Spinal Biomechanical Analysis Cooperative Spine Care Anatomical VS. Biomechanical Spine Pain William J Owens Jr, DC, DAAMLP, CPC About Me Adjunct Faculty - Clinical Assistant Professor - State University of New York at Buffalo School of Medicine and Biomedical Sciences, Department of Family Medicine, Buffalo NY, 2012-present Adjunct Faculty Assistant Professor of Health Sciences University of Bridgeport, College of Chiropractic, Bridgeport, CT, 2012-Present Coordinator Chiropractic Elective State University of New York at Buffalo School of Medicine and Biomedical Sciences Family Practice Residency Program, Buffalo NY, 2011-present Clinic Director, Chiropractor, Greater Buffalo Accident and Injury Chiropractic, Buffalo NY, 1998 Present Clinic Director, Chiropractor, Greater Rochester Spine and Injury Chiropractic, Buffalo NY, 2011-Present Certification in MRI Interpretation 2012 Certification in Spinal Biomechanical Engineering - 2014 Research Cooperative Spine Care House Keeping 1. Relax HAVE FUN and ASK QUESTIONS 2. CME course evaluation and CME request form. 3. Primary Care Evals and MVA/Comp a) Musculoskeletal not evaluated b) Chief Complaint presents for Flu Shot under specialist care for injury. 3 1
Physician s Assistant Example Communication V S sciencephoto.com drkowalik.com Current and Future Trends in Primary Care Increased pressure to see MORE patients ACA will increase that exponentially. Reduced individual patient reimbursement Outcomes driven model Grouped by diagnosis Incentivized to change behavior carriers require % of patient population with a specific diagnosis. 1000 patients with Hypertension requirement - 90% participation in preventative medicine and dietary changes Get paid based on PROVING the patients are in that system and that changed behaviors have occurred. How does this help us?? Stressed businesses are MORE open to suggestions! PCPs and Specialists are looking for more $! PCPs have a large musculoskeletal patient base that is VERY difficult to manage using the Allopathic Model do you know where the term Allopathic came from? 2
Please be sure that I have your email address I send these types of research reviews out not all about chiropractic, these also contain language to increase collections and rebut denials of care. 8 9 3
10 http://www.scielo.br/scielo.php?pid=s1413-35552011000100009&script=sci_arttext&tlng=en 11 4
13 Pain Intervention Sales of OPR quadrupled between 1999 and 2010. Enough OPR were prescribed last year to medicate every American adult with a standard pain treatment dose of 5 mg of hydrocodone (Vicodin and others) taken every 4 hours for a month. Abuse of OPR costs health insurers approximately $72.5 billion annually in health-care costs. (p1489) 5
The Primary Care Approach How the patient is handled in the beginning of a spinal complaint is critical. FORGET about the stuff we fight about internally when you want referrals from MDs it doesn t matter Diagnosis FIRST What is the tissue that is causing the pain and ensuing functional loss? Muscle, tendon, ligament, intervertebral disc or nerve? How does that effect prognosis. Integrated Conservative Care Pain Management Chiropractic, Acupuncture, Injection Therapy, non-narcotic medication targeting inflammatory response without creating hypersensitization Biomechanical Correction Rehabilitation Residual Management Home care, behavior modification, medication, spinal manipulation. Workers Compensation Fee Schedule Changes? 17 6
In the sample of 1,885 workers, 174 (9.2%) had a lumbar spine surgery within 3 years. V S Reduced odds of surgery were observed for those under age 35, women, Hispanics, and those whose first provider was a chiropractor. 42.7% of workers who first saw a surgeon had surgery, in contrast to only 1.5% of those who saw a chiropractor. There was a very strong association between surgery and first provider seen for the injury, even after adjustment for other important variables. 7
Chiropractic and Pain Management Reductions in pain sensitivity, or hyperalgesia, following SMT (spinal manipulative therapy) may be indicative of a mechanism related to the modulation of afferent input or central nervous system processing of pain. The mechanism of SMT remains elusive, but SMT appears to modulate pain through both central and peripheral pathways. Talking to the MDS about non-factual clinical assumptions Lower back pain has a natural history and if we don t do anything it will eventually resolve on its own Dispel the MYTH with RESEARCH 8
In our study, after controlling for demographics and severity indicators, the likelihood of recurrent disability due to LBP for recipients of services during the health maintenance care period by all other provider groups was consistently worse when compared with recipients of health maintenance care by chiropractors. (p 403) *NYS WC Example Chiropractic Management Pain Management Interventions Focuses on stimulation of the CNS and decreasing sensitivity to pain. While increasing active function USE THE PAIN PAPER TO TEACH THEM! Side note why is it PTs doing this? Why not chiropractors? OMT Article Example http://www.frca.co.uk/article.aspx?articleid= 100118 Biomechanical Interventions Biomechanical correction FIRST, Rehabilitation SECOND. You CANT exercise away a biomechanical problem!! That is why REHAB is second 9
Referral Patters and Attitudes of Primary Care Physicians Towards Chiropractors Several studies have revealed that general practitioners refer to alternate care providers for back pain, musculoskeletal conditions, and neck problems [21,23]. This is consistent with our finding that the most frequent reason for referral to a chiropractor was chronic musculoskeletal pain that does not respond to conventional treatments. BASSAKWARDS! [Educate and Teach] Referral Patters and Attitudes of Primary Care Physicians Towards Chiropractors In our study, clearly a majority of PCPs were willing to recommend that patients consult a chiropractor, yet they were reluctant to actually make a formal referral themselves. Only 30% of PCPs in our study and 50% in previous studies [16-18] have ever made a formal referral to a chiropractor. An important finding from our study is that when PCPs recommend chiropractic care, close to 88% preferred that patients contact a chiropractor on their own. [that is why we are still around patients LOVE US] 10
Referral Patters and Attitudes of Primary Care Physicians Towards Chiropractors There are several possible explanations for their unwillingness to "formalize" their relationships with chiropractors. PCPs fear malpractice litigations [19]. A perception that alternative care providers could be a threat to their practices could also have been an influence. [Malpractice ins] Some of the PCPs in our study mentioned that they do not know enough about chiropractic to have an opinion, or do not view chiropractic as a legitimate health profession. Referral Patters and Attitudes of Primary Care Physicians Towards Chiropractors Patients are caught directly in the middle of this uncertainty between provider types. More research needs to be directed at better understanding of those issues surrounding the coordination and the loss of care which results from the poor professional relationships between these two provider types SIMILAR TO ORTHO PAPER 11
Seeking care for any condition is not static but a process particularly for long-term conditions such as CMP. This may need to be taken into account by both CMP patients and their treating health professionals, in that both should not assume that their views about causation and treatment are static and that instead they should be revisited on a regular basis. Adopting a shared decision-making approach to treatment may be useful particularly for long-term conditions; however, in some cases, this may be easier said than done due to both patients and health professionals sometimes discomfort with adopting such an approach. Training and support for both health professionals and patients may be helpful in facilitating a shared decisionmaking approach. 35 Cauda Equina 36 12
CNS & PNS Distribution This presentation is licensed to Dr. Mark Studin. If you are participating in a presentation with another person or entity, you are participating in theft of intellectual property please leave. Human Anatomy & Physiology, 2nd. ed. Solomon, Schmidt, Adragna, 1990, 1983 Saunders College Publishing, page 484, Fig 14-5. 37 Typical Spinal Nerve Neural Canal This presentation is licensed to Dr. Mark Studin. If you are participating in a presentation with another person or entity, you are participating in theft of intellectual property please leave. Nerve Root Anatomy, Clemente, 4th Edition Plate 405 38 Annular Tear/Fissures There is general agreement about the various forms of loss of integrity of the annulus, such as radial, transverse, and concentric separations. Although the North America Spine Society has recommended in 1995 that such lesions be termed "fissures" rather than "tears," primarily for fear that the word "tear" could be misconstrued as implying a traumatic etiology, a T2 hyperintensity with gradient studies or a STIR study can clearly delineate a radial tear from a circumferential tear. This difference clarifies the trauma vs. non trauma argument. A single distinct trauma will cause a radial tear, where constant abnormal pressure form the annulus in repetitive micro-traumas will cause the annulus to have numerous circumferential tears. These circumferential tears of the bridging fibers which hold together the annulus will cause the annulus to push outward and can deform the disc upwards of 3mm past the normal end-plate boundaries. www.doereport.com http://www.backache.md/compression-forces.htm 39 13
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Chemical Radiculitis In the absence of compression with MRI, an MRI with contrast could diagnose inflammation around the nerve roots or this requires an EMG/NCV to diagnose the cause and does not change the treatment plan. Inflammation 43 Stenosis: Constriction or narrowing of a passageway or opening, such as the spinal canal when a disc herniates and causes the canal to become smaller (pix) 44 Cerebral Spinal Fluid L3-4 Disc L4-5 Disc WWW.DOEREPORT.COM 45 15
T1 STENOSIS L-Spine T2 Ligamentum Flava Cauda Equina Schmorl s Node Disc Epidural Fat 46 Cord Compression: Any compression of the spinal cord by a space-occupying lesion as a herniated disc (pix) Myelopathy: A compression of the spinal cord with the ensuing clinical signs; signs of weakness, hyperreflexia, Babinski sign and sensory deficit below the level of compression 47 47 Spinal cord pushed against the back of the spinal canal Herniated Disc WWW.DOEREPORT.COM 48 16
Cord Compression Courtesy of: All County MRI This presentation is licensed to the doctor on the screen. If you are participating in a presentation with another person or entity, you are participating in theft of intellectual property please leave 49 http://members.cox.net/injections/images/snb_images/roots.jpg Thecal Sac (aka) Dural Sac The thecal sac is the membranous encasement of the spinal nerve roots and cerebral spinal fluid & cord. The outer layer is the dura mater, which is adjacent to the arachnoid. http://www.chirogeek.com/anatomy_wnl_axial_final-7-0.gif Since this structure is pain sensitive where pressure on it can cause numbness and tingling in various parts of the body. http://www.spinalinjuryfoundation.org/101_new/read7835522211mri844333/ ThecalSac.htm This presentation is licensed to Dr. Mark Studin. If you are participating in a presentation with another person or entity, you are participating in theft of intellectual property please leave. 50 Thecal Sac This presentation is licensed to Dr. Mark Studin. If you are participating in a presentation with another person or entity, you are participating in theft of intellectual property please leave. 51 17
Facet Syndrome Facet joints have been shown to be a source of chronic spinal pain by means of diagnostic techniques of known reliability and validity. R BMC Musculoskeletal Disorders 2004, 5:15 52 Pre-Existing Conditions ARTHRITIS A Risk for GREATER Bodily Injury with LESS FORCE 53 R Pre-Existing Conditions Degenerative Joint Disease-Arthritis and Spondylosis are synonymous They all contribute to more bodily damage with LESS TRAUMA Green Twig vs. Dry Twig Therefore An individual with arthritis is more susceptible to injury then a healthy person R The argument of The herniation is pre-existing because arthritis is present is not based on any physiological accurate statement. 54 18
Spinal Biomechanics & Arthritis Risk Factors in Trauma Rear Ends 92 years old Riddled with arthritis 68 lbs, 4 8 Rippling 12-pack Buns of Steel 2% Body Fat Who Gets Hurt More? Backseat Buddies Narrative Language Mrs. Jones has suffered from a preexisting arthritic dengerative joint (name body part) that is not as a result of this injury, however, the arthritic joint increased the susceptibility of the (joint name) to more damage with less trauma R 56 Spondylolysis is never congenital It is always from trauma, the question when did the trauma occur WWW.DOEREPORT.COM How do you differentially diagnose recent vs. old fracture? This presentation is licensed to Dr. Mark Studin. If you are participating in a presentation with another person or entity, you are participating in theft of intellectual property please leave. 57 19
Radiculopathy vs. Radiculitis Radiculopathy is a condition due to a compressed nerve in the spine that occurs in the neural canal, neuroforamin or in the central canal on the cauda equina. Radiculitis is pain "radiated" along the dermatome (sensory distribution) of a nerve due to inflammation or other irritation of the nerve root (radiculopathy) at its connection to the spinal column. 58 Nerve Root 59 Strain/Sprain Strain is an overstretching of the muscle Sprain is damage to the ligament Is the diagnosis of strain/sprain a permanent or transient diagnosis does it have any permanency implications? This presentation is licensed to Dr. Mark Studin. If you are participating in a presentation with another person or entity, you are participating in theft of intellectual property please leave. 60 20
Grades of Strain/Sprain Grade I Sprain (primary): Grade I sprains cause stretching of the ligament. The symptoms tend to be limited to pain and swelling. This is transient. Grade II Sprain (secondary): A grade II sprain is more severe partial tearing of the ligament. There is usually more significant swelling and bruising caused by bleeding under the skin. This is permanent and will lead to permanent limitation of function in varying degrees. Grade III Sprain (tertiary): Grade III sprains are complete tears of the ligaments. The area is usually quite painful, and functioning can be difficult. Patients have severe instability. This is permanent and will lead to permanent, very significant limitation of function that will alter their everyday activities of daily living. This presentation is licensed to Dr. Mark Studin. If you are participating in a presentation with another person or entity, you are participating in theft of intellectual property please leave. 61 Tendon /Ligament Repair in Strain/Sprain Injuries R No treatment currently exists to restore an injured tendon or ligament to its normal condition Birth Defects Research (Part C) 75:226-236 (2005) Despite remodeling (healing,) the biochemical and mechanical properties of healed tendon tissue never match those of intact tendons. The Royal College of Surgeons of Edinburg and Ireland, Surgeons 3: 5; 309-316 2005 This presentation is licensed to Dr. Mark Studin. If you are participating in a presentation with another person or entity, you are participating in theft of intellectual property please leave. 62 Hauser R., Dolan E., Phillips H., Newlin A., Moore R., Woldin B., Ligament & Healing Injuries: A Review of Current Clinical Diagnostics and Therapeutics, The Open Rehabilitation Journal, 2013, 6, 1-20 THE CURRENT MEDICAL STANDARD FACTS SOLUTION 63 21
MRI Disc & Spinal Pathology 64 Disc Herniations MISSED by Medical Radiologist Lurie et. al. sought To compare the interpretation of lumbar spine magnetic resonance imaging (MRIs) by clinical spine specialists and radiologists in patients with lumbar disc herniation (pg 701). The goal of this study was to determine whether the standardized guidelines for the description of disc pathology where being following in clinical practice. In other words, was the information being transferred from the academic world to the clinical arena? The Spine Patient Outcomes Research Trial (SPORT) is a clinical trial with both randomized and observational cohorts conducted at 13 sites with multidisciplinary spine practices across 11 states. Using patients with disc herniation from the randomized cohort of this study, we compared the interpretation of a radiologist and a clinician reading the same image (pg 701). The results of this study showed the following: the specific morphology of the herniation was not reported by the radiologist in 42.2% of cases (pg 703). the radiology dictation did not provide enough detail to classify the herniation as a protrusion, extrusion, or sequestered fragment (pg 704). It is critically important to work with clinicians who have extensive knowledge in the interpretation of spine MRI when representing the traumatically injured. Clinicians who read their own films and do not rely on the interpretation of the radiologist ensure the proper diagnosis; prognosis and triaging of those that have sustained a traumatic injury. Reference: Lurie, J. D., Doman, D. M., Spratt, K. F., Tosteson, A. N. A., & Weinstein, J. N. (2009). Magnetic resonance imaging interpretation in patients with symptomatic lumbar spine disc herniations. Spine, 34(7), 701-705. 66 22
Typical Spinal Nerve Anterior Horn Motor Recurrent Menigeal Nerve Spinal Cord Nerve Root Posterior Horn Sensory This presentation is licensed to the doctor on the screen. If you are participating in a presentation with another person or entity, you are participating in theft of intellectual property please leave Anatomy, Clemente, 4th Edition Plate 405 67 Recurrent Meningeal Nerve Innervation Outer 1/3 of the disc in ner vate 1. To supply (an organ or a body part) with nerves. 2. To stimulate (a nerve, muscle, or body part) to action. AF=Annulus Fibrosis NP=Nucleus Pulposis 68 Disc Definitions Based on the American Society of Neuroradiology 1. 2. 3. 4. Normal Annular Tears/Fissures Disc Degeneration Herniated Disc A. B. C. R Protruded Disc Extruded Disc Sequestered Disc 5. Location of Fragments 6. Volume of Composition of Displaced Material 7. Containment/Continuity This presentation is licensed to the doctor on the screen. If you are participating in a presentation with another person or entity, you are participating in theft of intellectual property please leave This entire section comprising of the 10 definitions are based on the ASNR s definitions and a copy will be delivered to you if you fill out the yellow paper in your handout 69 23
Disc Bulge Circumferential thinned disc wall Annulus Fibrosis Nucleus Pulposis This presentation is licensed to the doctor on the screen. If you are participating in a presentation with another person or entity, you are participating in theft of intellectual property please leave Yussen and Swartz 70 Disc Bulge / Degeneration The term "bulge" refers to an apparent generalized extension of disc tissues beyond the edges of the apophyses. Such bulging occurs in greater than 50% of the circumference of the disc and extends a relatively short distance, usually less than 3 mm, beyond the edges of the apophyses. "Bulge" describes a morphologic characteristic of various possible causes. Bulging is sometimes a normal variant (usually at L5-S1); can result from advanced disc degeneration or from vertebral body remodeling (as consequent to osteoporosis, trauma, or adjacent structural deformity); can occur with ligamentous laxity in response to loading or angular motion; can be an illusion caused by posterior central sub-ligamentous disc protrusion; or can be an illusion from volume averaging. Presence of disc tissue "circumferentially" (50-100%) beyond the edges of the ring apophyses : not considered a form of herniation, nor are diffuse adaptive alterations of disc contour secondary to adjacent deformity as may be present in severe scoliosis or spondylolisthesis Bulging discs may be symmetrical or asymmetrical This presentation is licensed to the doctor on the screen. If you are participating in a presentation with another person or entity, you are participating in theft of intellectual property please leave 71 José García-Cosamalón, Miguel E. Del Valle, Marta G. Calavia, Olivia García-Suárez, Alfonso López- Intervertebral disc, sensory nerves and neurotrophins: who is who in discogenic pain,? Journal of Anatomy, Volume 217, Issue 1, pgs 1-15, July Muñiz, Jesús Otero, José A. Vega 2010 ABSTRACT The normal intervertebral R disc (IVD) is a poorly innervated organ supplied only by sensory (mainly nociceptive) and postganglionic sympathetic (vasomotor efferents) nerve fibers. Interestingly, upon degeneration, the IVD becomes densely innervated even in regions that in normal conditions lack innervation. This increased innervation has been associated with pain of IVD origin. The mechanisms responsible for nerve growth and hyperinnervation of pathological IVDs have not been fully elucidated. Among the molecules that are presumably involved in this process are some members of the family of neurotrophins (NTs), which are known to have both neurotrophic and neurotropic properties and regulate the density and distribution of nerve fibers in peripheral tissues. NTs and their receptors are expressed in healthy IVDs but much higher levels have been observed in pathological IVDs, thus suggesting a correlation between levels of expression of NTs and density of innervation in IVDs. In addition, NTs also play a role in inflammatory responses and pain transmission (CFibers) by increasing the expression of pain-related peptides and modulating synapses of nociceptive neurons at the spinal cord. This article reviews current knowledge about the innervation of IVDs, NTs and NT receptors, expression of NTs and their receptors in IVDs as well as in the sensory neurons innervating the IVDs, the proinflammatory role of NTs, NTs as nociception regulators, and the potential network of discogenic pain involving NTs. 72 24
As the annulus of the discs thins, the nerves reach further into the entire disc and display properties of ingrowth further causing sensitivity of the disc 73 Degenerative/Bulging Discs Narrative Language Simply explained, Ms. Patient 's degenerative/bulging discs in the cervical and lumbar spine has nerve fibers that have grown into the annulus fibrosis and nucleus pulposis of the disc, and upon trauma, an inflammatory response was created causing pain in her previous asymptomatic degenerative disc. Without the accident date 4/02/2011, this process would never have been initialed and explains the persistent pain cycle that will never reverse based upon the risk factor of a pre-existing degenerated/bulging disc. 74 Herniated Disc The term "herniated disc," refers to localized (focal) displacement of nucleus, cartilage, fragmented apophyseal bone, or fragmented anular tissue beyond the intervertebral disc space (disc space, interspace). The interspace is defined, craniad and caudad, by the vertebral body end-plates and, peripherally, by the edges of the vertebral ring apophyses, exclusive of osteophytic formations. To be considered "herniated," disc material must be displaced (from trauma as forces exerted internally and expulsion externally (like a balloon) from its normal location and not simply represent an acquired growth beyond the edges of the apophyses, as is the case when connective tissues develop in gaps between osteophytic formations. Displacement, therefore, can only occur in association with disruption of the normal anulus or, as in the case of intravertebral herniation (Schmorl's node), a break in the vertebral body end-plate. This presentation is licensed to the doctor on the screen. If you are participating in a presentation with another person or entity, you are participating in theft of intellectual property please leave www.doereport.com 75 25
Disc Herniation circumferential Annulus Fibrosis Nucleus Pulposis Focal This presentation is licensed to the doctor on the screen. If you are participating in a presentation with another person or entity, you are participating in theft of intellectual property please leave Yussen and Swartz 76 Herniated Disc Since details of the integrity of the anulus are often unknown, the distinction of herniation is usually made by observation of displacement of disc material beyond the edges of the ring apophyses that is "localized," meaning less than 50% (180 degrees) of the circumference of the disc. Generalized, meaning greater than 50%, displacement of disc material beyond the ring apophyses, or adaptive changes of the apophyses and/or outer anulus to adjacent abnormality, such as may occur with scoliosis or spondylolisthesis, are not herniations. localized herniation displacement of disc material beyond the limits of the intervertebral disc space (involving less than 50% (180 ) of the disc circumference). This presentation is licensed to the doctor on the screen. If you are participating in a presentation with another person or entity, you are participating in theft of intellectual property please leave Herniated Disc 77 This presentation is licensed to the doctor on the screen. If you are participating in a presentation with another person or entity, you are participating in theft of intellectual property please leave Protrusions may be "focal" or "broad-based." The distinction between focal and broad-based is arbitrarily set at 25% of the circumference of the disc. Protrusions with a base less than 25% (90 degrees) of the circumference of the disc are "focal." If disc material is herniated so that the protrusion encompasses 25% to 50% of the circumference of the disc, it is considered "broadbased protrusion." Focal Herniation: < 25% of the disc circumference Broad-based Herniation: between 25 and 50% of the disc circumference 78 26
Protruded and Extruded Discs aka: Herniated Disc A disc is "protruded," if the greatest distance, in any plane, between the edges of the disc material beyond the disc space is less than the distance between the edges of the base in the same plane. The term "protrusion" is only appropriate in describing herniated disc material, as discussed above. Protrusions may be "focal" or "broad-based because is a herniation." Protrusion/Herniation: depth in any plane < base of herniation in the same plane Extrusion: depth in any plane > base of herniation in the same plane, or no continuity exists between the disc material beyond the disc space and that within the disc space 79 Extruded Discs Sequestered or Migrated Disc Disc extrusions may be further classified into sequestered or migrated discs. A migrated disc is a disk or fragment that has been displaced away from the site of extrusion but still retains continuity with the disk from which the extrusion originated. Sequestrations are disk extrusions that become detached from the parent disk. Migrated Sequestered 80 Sequestered Disc Displaced disc fragments are sometimes characterized as "free." A "free fragment" is synonymous with a "sequestrated fragment" and not the same as "uncontained," as the latter refers only to the integrity of the outer anulus and has no inference as to the continuity of the displaced disc material with the parent disc. A fragment should be considered "free," or "sequestrated," only if there is no remaining continuity of disc material between it and the disc of origin. Sequestration: Extrusion may be further specified as sequestration, if the displaced disc material has lost completely any continuity with the parent disc (C) Migration: displacement of disc material away from the site of extrusion, regardless of whether sequestrated or not (B,C) This presentation is licensed to the doctor on the screen. If you are participating in a presentation with another person or entity, you are participating in theft of intellectual property please leave 81 27
Schmorl s Nodes Acute vs. Chronic A question of causality and spinal compensation in a previously considered degenerative condition Definitions and Background Schmorl's nodes or Schmorl's nodules are protrusions of the cartilage of the intervertebral disc through the vertebral body endplate and into the adjacent vertebra.1 Essentially a vertical disc herniation 1: http://en.wikipedia.org/wiki/schmorl's_nodes Historical Concepts Very common in degenerative spines May or may not be symptomatic Found in the upper lumbar spine and lower thoracic A significant deformation of the spine Can occur as a result of trauma, without frank disc herniation or degenerative disc disease. 28
T12 Schmorl s Nodes: L1 L2 Superior Endplates L2, L3 and L5 L3 L4 L5 Inferior Endplates L3 and L5 What is this?? Current Concepts Using imaging to determine Acute or Chronic. Comparing Plain Film Radiography and MRI studies. ER films are CRITICAL not reports, FILMS Current Concepts The Pathogenesis of Schmorl's Nodes in Relation to Acute Trauma: An Autopsy Study. Spine. Volume 23(21),1 November 1998,pp 2272-2275 Fahey, V. MBBS; Opeskin, K. FRCPA, MBBS; Silberstein, M. MD, FRACR; Anderson, R. FRCPA, MRCPath; Briggs, C. PhD, BSc Radiologic Findings in Two Cases of Acute Schmorl s Nodes. AJNR Am J Neuroradiol 20:1717 1721, October 1999 Elisenda Grive, Alex Rovira, Jaume Capellades, Antoni Rivas, and Salvador Pedraza 29
The Pathogenesis of Schmorl's Nodes in Relation to Acute Trauma: An Autopsy Study. Spine. Volume 23(21),1 November 1998,pp 2272-2275 Fahey, V. MBBS; Opeskin, K. FRCPA, MBBS; Silberstein, M. MD, FRACR; Anderson, R. FRCPA, MRCPath; Briggs, C. PhD, BSc no studies have shown a direct causal relation between a traumatic episode and the formation of an acute Schmorl's node. (p2273) Seventy thoracolumbar spines from cadavers of individuals killed in motor vehicle accidents were examined pathologically and radiologically, particularly for the occurrence of acute Schmorl's nodes. Objectives: To document whether Schmorl's nodes occur acutely as a result of trauma. Summary of Background Data: Theories proposed to explain the pathogenesis of Schmorl's nodes include developmental, degenerative, traumatic, and disease influences. Few studies show a direct causal relation between a traumatic episode and acute Schmorl's node formation. Methods: Thoracolumbar spines were removed at autopsy, underwent radiography in the anteroposterior and lateral planes, fixed, sagittally cut, and underwent radiography a second time. Pathologic and radiographic examinations were performed. Results: Nine acute Schmorl's nodes were detected, most in association with other acute injuries to the spine. Most acute Schmorl's nodes were present in spines from individuals aged 11-30 years, with a male to female ratio of 9:1, and were localized to the T8-L1 region. Spines from motorcyclists showed the highest percentage of acute Schmorl's nodes. No acute Schmorl's nodes were detected radiologically. Conclusion: Schmorl's nodes do occur acutely as the result of a single traumatic episode, and are almost always associated with other acute spinal injury. The frequency and occurrence of acute Schmorl's nodes in motorcyclists suggest that axial loading is an important mechanism. Their predominance in the T8-L1 region suggests that this region is particularly susceptible to stress. 30
None of the nine acute Schmorl's nodes detected pathologically was seen radiologically. Schmorl's nodes can be seen radiologically only when the typical osseous casing has formed, and this take about 6 weeks. The results of the current study support the observation that acute Schmorl's nodes cannot be visualized radiologically immediately after the traumatic episode. Magnetic resonance imaging obviously would be the radiologic detection method of choice for assessment of Schmorl's nodes and confirmed by their absence in the radiology study. 91 Radiologic Findings in Two Cases of Acute Schmorl s Nodes. AJNR Am J Neuroradiol 20:1717 1721, October 1999 Elisenda Grive, Alex Rovira, Jaume Capellades, Antoni Rivas, and Salvador Pedraza Regardless of the specific etiology, Schmorl s nodes are typically seen on plain film and CT scans as radiolucent lesions of varying size contained within the vertebral body at the endplate and are surrounded by a sclerotic margin that in extreme cases may involve most of the vertebral body (1). In the acute stage, Schmorl s nodes are difficult to diagnose and even to detect, because sclerosis around the margin of the herniation has not had time to develop. MR imaging is the most sensitive noninvasive procedure for imaging acutestage Schmorl s nodes. In a young individual, traumatic lesions are the common cause of focal endplate herniations, which only develop vertically because the annulus fibrosus is intact. After the third or fourth decade of life, herniations occur more gradually, often through disrupted portions of the degenerated cartilaginous plate, and in most cases they are associated with transverse disk herniation. 31
Causality and Herniations Pre-Existing vs. New R 95 Clinical Necessity for MRI Radicular Pain 1. Arms 2. Legs 3. Flank to chest Intermittent, lancinating, electric, burning Radiculopathy 1. Motor weakness 2. Sensory weakness / paraesthesia 3. Diminished reflexes Worsens with axial loading and relieved by moving or lying R 96 32
MRI & Spinal Anatomy This presentation is licensed to the doctor on the screen. If you are participating in a presentation with another person or entity, you are participating in theft of intellectual property please leave 97 NORMAL ANATOMY Saggital View 2 4 5 3 4 A 6 1 C B This presentation is licensed to the doctor on the screen. If you are participating in a presentation with another person or entity, you are participating in theft of intellectual property please leave 98 Normal Anatomy Axial View Nerve Root Disc Spinal Cord Cerebral Spinal Fluid This presentation is licensed to the doctor on the screen. If you are participating in a presentation with another person or entity, you are participating in theft of intellectual property please leave 99 33
Apparent Cord Compression This presentation is licensed to the doctor on the screen. If you are participating in a presentation with another person or entity, you are participating in theft of intellectual property please leave 100 This presentation is licensed to the doctor on the screen. If you are participating in a presentation with another person or entity, you are participating in theft of intellectual property please leave 101 2 Views confirm abutment of the cord & rules out compression This presentation is licensed to the doctor on the screen. If you are participating in a presentation with another person or entity, you are participating in theft of intellectual property please leave 102 34
Cord Compression Courtesy of: All County MRI This presentation is licensed to the doctor on the screen. If you are participating in a presentation with another person or entity, you are participating in theft of intellectual property please leave 103 Central Herniation Patent Neural Canals Neural Canals? 105 35
Is this cord abutment or cord compression? Courtes y of: All County MRI This presentation is licensed to the doctor on the screen. If you are participating in a presentation with another person or entity, you are participating in theft of intellectual property please leave 106 Is this cord abutment or cord compression? Neither It is a radiculopathy as the cauda equina is compressed Cord Ends Courtesy of: All County MRI This presentation is licensed to the doctor on the screen. If you are participating in a presentation with another person or entity, you are participating in theft of intellectual property please leave 107 Structural, Mechanical and Functional assessment of the Human Spine A primary care perspective on biomechanical back pain 36
Spinal Distortion Spinal distortion creates abnormal loading of the joints, ligaments and muscles Over time this produces chronic pain, tissue failure and degeneration Only spine rehabilitation can restore the normal balance and function to the spine And correct the cause of pain, dysfunction and degeneration Surrounding musculature is a response to the underlying biomechanical problem How the Spinal Analysis System Works A/P and Lateral xrays are placed on an electromagnetic grid. In most difficult cases, full spine assessment is required. The architecture of each vertebra is entered into the computer by recording specific (x,y) coordinates of each vertebra Data Processing: Structural Analysis The (x,y) coordinates of each vertebra are used to calculate the spinal geometry. Measurements include: The shape of the vertebra The relative rotation of each vertebra The anterior and posterior disc heights The disc angles Lateral bending of the spine The shape of the lateral curves of the spine 37
Mechanical and Loading Analysis of the Spine Specific measurements are combined to assess the balance and loading of the spine The patient findings are compared to an optimum reference spine for each spinal region The optimum reference geometry was developed from a database of 100,000 x-rays Optimized does not mean normal it means biomechanically balanced Reference Patient Quantitative Scale of Severity The patient geometry is compared to the reference spine to determine biomechanical severity This gives us an objective and individualized measurement Biomechanical Severity Ratings Each category of severity represents one standard deviation away from the geometry of the reference The results of treatment are evaluated quantitatively and qualitatively The severity categories are Minimum Mild Moderate Severe Very severe 38
Mechanical Organization of the Spine: Vertebral Body Rotation In the A/P plane the alignment and rotational position of each vertebra is illustrated graphically and compared to an optimum spine. This analysis identifies specific vertebra for adjusting Mechanical Organization of the Spine: Stress Line/Lateral Bending In the A/P plane lateral bending of the spine is illustrated graphically and compared to a spine in ideal compensation The global balance of the spine is determined In combination the lateral bending analysis and the vertebral body rotation analysis identifies specific spinal failures Functional Analysis Functional analysis of the cervical spine is performed by measuring the range of motion for each motion segment. 39
Cervical Functional Analysis Identifies specific motion segments that are functioning improperly and determines appropriate adjustment vectors to correct function Adjusting Cervical Spine from Functional Analysis The functional analysis determines specific vertebra and specific direction to adjust cervical vertebra Additional Functional Analysis The following functional analyses are important to the whole picture, not just stationary films. [Important in failed back surgery and scoliosis] Cervical flexion / extension Cervical lateral bending Lumbar flexion / extension Lumbar lateral bending 40
Exercise Program A specific exercise program can be prescribed based on the patient spinal distortion The exercises will strengthen specific weak muscles and help return the spine to normal compensation Complete Patient Treatment Analysis The complete biomechanical analysis is summarized for the doctor to use at each treatment session The doctor marks the specific vertebra that will be adjusted and indicates in which direction for the adjustment With this information the doctor can give each patient specific treatment to rehabilitate the spine Most exercises are unilateral based on spinal configuration. Bilateral exercises are generally ineffective. Advanced Spinal Analysis Functions The Spinal Analysis Software makes over 500 measurements of the spine These measurements can be exported to Alpha4 database program for statistical and clinical research. [publishing as we speak] Initial and secondary x-rays studies can be compared and program will calculate geometric and loading changes 41
Spine Rehabilitation Program The spine rehabilitation program includes Computer analysis of the complete spine Specific spinal adjusting including Drop table technique Flexion distraction technique Multiple impulsing instrument technique Functional lateral bending and instrument technique Support therapies and exercise Medical management medication (acute), injection therapy. Results Using the Spinal Analysis System and Rehabilitation Techniques In a study of 580 patients, patients reported initial pain as SEVERE and after 10 treatments patients reported pain as MINIMUM Spine Rehabilitation Technique The rehabilitation procedures includes patient assessment based on computer modeling and xray data analysis spinal adjusting using specific adjusting tables with drop pieces Mechanical impulse instruments and hands on Traction Physical therapy and Specific exercises (unilateral typically) Balance and proprioceptive techniques at home Yoga 42
Computer Modeling A structural engineering approach to measure and analyze the geometry, mechanical organization and function of the spine and pelvis Rehabilitation to promote healing and decrease pain The analysis identifies specific locations for spinal adjusting to align and balance the spine. Bill Owens / Ryan Ludwig 1580 Elmwood Ave E1 Rochester NY 585-402-7996 716-228-3847 716-316-1053 drowens@teachdoctors.com This presentation is licensed to Dr. Mark Studin. If you are participating in a presentation with 128 129 43
The Human Body Is made of three basic systems Mechanical (skeletal/ligament/muscular) Chemical (blood vascular/cellular and glandular system) Neurological, electro-magnetic (central and peripheral nervous system) Each system is functionally organized and coordinated to interact with each other to the highest level of efficiency Coordination of these systems meets the needs of the internal and external environments within the limits of each system. The Human Body as a Machine The Mechanical System The spine is a multi-component mechanical system that is genetically designed to be functionally organized to provide strength and flexibility. These properties are dependent on the integrity of the ligament system Like a machine, each component interacts with each other so that for every action there is a predictable combination of related interactions When the spinal system is injured it rebalances using a combination of related interactions Rebalancing the spinal system is called compensation. Compensation at first is organized and over time becomes disorganized. Ligaments are elastic materials that primarily transmit tensile (pulling) forces. Elastic materials when subjected to tensile forces elongate and store energy. When the tension is removed the stored energy is released and the material returns (recoils) to its original shape. Elasticity of the ligament system maintains the mechanical organization (neutral joint alignment) of the spinal system When the spinal system becomes misaligned there is stored energy in multiple ligaments pulling the spine toward neutral alignment Elastic Materials 44
Righting Reflexes Control Spatial Orientation of Spine The upright neutral posture is maintained by the righting reflexes which include Visual processing Auditory processing and Proprioceptive processing In combination these sensory impulses are processed by the central nervous system to keep the eyes level in a perpendicular relationship with gravity i.e., looking forward to the horizon Balance is maintained at a minimum energy state when the skeletal system is optimum and vertical and the joints are aligned in a neutral position The minimum energy state is the least amount of muscle effort and ligament loading needed to maintain a neutral balanced position. Regional and Global Balance Regional and global balance of the spinal system is maintained by two inherent mechanisms 1) regional muscle tension and 2) off-setting of body masses These two actions produce equal and opposite torques around key pivot points Global balanced is maintained by 1) and 2) through a central pivot within the pelvis at approximately S2, the center of the sacro-iliac joint These same mechanisms are active during normal activities and during reactive compensation to balance the spinal system. Spinal Injury and Compensation The spinal system is frequently injured from the external environment including accidents, sports and day to day activities. When the spinal (mechanical) system is injured and not corrected it produces Altered spinal geometry (global imbalance) Abnormal joint loading, (loss of normal ranges of motion) Decreased functional efficiency (muscle and ligament strain/sprain) That over time with gravity deteriorates the mechanical system (degeneration) And causes tissue and joint dysfunction (activating pain receptors) Injury to the spinal system can be evaluated by measuring the mechanical organization of the spine. This can be performed from normal x-ray views. 45
Optimum Spine Geometry: Frontal Plane Viewing the spine from the back L R The optimum spine demonstrates the following geometry in the frontal plane Spine is vertical Pelvis level Shoulders level Head level Eye line level Balanced and symmetrical. Optimum Spine Geometry: Sagittal Plane Optimum Geometry and Alignment Produces Optimum Joint Function In the sagittal plane there are four reciprocating curves.three are functional curves Cervical Thoracic Lumbar One is a static curve Sacral The head is positioned over the center of the pelvis The spine is balanced front to back. Spinal Compensation When the spinal system gets injured and optimum balance is disturbed it predictably rebalances or compensates. Compensation is controlled by the righting reflexes. The primary mechanism of compensation is directly related to the combined motions of gait. Gait includes the coupled motions of torso rotation and pelvic rotation. These motions are inseparable Compensation is a 3D adaptation of the spine and pelvis. When the cervical curve has a flexion injury lumbar extension is part of the compensatory reaction Compensation continues until mass displacements and muscle activation achieves balance Over time compensation proceeds from organized to disorganized due to the severity of injury, repeated injury and from chronic destabilization due to unbalanced forces. 46
The Optimum Spine in a Position of Rotational Compensation The x-ray image is altered The frontal plane geometry of the optimum spine projects an altered image on x-ray when the spine has rotational compensation This is due to rotation of the torso in relationship to the x-ray central beam and partial projection of the sagittal curves. The torso of an injured/compensated spine rotates in the range of 4-12 Projected Regional and Global Geometry of the Optimum Spine due to Torso Rotation On x-ray the effects of right torso rotation produces a projected image of a balanced scoliosis L Neutral Compensatory Torso Rotation Projected Frontal Plane This occurs as the sagittal plane spinal curves project into the frontal plane The x-ray image demonstrates organized regional and global distortion (reciprocating lateral bends) When the spine is in compensation this organized geometry provides an optimum reference for patient comparison Organized Geometry Due to Compensatory Torso Rotation On x-ray the compensatory spine demonstrates full geometric organization from left or right torso rotation There are reciprocating lateral bends in the (C,T,L) regions The vertebral body rotations (illustrated as horizontal bar graphs ) are All on one side Have increasing and decreasing amplitude within each spinal region The head is balanced over the sacrum The geometric organization is an indirect measure of the mechanical efficiency of the spine. Right torso rotation Left torso rotation 47
Biomechanical Findings of Organized Compensation Right Compensatory Pattern Associated with Right Torso Rotation and coupled motions of Gait L R Right inferior sacrum Right ilium rotated posterior (PI) Resulting in functional right short leg Left ilium rotated anterior (AS) Right lumbar convex curve with right vertebral body rotations Left thoracic convex curve with right vertebral body rotations Right cervical convex curve with right vertebral body rotations These geometric characteristics and physical findings are compared to the patient to assess spinal organization and to determine specific spinal adjustments. Patient Assessment Data points (x,y coordinates) representing the architecture of the vertebra are obtained from x-rays and transferred to a computer spinal model Measurements are combined into functional analyses that are reported in tabular and graphical formats. The patient findings are compared to the geomertry of a spine in ideal compensation Adjustment vectors are determined for specific misaligned vertebra to restore normal position and function. (X,Y) (X,Y) (X,Y) (X,Y) Computer Analysis Regional and global distortions of the patient spine are displayed from the xray analysis. (Solid black line) Bending Distortion This allows the doctor to see the patient spinal distortion and compare it to optimum compensation. (Dotted yellow line of reciprocating bending) In this example the cervical spine is bending to the left. It should be bending to the right. During the adjustment procedure the patient is positioned into right lateral bending. This brings the patient into normal balanced compensation. 48
Computer Analysis The vertebra body rotations of the patient spine are displayed from the x-ray analysis. (Solid black bar graphs) Vertebral Body Rotations The patient vertebral body rotations are compared to the organization of a spine in ideal compensation. (Hatched bar graphs) In this example L5 vertebral body should be rotated left L2 vertebral body should be rotated right These adjustments will begin to establish optimum mechanical efficiency. Chiropractic Is the study of the structure and function of the spine and the pathologies that result from abnormal alignment and loading Normal Spinal Injury and Spinal Compensation One of the most common distortions to the spinal system in a clinical setting is injury to the cervical spine. (Over 99% in sample of 5000 patients) This is due to a sudden impact or acceleration injury Ligament damage typically occurs to the inter and supra spinous ligaments at C4/C5 The cervical spine falls forward from the weight of the head The upper and lower portions of the curve are diminished The righting reflex is disturbed The spinal system rebalances (compensates) to a horizontal eyeline by Shifting body masses and contracting muscles Compensation decreases the functional efficiency of the spinal system The result is Abnormal joint loading that over time causes Chronic strain/sprain Chronic pain syndromes 49
Compensation: Static Equilibrium Achieved by Balance of Masses and Muscle Contraction With cervical injury center of gravity / mass of head moves forward Optimum T1 D2 The spinal system compensates 3D in the frontal plane and sagittal planes to achieve balance. This includes torso D1 rotation, pelvic rotation and Τc=FHxD1 lumbar extension The torso center of mass moves backwards ΤT=FTxD2 This results in an opposite torque around S2. Lumbar and pelvic extensors are deactivated and the spinal system is balanced. ΤT = Τc S2 This creates unbalanced torque at T1 and S2. Cervical, lumbar and pelvic extensors activated Pain Symptoms Common to Injured Cervical Curve Injury to C4/5 interspinous ligament Loss of cervical curve and head goes anterior Stretches splenius capitus and cervicus ms Pulls on origin and insertion causing pain Stretches levator scapula causing pain Normal curve Abnormal disc and joint loading 3D reactive compensation in the thoracic, lumbar and pelvic regions. Physical Sources of Pain The Structural Spinal Model The spinal model identifies abnormal alignment that produces abnormal structural loading These variables produce pain from Chronic sprain / strain of the ligaments and muscles Abnormal joint pressure on the vertebra facet and stretching of the capsular ligament Irritation to the nerve root at the intervertebral foramina Irritation to the nerve root from disc bulging or herniation. 50
Rotational Misalignment Between Two Vertebra Mechanical Disruption of the Disc A rotational misalignment creates rotational shear stresses in the disc. Over time and in combination with other unbalanced forces the lamina of the annulus cracks and the nucleus begins to migrate outward The disc bulge moves in a direction from a high to a low pressure zone This is the beginning of disc failure. Clinical Goal Spinal Adjusting and Soft Tissue Rehabilitation The goal of clinical intervention is to introduce specific physical forces (spinal adjustments) that three dimensionally rehabilitate the spinal system toward organized compensation This includes correcting rotational misalignments, abnormal lateral bends and abnormal sagittal curves As the spine organizes it equalizes joint loading, disc pressure and relieves chronic stress and strain of the ligamants and muscles It diminishes the functional component of stenosis Support therapies are included to promote tissue healing, diminish pain and strengthen specific muscle groups Adjusting the Patient with Specific Cervical Adjustment Vector Flexion fixation: Superior to Inferior correction vector Vertebra rotates into extension Extension fixation: Inferior to superior correction vector Vertebra rotates into flexion 51
Spinal Analysis Clinical Application A global match of the patient geometry to the ideal compensatory pattern is determined in the frontal plane Abnormal vertebral body rotations are identified C4, C5, T2, T7, T9, L4, L5 Abnormal lateral bends are identified (cervical region) PI L Pelvic distortion is determined AI Sacrum (L), PI (L). Clinical Intervention Specific vectors (force and direction) are applied to the spinal system Patients are adjusted using a combination of the following procedures * Drop table; cervical, pelvic, lumbar, thoracic Flexion distraction Instrument adjusting with lateral flexion Instrument adjusting with flexion distraction Cervical instrument adjusting Extremity adjusting. *This is a system of analysis and is not technique specific Clinical Example Male 69 Acute on Chronic LBP 50 years duration Left compensatory pattern Severely unbalanced left Cervical curve rated severe Abnormal compensation C,T,L Sacrum AI (L) Pelvis AS (R) Rotational misalignments C3,C4, T1,T2,T8,T11,L1,L4 Brazelton 52
Adjusting C5 To correct cervical curve Multiple Impulsing Instrument Adjusting Sacrum sacro-tuberous ligament Rotate sacrum clockwise Drop Table Adjusting Right AS Pelvis Rotate right ilium posterior 53
Drop Table Adjusting L4, L1, T11 rotating vertebra body to left Flexion Distraction Full Spine Stretching ligaments and muscles disc decompression Adjusting Lumbar vertebra with lateral flexion and impulsing Dynamic adjusting Improve normal coupling of rotation and lateral bending 54
Flexion Distraction with impulsing Mobilizing T12- T9 Improve segment range of motion and alignment Flexion Distraction with impulsing bilateral T4-T1 Improve segment range of motion and alignment Flexion Distraction Full Spine Stretching ligaments and muscles disc decompression 55
Adjusting Occiput with multiple impulsing SI Flexion Fixation Adjusting Cervical spine C4 IS with multiple impulsing. Extension fixation Adjusting Cervical C6,C7 SI with multiple impulsing. Flexion fixation 56
Adjusting T1, T2 Vertebral body to the right Turn head right to begin right vertebra body rotation Clinical Outcomes Using the Spinal Model Random Sample of 580 Patients The spinal model has been used clinically for 25 years helping over 10,000 patients recover from pain and dysfunction On average patients presented to the doctor rating their pain as SEVERE Pain requires modification of activity and limits activity After ten treatments the majority of patients rated their pain as MILD Pain is annoying sometimes but absent with activity The majority of patients also reported 90% improvement in ten treatments Patients with surgical failure and disc herniation had longer profiles for recovery but results were similar 57