it early and there is
good scoliosis screening now in schools.
Overview of Diagnostic studies
The typical x-rays you see are AP, lateral and obliques. We do not usually
get obliques because they do not add much and there is a lot of radiation.
The only thing to see in the obliques is the pars interarticularis for spondylolysis and you can usually see that on the lateral too. X-rays in general do not show you very much. You can tell by talking to the patient whether he has a disc tear or whatever is going on. So you just see the trail of the jet plane, kind of, by looking at the bones. To tell what is going on you need to have a scan done. MRI scan is probably the best screening test to get. If you are just looking for stenosis, then a CT scan or myelogram/CT scan
is the best. If an old person has stenosis in the lumbar spine you need
to go up to the thoracic spine if there is going to be any surgical procedure
done because there are skip lesions and thoracic spine lesion can cause
clinical symptom complex which is just like lumbar stenosis. You need to
have a good view of what is going on. On MRI, you can usually run it up
to the conus level which is usually enough. If you get a CT scan, they usually
do three or four levels which is not enough. A CT scanwill miss and some
intermedullary tumors whereas the MRI is very good for tumors. Myelogram
is still a good test. There is a group of patients who have lesions that
can only be demonstrated on myelogram because they are dynamic. So on the
myelogram we can bend them forwards and backwards and sometimes the disc
will pop out in the neck or lumbar region but will not show up when the
patient is lying flat. Like they are for CT or MRI. The discogram we talked
about is not a very good test but it is the only test which tells you where
the pain is coming from. The other things just give you a picture and do
not tell you about pain. The disco/CT scan is the most accurate test for
a herniated disc. So it is the best thing. Especially with people who have
had surgery before and they cannot differentiate the scar tissue from other
scar tissue or disc material.
Thermograms. This looks like a PET scan picture. It is a photographic way to measure heat on a scan and it is not a useful because it is too sensitive so it is not really accepted but you mainly just hear about it. It gives information like an EMG. It is too sensitive and is not thought to be worthwhile by the great majority of people in the field.
Brevital interview. This means they put the patient to sleep a
little bit, examine them and see if there is a lot of pain behavior like
a truth test. Things are self-explanatory.
Blocks. There are many types of injections we do.. Basically, we are putting local anesthetic and cortisone into the area we think the
disease is coming from. If the patient has burning pain then sympathetic
blocks within the neck or low back are useful. On most things, you block
the sympathetic ganglion with some local anesthetic. Sometimes it will break
the cycle.
Q: I do not understand what you just said. Breaking the cycle. I
do not know if anybody would understand this, if the pain is coming there,
you numb it out, but what is the cycle?
I was specifically talking about sympathetically mediated pain. You
know, the classic cases are sympathetic dystrophy in which the patient
has an ankle sprain and then they have severe pain and won't move the foot
because it hurts too much. This is associated with a severe burning pain
and hypersensitivity on the skin and you actually get atrophy of the foot
and the joints dissolve at the end stage. And it has been found through
knocking out the function of the sympathetic ganglion which mediates the
sympathetic nerve innervation that during the time that it is blockaded,
the symptoms are gone. So this is just one segment of people who have pain
and sometimes people who have back pain have that type of sympathetically
mediated pain. The sympathetic ganglion become miscalibrated so that they
take the somatic pain and they greatly escalate it. If you get it early,
you can block them and the burning part of the pain, the sympathetic part,
will go away and not come back sometimes. If it is later on, they still
just get temporary relief and you can try doing a series of blocks. Sometimes
it will gradually get better. If they do not, we will even do sympathectomies
on them for pain. We have done studies on that. We have done about 12 patients. About two-thirds of them got better.
So breaking the cycle I think is a valid thing for sympathetic dystrophy
because it clearly is a disorder of the pain system. There is no structure
correlate identified currently. The other type of blocks, you are putting
usually steroid into the area so you are blocking local inflammation. The
other thing on these blocks, in any type of injection there is a 40% placebo
response. That is a lot. Anytime you stick a needle in someone, they are
going to feel better for awhile. Anytime you stress someone, they are releasing endorphins for awhile. So that is effective too. You wheel them into that room, splash a bunch of needles at them, they are already going to get
better from an endorphin route. |
