MRI annular tear

Why do annular tears hurt so much?

Annular tears are seen on MRI scans of the lumbar spine.  They appear as tiny white dots in the back of the disk.  The radiologist will call annular tears “posterior high intensity zone lesions.”  In addition to severe low back pain, they are a source of confusion, concern, and unanswered questions about their significance and treatment.

Here is a short video where I review the MRI scan of someone with an annular tear of the L5-S1 disc

Here is a short description of his symptoms in his own words:

  • prior to August 2016 I was doing a lot of recreational running

  • At the end of July 2016 I fell while biking, felt a sharp pain immediate after fall but everything seemed OK after two days.

  • early Dec 2016, moved a piece of furniture and felt sharp pain in back – obviously this caused severe injury of the disc

  • mid Dec 2016 – got my MRI scan

  • end Dec 2016 – new sharp pain bottom of pelvis. Obviously I re-injured the disk again and made things worse. Back pain lasted for 2-3 weeks before slowly improving.

  • Jan 2017 – back pain started to improve and I was able to do some back pain excercises

  • beginning Feb 2017 – started to feel numbness (I assume it was because I took a business trip, more sitting, traveling with bag, airports… that caused things worse)

  • last 7 days I was very careful and things have improved slowly.  my tensor latae fasciae spasm continues.  I cannot run.

  • Through all this time I felt almost no leg pain. I had some occasional pain in the toes which I was not sure if originates from spine (not severe, one day episodes). Numbness scared me but it was not very severe.

What I ask myself all the time is:

  • I can hear popping in my back with certain moves (for example changing position while sleeping from one hip to another or with some leg movements). Does this come from the disc tear or herniation? It is painless.  I have feeling it comes from the back.

  • What is my prognosis? As most people would, I would like to avoid surgery but do not want to make things worse. I have no problems with pain at the moment but would like to return to some sport activities in the future. I learned that healing should take at least 6 months. Is this possible without surgery in my case?

  • What would be your recommendation in my case?

And here is his MRI scan

In this patient’s case, I recommend that he continue with non-operative care.  His pain has already started to decrease and he is still active.  We would reasonably expect that with time this should heald and he should feel like he has a normal spine.

Here are some other examples of MRI scans of the spine with an annular tear

In this first example of an annular tear in the L4-5 disk in a 22 year old female, there is a tiny white dot in the back of the disk where the fibers of the annulus are torn.

annular tear L4.5

In this second example, in the L5/S1 disk, the annular tear is centrally located and is more apparent on the axial view.  These are T2 sequences, and the computer algorithm that creates the T2 images from the raw MRI scan data makes fluid look bright white.  You will notice that the cerebrospinal fluid appears bright white.  CSF is a filtrate of plasma.  Since the CSF appears white, we conclude that the annular tear is probably a gap in the fibers of the annulus fibrosis that is fluid filled.

Most patients with annular tears have similar histories.  They report that they were lifting a heavy object, moving awkwardly, or twisting at the same time.  Suddenly they felt like they were shot or stabbed in the back.  They are often in a tremendous amount of pain.  Since they do not have a large disk herniation on the MRI scan, these patients are often described as having “pain out of proportion to expectations”.  This is a little unfair because in my experience, annular tears seem to be very slow to heal and they can be a cause of long lasting and disabling back pain.

Why?

I believe that annular tears represent a partial disk herniation.  The annulus fibrosis that surrounds the intervertebral disk is made up of many layers.  When an annular tear occurs, the central portion of the disk, the nucleus pulposus, herniates through most, but not all of the layers of the annulus.  A fragment of disk material is stuck in the middle of the tear and it is surrounded by fluid and inflammation.

The nucleus of the intervertebral disk is made of a protein core consisting of proteoglycans.  These long, branched proteins are relatively acidic, viscous, and naturally slippery.  As such, they are designed to prevent adhesions and scar tissue formation since they are natural shock absorbers.  When they get trapped in between the fibers of the annulus, they prevent the collagen fibers in the annulus from healing.  As a result, there is a permanent weak spot in the fibers of the annulus which is a constant source of pain.

Whats the best treatment for annular tears?

A number of times in my surgical career I have operated on patients with broad based disk bulges, an annular tear, and both back and leg pain.  When I make a small incision in the outer covering of the disk, a fragment of disk material squeezes out as if it were under pressure.  Typically, there is a small cavity where the annular tear is located that is filled with fragments of disk material.  The patient’s leg pain gets better after the operation because of the microsurgical decompression.  Interestingly, the patient’s back pain improves rapidly after the operation because without the fragment of the disk stuck in the tear the annulus can finally heal.

I’ve arrived at the conclusion that for some patients with relentless back pain related to an annular tear it makes more sense to have a microsurgical decompression with an exploration of the annular tear and a removal of the fragment of the disk that is just underneath the surface.  This seems to kick start the healing process and let them get on with their lives faster. My favorite technique for treating annular tears is now an endoscopic technique. Here is a video of how I do that operation:

Other patients, however, will get better with non-operative treatment.  With time, and and a gradual return to normal activities, their back starts to settle down and they have less and less pain.

The other option is an injection into the disk space of either platelet rich plasma or adipose derived stem cells.  There is good evidence to suggest that PRP injections are effective in shortening the time that annular tears hurt.  Stem cell injections are also a really exciting area of active clinical research and there is some early evidence to suggest that stem cells injected directly into the disc may help.  At the moment, the best evidence suggests that either a microscopic decompression with a removal of the trapped fragments or a platelet rich plasma injection is the best treatment if non operative treatment simply isn’t working.

What kind of options do you have if you have an annular tear?

Many annular tears will get better with non operative treatment, but some don’t.  If you’ve had pain for more then 6 weeks and you have already had an MRI scan of the spine, I can review your MRI scan for you and tell you what options you have.   To get started with this process click here: MRI review service

reverse hyper

Spondylolisthesis: can it be reversed?

What is spondylolisthesis?

Spondylolisthesis is a common cause of back and leg pain.  The most common question that I get asked immediately after I tell someone that they have a “spondy”, is a variation of….

  • “Can it be fixed without surgery?”
  • “Will it go back into place if I do a lot of back bends?”
  • “Can I reverse my spondylolisthesis with physical therapy?”

Let’s look deeper into questions surrounding the idea of reversing spondylolisthesis.  The word spondylolisthesis has two words with Latin roots.  “Spondy” is latin for spine, and “listhesis” is latin for slipping.  In this condition one vertebral body slips forward with respect to the one immediately underneath it.  The two most common locations of a spondylolisthesis are L4-5 and L5-S1.

Case Examples

Here is an X-ray of the spine with a spondylolisthesis at the L4-5 level.  In this case, this a grade 1 slip — L4 has slipped about 20% of the length of the L5 vertebral body.

 

L4.5 grade 1 spondy lateral preop

This condition has a couple of different causes.  The most common cause of a spondylolisthesis is degenerative disk disease caused by the normal aging process.

The other most common cause is repeated hyperextension during sports as an adolescent when the spine can develop a stress fracture called a “spondylolysis”.  This typically causes back pain during adolescence and may later progress to a spondylolisthesis.

Why do some people develop a spondylolisthesis?

The risk factors for developing a spondylolisthesis include:

  • female sex
  • hyper flexibility
  • increased lumbar lordosis
  • according to Readysteadygymnastics.co.uk, sports such as football and gymnastics that involve hyperextensions of the spine.

I’ve written a more detailed article about there natural history and treatment of spondylolisthesis here: https://sohrabgolloglymd.com/spondylolisthesis/

Reversing Spondylolisthesis: is it possible?

Since the surgical treatment for fixing a spondylolisthesis typically involves a single level fusion of the spine, most people want to know about their alternatives.  Their two most common concerns / desires are as follows:

1. They are reluctant to jump right into a fusion

2. They are very interested in alternatives.

I’m a cross fitter.  I love to surf.  If I had a spondy, I’d want to wait for as long as I could before I got a fusion.  I’d also do all the PT and non-operative treatment that I could.  I checked the crossfit boards and found this thread on spondylolisthesis:

“I am an active duty Army officer diagnosed with Spondylolisthesis, L5 shifted approx 30-35% forward (anterior) over S1. I most likely incurred my injury during my early years in the military. To my knowledge, the degree of shift has not changed over the years. I have been crossfitting for 4 years, and my back issues have fluctuated over the years in terms of severity and impact to my workouts. However, it has not impacted my ability to do my job or deploy. At this time, I am mid way through my 8th deployment, and I’m trying to proactively minimze my syptoms as much as possible on a daily basis.

I avoid heavy deadlifts and GHDs, but pretty much do every thing else as Rx’d. My symptoms sometimes include back soreness, which gets too severe to exercise about 1-2 times a year for a few days. I do my best to listen to my body and reduce my activity when this happens.”

The recommendations that follow this post include an excellent discussion about the pros and cons of reverse hyper-extension exercises with the lumbar spine, inversion therapy, and avoiding certain heavy lifts — like deadlift and squats.  If you want to read the entire thread, follow this link — http://board.crossfit.com/showthread.php?t=61980

This is a picture of rogue’s reverse hyper extension machine for the lumbar spine:

reversing spondylolisthesis

http://www.roguefitness.com/rogue-reverse-hyper-2

What should you do next?

Here’s my opinion.  FORM is critically important if you have a spondylolisthesis.  If you think about it, a spondylolisthesis is probably a normal response to an abnormal movement pattern.  Most of these patients trend towards the hyper flexible part of the athletic spectrum.  Their joint laxity and movement patterns probably put increased stress on the intervertebral disk during physical exercise.  Most likely, this is a shear type of force where the trunk is trying to slide anteriorly with respect to the pelvis.  If the core is strong and the trunk is solidly anchored to the pelvis, this shear force should be offset by the stabilizing strength of the glutes and spina erecta musculature.

If you workout with PERFECT FORM, you should theoretically neutralize the forces trying to push your slipping vertebral body anteriorly.  If you strengthen the muscles that neutralize these forces, you should be able to work out with risking progression while also stabilizing your core.   Do this for long enough and you’ll have a bullet proof core and less pain.

My favorite book on this subject is Kelly Starrett’s Becoming a Supple Leopard, but you can always start with https://www.mobilitywod.com.

Neutral Spine.  Neutral Spine.  Neutral Spine.  That’s the mantra you should be repeating to yourself every time you lace up your shoes if you have a spondylolisthesis.

What about surgery?

Finally, a word about surgical treatment.  As the field of microscopic spine surgery has evolved, I have become much more willing to perform an microscopic decompression of the nerve roots affected by the spondylolisthesis, especially if someone has leg pain on only one side.

In my opinion, correct body mechanics has just as much ability to stabilize a spondylolisthesis as a fusion does, and if I needed an operation because I had relentless leg pain due to a spongy, I’d have a microscopic decompression and be absolutely meticulous about my rehab.

If you’ve got questions about what to do about your spondylolisthesis and you’d like us to review your MRI scan, we’d be happy to just visit this page here to get started.

back-pain-and-strength-training

Back pain and strength training…. are free weights an answer?

Back pain and free weights?

I practice spine surgery in Monterey, California, which is home to the Naval Post Graduate School and the Defense Language Institute.  In the years that I’ve been in practice I’ve seen a lot of active duty soldiers rotate through Monterey for advanced degrees or language proficiency training.  They share similar histories.  They are fit, strong, and all of them have a lot of “mileage” on their backs.  Running around the desert with a heavy rucksack on, or jumping in and out of helicopters in the middle of the night is certain to cause back pain at some point.  Most of these soldiers report that they were fine while they were with their units in Afghanistan or Iraq and their back pain was manageable.  If anything, it was made better by staying active.  However, once they are crammed into a desk learning 40+ words of a foreign language a day, their backs start to ache.

Back pain and military service

Not surprisingly, all of their MRI scans are abnormal with degenerative changes typical of someone who is used to carrying a heavy rucksack and jumping in and out of a helicopter for a living.  I’ve help enough of them rehabilitate themselves that I know they are able to return to active duty, including paratrooper and flight duty, in spite of relatively significant degenerative changes and disk bulges.  I have also performed enough microscopic decompression surgery on active duty soldiers to know that after a well done microdiscectomy they will pass their fit for duty physicals and can return to service.  However, if they have a fusion, their military careers are basically over.

Since this is a patient population that prides itself on strength, endurance, and toughness, I get asked a lot of questions about strength training for both non-operative and post-operative rehabilitation.  My response is always encouraging, with a caveat.  Just like your mother said, POSTURE is IMPORTANT.  In my opinion, the following article does a great job of summarizing the arguments in favor of strength training as a way of avoiding back pain — especially the counter-intuitive exercises like deadlifting and squatting.

https://pjmedia.com/lifestyle/2016/11/30/back-pain-and-back-strength/

back-pain-and-strength-training

I caution these patients that this is one of those times where form truly is more important than function.  It’s better to lift correctly than to lift heavily, especially if your back is already injured.  I also believe that Kelly Starrett — of mobilityWOD and Becoming a Supple Leopard fame — is probably the most articulate advocate for proper form.

Is weight lifting safe if you have back pain?

The clear answer is Yes.  As long as it is done correctly.  If you are getting back into the gym after an episode of low back pain, or if you are rehabilitating after surgery, get some help.  Find someone who is really knowledgeable, like a strength and conditioning coach or a really good physical therapist.  Make sure your form is perfect.  Start light, and work your way up.  Done properly, even deadlifts and squats can help reduce back pain.

ligamentum-flavum-hypertrophy-disk-bulge

Lateral lumbar surgery for the treatment of degenerative lumbar scoliosis and stenosis

Decompression and stabilization of the degenerative lumbar spine using a minimally invasive extreme lateral approach: the XLIF experience

Degenerative scoliosis of the lumbar spine is a consequence of the natural deterioration of the intervertebral disks with age.  The biomechanical integrity of the disk declines with age.  Wear and tear on the disc causes oxidative damage to the proteins that make up the core of the disk.  Over time, the joint becomes unstable and the vertebral bodies start to slip out of alignment.  Some patients will develop degenerative disease of the lumbar spine without scoliosis, while others will develop significant scoliotic and kyphotic deformities.  The reason for this is unclear: why do some people get degenerative disease without scoliosis, while some people get severe scoliosis.  I presume that it may have something to do with posture, handedness, and asymmetrical forces acting on the spine over years and years of activities of daily living.

The symptoms of degenerative scoliosis

Patients with degenerative scoliosis of the lumbar spine typically come to clinic with two complaints: (i) back pain and (ii) leg pain.  In conjunction with their leg pain, they often have difficulty walking.  Usually, their walking endurance has declined in recent years.  Many of these patients will report that after walking a short distance they have to stop, sit down, lean forward.  After a few minutes their legs feel refreshed and they are able to get up and walk again.  Declining walking endurance is a symptom of neurogenic claudication.  Claudication is a word that means cramping pain.  In this case, the cramping pain is caused by spinal stenosis squeezing the nerve roots.  The blood supply to the nerve roots in the lumbar spine is decreased by increased disk bulging associated with weight bearing.  Forward flexion of the spine alleviates the pressure and restores the blood flow to the neural elements.  Here are two slides from a famous pathological collection of images that demonstrate the changes that occur — disk bulging and ligamentum flavum hypertrophy — that cause stenosis.  The first picture is from a young male, the second from someone in their 60’s or 70’s.

 

normal lumbar spineligamentum-flavum-hypertrophy-disk-bulge

Back pain and degenerative scoliosis

The back pain associated with degenerative scoliosis of the spine is a mechanical ache.  Patients typically feel worse at the end of the day or after spending a long time on their feet.  The pain is typically in the midline but tends to radiate around to the hip in a “belt like” distribution, and they often have bilateral deep seated buttock pain.
degenerative-scoliosislateral-xray-degenerative-scoliosisdegenerative-kyphoscoliosis

XRAY and MRI findings in degenerative scoliosis

Here are several plain xrays and the MRI scan of a 60 year old physically active male with degenerative kyphoscoliosis of the lumbar spine and associated spinal stenosis.  The plain xrays are taken in the standing position and they demonstrate that the disks have deteriorated and the vertebral bodies have started to slip out of alignment with respect to each other.  There is an abnormal side to side curvature of the spine.  This is the scoliotic component of degenerative diseass.  The anterior aspect of the lumbar spine has collapsed resulting in a flat or rounded low back.  This is the kyphotic component of degenerative disease.

Nerve root compression caused by degenerative scoliosis

The MRI scan demonstrates that at several levels there is significant compression of the space available for the nerve roots.  The most frequent area of compression is in the lateral recess areas of the spinal canal and in the neuroforamen where the nerve root is particularly vulnerable to compression.  Here several key images and the radiologist’s report of this patient’s pre-operative MRI scan:

pre op para saggital neuroforamenpre op axial L3.4

 

The Radiologist’s Report

MR LUMBAR SPINE WITHOUT CONTRAST
CLINICAL HISTORY: Sciatica pain and weakness with numbness left leg.
COMPARISONS: No previous.
TECHNIQUE: Sagittal T1, sagittal STIR T2, high spatial resolution sagittally acquired 3D T2 SPACE which was also reformatted as axial T2 images, and axial Tl images were acquired on 1.5T Siemens Magnetom.
CONTRAST: Noncontrast exam.

FINDINGS:

Lower T-spine: Visualized portions of the lower T-spine from T9 to T12 are relatively normal in appearance for age without canal or foraminal stenosis and without any distal cord or conus imprint or compression. Posterior disc protrusions are seen at T6-7, T7-8, T8-9 and T9-10 levels. While these indent the anterior CSF space no frank cord compression is appreciated.

Alignment: Mild focal dextroscoliosis of lumbar spine at L2-L3 levels is present. Degenerative translational spondylolisthesis to the right of L2 and L3 with respect to Ll and L4 is present. In addition L3 shows anterolisthesis with respect to L2 and L4.

Anatomy: Nonnal vertebral anatomy is present in that the last rib bearing vertebral body is presumed to be T12 and 5 lumbar type vertebral bodies are present. The tip of the conus is seen at the T12-L1 level.

Lumbar discs:

T12-L1: Normal for age disc level.

L1-2: Moderate degenerative disc disease is present. Broad posterior disc osteophytic ridging indents the anterior margin of the central CSF space without central canal stenosis and causes mild right foraminal narrowing and moderate left foraminal narrowing but no definite nerve root abutment, displacement or impingement is seen at this level.

L2-3: Severe degenerative disc disease is present especially on the left with obliteration of the disc space and endplate irregularities. Broad posterior osteophytic ridging related to the anterolisthesis of L3, causes mild central canal narrowing but more importantly causes moderately severe left neural foraminal narrowing, moderate left lateral recess encroachment, mild right lateral recess narrowing and mild/moderate right neural foraminal narrowing. There may be some nerve root abutment within the lateral recesses but no definite nerve root impingement is seen at this level.

L3-4: Severe degenerative disc disease is present due to Grade I, borderline Grade II anterolisthesis of L3. Osteophytic ridging in conjunction with facet arthrosis and hypertrophy results in moderate central canal stenosis with central nerve root abutment. More importantly there is severe bilateral neural foraminal narrowing with nerve root impingement suggested in both neural foramina.

L4-5: Mild degenerative disc disease with 3-4 nun broad posterior disc protrusion centrally. This effaces the anterior epidural fat and minimally indents the anterior margin ofthe central CSF space without significant central canal stenosis. There is mild bilateral lateral recess encroachment with nerve root abutment but no definite displacement or impingement. Neural foramina are moderately narrowed on the left and moderately severely narrowed on the right with some nerve root abutment within the foramina but no definite impingement.

L5-S1: Moderate to moderately severe degenerative disc disease is present with large right anterior and far right lateral osteophytic ridging. Broad posterior disc osteophytic ridging effaces the epidural fat but no central canal stenosis is seen. Broad posterior disc osteophytic ridging does abut descending nerve roots within the lateral recesses bilaterally. The right neural foramen is severely narrowed with nerve root abutment if not imprint. The left neural foramen is more patent without evidence of nerve root abutment.

Facet Joints: Facet joints demonstrate asymmetical arthrosis at L1-2 and L2-3. Facet arthrosis is relatively severe on the right at L3-4. Mild arthrosis right worse than left is seen at L4-5 and L5-S1.

Paraspinous spaces and soft tissues: Within normal limits. STIR images show disc dehydration L1 to S1 levels and there is marrow edema surrounding the severe degenerative disc disease changes at L3-4 consistent with active ongoing degenerative disc disease superimposed on chronic degenerative disc changes .

REPORT SUMMARY:
1. Grade I to borderline Grade II anterolisthesis of L3 with respect to L2 and L4 with severe degenerative disc disease at L2-3 and L3-4levels and severe foraminal narrowing at L3-4 with apparent nerve root impingement.  Serpiginous nerve roots within the lumbar levels are secondary evidence of nerve root impingement.
2. Relatively severe anterior and far right lateral osteophytic ridging at L5-S 1 as well as broad posterior disc osteophytic ridging L5-S1 that abuts nerve roots within the lateral recesses and appears to cause some imprint of the nerve root within the right neural foramen at L5-S1.

Interpreting the MRI report

These are the images from the MRI scan that demonstrate spinal stenosis.  The axial images are often the most helpful, and I explain to patients that the normal spinal canal should look a little bit like the Texas Longhorn’s logo.  You should be able to clearly trace the path of the neuroforamen along the length of the longhorn.  In stenosis, the area at the base of the horn become obliterated by arthritis from the facet joint and disk space bulging.

neuroforamen-minimal-stenosisaxial-MRI-neuroforamenMRI-severe-stenosissevere-stenosis-L4.5
The extreme lateral approach for degenerative scoliosis

Approximately 10 years ago, a very innovative surgeon in Sao Paulo, Brazil, developed a novel technique for decompressing and stabilizing degenerative disease of the lumbar spine.  He recognized that there is a surgical corridor to the spine through the side of the patient’s trunk — called the extreme lateral approach.  This approach has many advantages over the standard posterior midline approach to the spine, and one or two distinct disadvantages.  Via the extreme lateral approach, the intervertebral disks of the lumbar spine can accessed, and with the use of specially designed devices, the height of the disk spaces can be restored to their pre-degenerative height and alignment.  A company in San Diego, California, known as NuVasive has been instrumental in developing the specialized tools and implants used during this surgery.

The advantages of the XLIF approach

The advantages of the extreme lateral approach include the fact that the surgical approach (i) does not disrupt the large muscles of the back (ii) is possible with minimal blood loss (iii) allows for the insertion of intervertebral spacers that rest on a strong part of the bone called the apophyseal ring that provides an excellent platform for restoration of disk height and alignment.  The disadvantages of this approach are related to the fact that intervertebral spacers must be carefully inserted through the psoas muscle without damaging a complex of nerves called the lumbar plexus.  The psoas muscle is the major muscle that flexes the hip joint.  There are techniques and special surgical tools available that make it possible to dilate surgical channels through the substance of the posas muscle with minimal bleeding, but some degree of posas irritation with thigh pain, numbness, and weakness in hip flexion is expected after the surgical approach.  These symptoms seem to be transient and most patients report that their strength returns rapidly and any pain or weakness is minimal within a few weeks of surgery.

The lumbar plexus can get in the way

The lumbar plexus is a dense collection of nerves that run through the substance of the psoas muscle.  Nerve fibers do not tolerate much surgical manipulation so the key to this procedure is knowing where the nerves are so that they can be avoided.  Nuvasive has pioneered a very innovative tool called Neurovision that makes it possible to stimulate the nerves with a tiny ball tip electrode so that the course of the nerves in the posas muscle can be visualized without being seen and therefore avoided.  The operation is technically challenging but has great potential to treat this problem with limited tissue disruption.

Surgery in this case for degenerative scoliosis

This patient was operated upon in the lateral position.  Lying on his side, a 2 inch incision between the ribs and pelvis was made, and with careful surgical dissection, working channels were established in line with three degenerative disks — L1/2, L2/3, and L3/4.  Prior to surgery these disks had basically completely collapsed, but during the course of surgery, 10mm high spacers made out of a biopolymer called polyetheretherketone (PEEK) were inserted into the degenerative disk spaces.  This process restores disk height, restores spinal alignment, and increases the amount of space for the nerve roots in the spinal canal.  On post-operative day #1, after a 1 night stay in the hospital, standing X-rays were taken of the spine and we also obtained a post-operative MRI scan.  These images demonstrate the improvement in spinal alignment, disk height, spinal canal and neuroforaminal volume.  In fact, the radiologist was kind enough to measure the the amount of improvement in the dimensions of the spinal canal.

 

preop lateral MRI lumbarpost op lateral lumbar MRI sagittalpre-op-axial-L3.4-with-localizerL34-minimal-stenosis

The radiologists report after the operation

POST OPERATIVE MRI REPORT

L1-L2:  Ligamentum flavum hypertrophy with degenerative facet change.  Mild narrowing of the left neural foramina.  The central canal measures 15 mm. There has been interval improvement in the degree of neural foraminal narrowing on the left.  The central canal is stable at this level.

L2-L3:  Ligamentum flavum hypertrophy and degenerative facet change.  There is moderate osseous narrowing of the bilateral neural foramina, the degree of neural foraminal narrowing improved when compared to the prior study.  The central canal measures 17 mm, this is also improved from 10 mm.

L3-L4:  Ligamentum flavum hypertrophy and degenerative facet change with moderate narrowing of both neural foramina.  The central canal measures 14mm.  There has been improvement in the degree of neural foraminal and central canal narrowing when compared to the prior study, with the central canal previously measuring 8 mm.

L4-L5:  Ligamentum flavum hypertrophy and degenerative facet change with a broad-based disc bulge.  There is moderate narrowing of the right greater than left neural foramina.  The overall appearance is stable.  The central canal is widely patent, measuring 12 mm.

This can be a minimally invasive operation

This surgical procedure for decompressing and stabilizing the lumbar spine is possible with relatively minimal blood loss, a short 1 or 2 day hospital stay, and a relatively quick recovery.  In published reports, the fusion rate is very favorable and in carefully selected patients it appears that it is possible to accomplish the goals of surgery — increasing space available for the nerve roots and realigning the spine — without resorting to supplemental posterior fixation using traditional pedicle screws.

degenerative-kyphoscoliosisAP-lumbar-post-oppreop lateral MRI lumbarpost op lateral lumbar MRI sagittal

After posting this link, the next patient that I treated in a similar fashion read this as part of his pre-operative preparation and his main question was as follows:

Dear Dr. Gollogly, I have read the material here and on your web page and have found it informative.

I have one question: What should I expect when I return home from the operation and hospital stay? Do I need to make any special accommodations at for sleeping, sitting, etc? You said I would be wearing a back brace of some sort. How will that limit my movement?

My response follows: After your operation you should not need to make any special accomodations for sleeping or sitting.  We will fit you in a lumbar brace that you fasten around your waist with velcro.  It looks like the sort of brace that you see the stockers at the supermarket wearing.  It supports your spine and prevents a little bit of movement, but it is not too restrictive.  It’s a soft brace, not a hard plastic shell.  You should try to avoid any kind of heavy lifting and sustained flexion (being bent over) of the lumbar spine for the first 6 weeks after surgery.  The brace helps to remind you to sit up straight, walk with good posture, and rather than bending over to pick things up off the ground, use your legs.

XLIF Youssef

spondy-lateral

Back pain in athletes

Low back pain in athletes

One of the more frequent reasons that a younger athletic patient, meaning anyone from the age of about 15 to 25, comes to see me in consultation is because they have severe activity related back pain that hasn’t responded to the usual treatments of rest, a couple of weeks of reduced activity, and over the counter anti-inflammatory pills. It’s a really challenging situation because in almost every case, the athlete can rest, rehabilitate, and get back to about 80% of their peak performance, but once they try to push it to become game ready, their pain returns.

 

Here’s a couple of actual examples of patient histories:

a 16 year old nationally ranked tennis player with plans to play Division 1 college tennis has been plagued by left sided back pain for the last 6 months. The pain is directly related to the number of overhead serves that he makes and to the number of sets that he plays. He has no pain at rest, no pain while cross-training, and no pain while playing at less than 80% of his full speed, hard hitting game. However, once he steps it up to match level play, after a few sets his back starts to seize up and he has had to withdraw from several tournaments.

a 17 year old competitive cross-country runner was cross training under the supervision of a strength and conditioning coach when she felt a sharp “pop” in her back while squatting with moderately heavy weights. Ever since, she has severe pain when sprinting, stair-climbing, or performing weighted lunges. The rest of the time she is basically normal. The injury happened over a year ago and in spite of rest, chiropractic massage, ice, and anti-inflammatories, she can’t sprint without her back seizing up.

I see similar histories up to about 25 years of age, so if this sounds familiar, keep reading.

Most of these patients have had plain X-rays of their spines before their visit, and many of them have had an MRI as well. Typically, these studies will demonstrate one of the following three conditions, in order of increasing severity:

1. a “stress reaction” in the pedicle of L5
2. spondylolysis or a “pars defect” of L5

or

3. spondylolisthesis at L5/S1

These findings are pretty common. For example, in a study of 19 competitive gymnasts attending a training camp that were selected basically at random and had MRI scans of their spine, spondylolysis was found in 3 of the 19 athletes, spondylolisthesis in 3 as well, and focal bone-marrow edema was found in both L3 pedicles in one gymnast. Since most of the patients are accomplished athletes to begin with, the usual prescription for six to eight weeks of physical therapy is rarely of much benefit. Most of the time they have already seen one or two trainers, conditioning coaches, or chiropractor-type practicioners before they come and see me, and they are usually pretty frustrated. Here are a couple of sample X-rays and MRI scans showing the findings that accompany them on their first visit.

These two slices of an MRI scan demonstrate a “stress reaction” in the pedicle of the vertebral body. The stress reaction shows up as white area in a part of the bone that normally has a darker appearance on MRI. This particular sequence of the MRI scan is formatted so that water shows up as a bright white signal and the presence of increased water content in this area is said to represent bony “edema”.
stress reaction in the pediclebilateral L5 bony edemaMRI pars defectL5 pedicle edema
Edema is defined as “a condition characterized by an excess of watery fluid collecting in the cavities or tissues of the body”, and we see edema in the bone underneath the cartilage of arthritic joints, surrounding fractures, and in bone that has been bruised by hard impacts. Here are a couple of examples of bony edema.

The presence of bony edema is definitely a pathologic finding. Something is wrong with the musculoskeletal system in the immediate area and the bone is not happy. In this case, this MRI scan belonged to a 16 year old male football player who was working out with a conditioning coach who was having him squat very deeply with pretty heavy weight — on the order of 1.5 times his body weight — and his pain seemed to be due to hyperextension of the spine at the bottom of the squat.

Here is an example of a spondylolysis or a “pars defect” of L5. In this case there is a physical break in bone across the pars inter-articularis. The break is usually described by the radiologist as a defect, a lysis, or a stress fracture. All of these terms are synonymous, and they all indicate that there is a physical gap in the bone. Occasionally I will get a patient who comes to the office in a bit of a panic after being told that he or she has a “fractured spine”, but this is probably a bit too strong of a phrase to describe this finding accurately. The classic X-ray finding of a spondylolysis is known as the “scotty dog” sign. This sign describes the manner in which the spondylolysis defect can look (to someone with a very healthy imagination) like the collar on a scotty dog on the oblique views of the limbo-sacral junction. While the gap can be seen on plain X-ray, often a CT or an MRI scan is needed to really confirm that it is there, because the X-ray can be a little bit unclear. The reason why the use of the word “fracture” is not terribly appropriate here is because this is typically not an acute break, the gap in the bone is often filled with fibrous tissue, and there is usually some degree of residual stability to the vertebral body. Sometimes there is edema surrounding the defect, and sometimes not. Typically, patients with more severe back pain tend to have relatively more edema, but this is not a perfect relationship.

lateral xray spondylolysisspondylolysis-obliquepars-interarticularisscotty-dog-parsspondylolysis-scotty-dogathletic-back-pain

Finally, here is a case of spondylolisthesis at L5/S1. In this case the to halves of the vertebral body have started to move apart and the spondylolysis defect is noticeably larger. The overall alignment of L5 with respect to S1 has shifted, and L5 has slipped anteriorly with respect to S1. This finding is more common in females who tend to have more supple ligaments and presumably more flexible intervertebral disks, and it is more common in patients with more vertically oriented L5/S1 disk spaces, presumably because there are greater forces acting to displace L5 on S1 in patients with more lumbar lordosis and vertically oriented sacral endplates.

Let’s imagine that all three of these patients have pain only with strenuous athletic activity. Why? My opinion is that area where the stress reaction, pars defect, or spondylolisthesis occurs is placed under some sort of tension or stress ONLY when the spine is moved to the limits of its range of motion under the heavy loads of torque, muscular contraction, and athletic movement. For example, it’s not hard to imagine why the lumbar spine would be stressed during the twisting, lunging, and hitting motions of these competitive tennis players in ways that are fundamentally different than the stress imposed by the more mundane activities of daily life.

tennis-spondylolisthesis

 

Will it heal? This seems to be the most frequent first-asked question once the diagnosis has been made, and the important thing that needs to be clarified what you meant by “healed”: less pain or a normal X-ray or MRI scan? When it comes to the actual findings on the X-rays or the MRI scan it’s hard to know for sure, but my opinion is that the stress reaction will probably subside and will not necessarily progress to a spondylolysis if the activity responsible for the pain is not a repetitive motion that the athlete plans to continue to perform. I think that once a spondylolysis has occurred, it is usually going to be a persistent defect and if there is any evidence of anterior displacement in the form of a spondylolisthesis bone certainly won’t bridge the gap or restore the alignment back to normal.

Should I use a bone stimulator? Unclear. Most patient’s will improve with some form of conservative treatment, so the gold standard supporting the use of a bone stimulator would be radiographic evidence of healing of the spondylolysis defect after treatment. As of 2013, there are no studies that have not been any published studies that have conclusively demonstrated that a bone stimulator results in radiographic healing in a large series of patients. In my practice, I leave the decision up to the athlete and the parents and to be perfectly frank, it usually comes down to a question of insurance coverage. If the family has good insurance and they are not terribly bothered about the cost, I have no problem recommending and prescribing a bone stimulator. However, it’s not something that I would push, especially if it was going to cause any financial hardship.

What about rehab? This is the most interesting part of the entire problem and the question that I think the most about. Here’s a short video on a competitive cross-fit athlete that successfully rehabilitated herself back to a very high level of functional movement after having an episode of back pain that appears to be due to a spondylolysis or spondylolisthesis.

 

I’ve been a big fan of Kelly Starrett for a number of years — mostly as a result of my own Crossfit experiences as a 40 year old + athlete, and I think he does an excellent job of explaining the body mechanics of a “stable” and “organized” spine and how this type of posture can reduce the stress and strains on the lumbar spine during functional movements. I’ve had a lot of good results with patients when I refer them to particular physical therapists who are skilled in coaching olympic weightlifters and who have a solid understanding of the protective effects of good posture and core strength and endurance. This is where I personally try to put most of my emphasis, but it’s hard to unlearn habits that work. For instance, in the case of the competitive tennis player who was case #1, his serve worked for him. He was able to achieve killer spin and power with dramatic hyperextension of his lumbar spine, and while his pars paid the price, so did his opponent. Unlearning that serve seems unlikely, but with a combination of cross training, postural education, and attempts to change his style of hitting, he has managed to reduce his pain to the point where he can play with a tolerable level of discomfort.

My advice is: spend the money on good coaching. The coast of california seems to have more Crossfit gyms than 7-11’s these days, and the increasing popularity of olympic weightlifting — with it’s attendant risks and benefits — has lead to a dramatic increase in the number of people in the local athletic community who really are knowledgeable about the ways to protect and stabilize the spine during functional movements under the loads imposed by athletics.

References:
1. Skeletal Radiol. 2006 Jul;35(7):503-9. Epub 2006 Mar 7.
Lumbar spine MRI in the elite-level female gymnast with low back pain.
Bennett DL, Nassar L, DeLano MC.
Source
University of Iowa, Roy J. and Lucille A. Carver College of Medicine, Department of Radiology, 200 Hawkins Drive, Iowa City, IA 52242, USA. lee-bennett@uiowa.edu
Abstract
OBJECTIVE:
Previous studies have shown increased degenerative disk changes and spine injuries in the competitive female gymnast. However, it has also been shown that many of these findings are found in asymptomatic athletic people of the same age. Previous magnetic resonance imaging (MRI) studies evaluating the gymnastic spine have not made a distinction between symptomatic and asymptomatic athletes. Our hypothesis is that MRI will demonstrate the same types of abnormalities in both the symptomatic and asymptomatic gymnasts.
DESIGN:
Olympic-level female gymnasts received prospectively an MRI exam of the lumbar spine. Each of the gymnasts underwent a physical exam by a sports medicine physician just prior to the MRI for documentation of low back pain. Each MRI exam was evaluated for anterior apophyseal ring avulsion injury, compression deformity of the vertebral body, spondylolysis, spondylolisthesis, degenerative disease, focal disk protrusion/extrusion, muscle strain, epidural mass, and bone-marrow edema.
PATIENTS:
Nineteen Olympic-level female gymnasts (age 12-20 years) were evaluated prospectively in this study. All of these gymnasts were evaluated while attending a specific training camp.
RESULTS:
Anterior ring apophyseal injuries (9/19) and degenerative disk disease (12/19) were common. Spondylolysis (3/19) and spondylolisthesis (3/19) were found. Focal bone-marrow edema was found in both L3 pedicles in one gymnast. History and physical exam revealed four gymnasts with current low back pain at the time of imaging. There were findings confined to those athletes with current low back pain: spondylolisthesis, spondylolysis, bilateral pedicle bone-marrow edema, and muscle strain.
CONCLUSIONS:
Our initial hypothesis was not confirmed, in that there were findings that were confined to the symptomatic group of elite-level female gymnasts.

physical-therapy1

Spondylolisthesis: Everything you ever wanted to know, and more…..

The History of Spondylolisthesis

Spondylolisthesis is a medical term that describes an abnormal anatomic alignment between two bones in the spine.  This anatomic abnormality has been around since antiquity.  It was first described in the modern medical literature by a Belgian obstetrician named Dr. Herbinaux.   In 1782, Dr. Herbinaux noticed that the abnormal alignment of the lumbar spine and pelvis in very severe cases made natural childbirth difficult.  He was the first one to name this condition in which one vertebral body is slipped forward with respect to the one underneath it.

The term spondylolisthesis comes from two greek words: “spondy” (σπονδυλος) which means “vertebra” and “listhesis” (ὁλισθος) which means “a slip”.

How common is spondylolisthesis?

Spondylolisthesis most commonly affects the lower lumbar spine, typically at the L4/5 or L5/S1 levels.  Spondylolisthesis is a very common condition, occurring in about 5% of the population.  The most common type of spondylolisthesis is a degenerative slip that occurs at the L4/5 level.  This type of slip is caused by degeneration of the intervertebral disk and the facet joints.  Natural aging results in an increase in the “sloppiness” of the joint, much like a worn bushing in a car.  Here are two images that depict the changes that occur as the disk degenerates.  The gel-like substance inside the disk shrinks, the edges of the disk become irregular, and bone spurs develop.

normal anatomy of the lumbar spine

mechanical wear and tear on the spine creates a spondylolisthesis  degenerative disk disease

In this series of images, I use a CV joint from a car to illustrate how the spine is a mechanical joint and many years of “wear and tear” will cause the joint to become sloppy.

 

 

The Medical Definition of a degenerative spondylolisthesis

A recent clinical consensus paper was produced by the North American Spine Society will be referenced throughout this guide.  Their version of the “best working definition” of a degenerative lumbar spondylolisthesis is as follows: an acquired anterior displacement of one vertebra over the subjacent vertebrae, associated with degenerative changes, without an associated disruption or defect in the vertebral ring.

The key elements in this definition — anterior slip, degenerative change, and no disruption of the vertebral ring are easy to demonstrate in a typical case of spondylolisthesis.  As the disk deteriorates it becomes less capable of absorbing all of the forces of normal human movement.  Because the joint has increased “play” or “sloppiness” L4 starts to slip forward with respect to L5.  Here are X-rays and an MRI scan of a typical case of a grade 1 spondylolisthesis.  Flexion and extension X-rays are often used to evaluate how much abnormal motion occurs at the level of the spondylolisthesis.

  spondylolisthesis AP xray grade 1  lateral xray grade 1 L4.5 spondylolisthesis   lateral xray grade 1 L4.5 spondylolisthesis flexion view  lateral xray grade 1 L4.5 spondylolisthesis extension view

The second most common type of spondylolisthesis that we see occurs at L5/S1.  This condition is especially common in people who have repetitively extended their spine during athletics in adolescence.  The theory is that repetitive hyperextension of the spine during athletics results in a stress fracture.  This stress fracture called a spondylolysis.  The stress fracture occurs in a part of the vertebral body called the pars inter-articularis which disrupts the continuity of the vertebral ring.  The lack of a connection between the posterior and anterior parts of the L5 vertebral body allows the L5 vertebral body to slip forwards with respect to S1.  The association between adolescent athletics and this condition is very strong.  About 95% of competitive gymnasts and about 35% of competitive football players have X-ray evidence of the stress fracture that may result in a spondylolisthesis later on in life.

hyperextension of the spine results in spondylolysis hyperextension of the spine during gymnastics spondylolysis  spondylolysis fracture of the pars inter-articularis high grade spondylolisthesis with spondylolysis

This condition usually develops in two stages.  First, the patient has an episode of low back pain during their adolescence which is when the stress fracture of the pars interarticularis occurs.  Then as the disk starts to degenerate later in life, they begin to complain of low back and leg pain.  In contrast to a degenerative spondylolisthesis, this type of slip does involve a disruption of the vertebral ring, so this is often called an “isthmic” spondylolisthesis

Symptoms of spondylolisthesis 

Patients with spondylolisthesis complain of low back pain and pain along the course of the nerves that are pinched by the spondylolisthesis.  The narrowing of the normal space available for the nerve roots in the spinal canal is called stenosis.  The back pain typically occurs in the area of the lower lumbar spine and often radiates around the abdomen and into the buttocks.  The location of the nerve root pain depends upon where the slip is occurring and where the nerve roots are compressed.

Nerve root compression due to stenosis is called a radiculopathy: radix is the greek word for “root” and pathos a word for “a disease of”.   Pain and numbness in the legs as the result of a spondylolisthesis occurs in patterns called a radiculopathy that are very characteristic.  The human body is divided into a series of dermatomes which can be visualized as a map of where the nerves travel after the leave the spinal canal.  When the root of the nerve is affected, the entire course of the nerve is typically painful, numb, or the skin in this area is unusually sensitive.  For example, here is a map of the normal dermatomes of the body, and then three diagrams of an L4, L5, and S1 radiculopathy.  Patients with a spondylolisthesis at L4/5 usually have L5 nerve root pain due to compression of the L5 nerve root in the neural foramen.  Patients with a slip at L5/S1 usually have both L5 nerve and S1 root pain due to tension on the nerve roots.  For example, a patient with an L4/5 spondylolisthesis will usually describe low back pain at the base of the spine, radiating into the buttocks.  There is usually also pain and numbness along the sides of the legs, down the front and sides of the calves, with numbness and tingling in the feet.

If your major problem is pain and numbness in the legs, and especially if it is only affecting one leg, you may be a good candidate for a microscopic decompression instead of a fusion.  If you are interested in exploring this option, I may be able to review your MRI scan for you.

L4 radiculopathy

L4 nerve root pain

L5 radiculopathy

L5 nerve root pain

S1 radiculopathy

S1 nerve root pain

   

The pain that is associated with spondylolisthesis is variable.  It is often worse with standing.  Many patients find that the length of time they can walk comfortably gets shorter and shorter as the disease progresses.  We call this finding “limited walking endurance”.   This is often an indicator of how severely the patient is affected and how much nerve root compression they have.  Patients who are able to walk for more than an hour rarely need operative treatment.   Those who can only walk for a few hundred yards before they are limited by back and leg pain are more likely to require surgery.  These patients will often experience substantial relief once their spondylolisthesis is corrected.  While the pain associated with a spondylolisthesis is usually worse when the patient is on their feet, many patients have a hard time sleeping at night because the nerve root pain keeps them awake.

 

Xray and MRI findings in spondylolisthesis.

The best test for diagnosing a spondylolisthesis is a lateral Xray of the lumbar spine with the patient standing.  It is important that the patient is standing because there are some slips that return to their normal position when the patient lies down.  This is why some cases of spondylolisthesis are not apparent on supine X-rays or an MRI scan.  The best test for evaluating the degree of nerve root compression and spinal stenosis caused by spondylolisthesis is an MRI scan of the lumbar spine.

Here are a series of X-rays and MRI scans showing the relevant anatomic finding in a typical L4/5 degenerative spondylolisthesis.  Click on these images to enlarge them to full size

And here are the X-rays and MRI scans of a patient with an L5/S1 spondylolisthesis with bilateral pars defects.

L5/S1 spondylolisthesis

Non-operative treatment of spondylolisthesis

Physical Therapy: While it may not be possible to reverse the degenerative changes that occur with aging, it is possible to strengthen the muscles that surround the spine.  I have written a blog post about this particular point, which can be read here: reversing spondylolisthesis

PT helps to stabilize the lumbar spine and will often result in a decrease in symptoms of low back and leg pain to the point where surgery becomes unnecessary.  This type of therapy MUST emphasize active rehabilitation, which means that the patient must work actively to strengthen the muscles of the abdomen, low back, and core.  Massage, hot pack treatments, and electrical stimulation may feel good at the time, but their effects are usually temporary.  While massage feels great, it usually does NOT result in sustained relief.  The type of therapy that we employ emphasizes core conditioning and strengthening and our therapists will instruct you on how to do these exercises properly.  If your symptoms are relatively mild and you are still able to exercise, hike, and play some sports, then often a Pilates or a Yoga program may be very beneficial, less costly, and more convenient than going to a physical therapist.

physical therapy for spinal instability  core exercises for spinal instability  

Medical Management

Non-steroidal pain relievers like Aspirin, Tylenol, Motrin, and Ibuprofen are very helpful in the management of spondylolisthesis.  The medications can calm down the inflammation that accompanies degenerative disk disease.  This often makes it possible to participate in physical therapy with less pain.  If you can do PT,  it makes it possible to work harder to strengthen the muscles of the low back and abdomen.

NSAIDs for spondylolisthesis

Selective Nerve Root Blocks:  In our clinic we have specialists who perform selective nerve root blocks with injectable medications like Cortisone and Kenalog.  These are much stronger than the anti-inflammatories you can take by mouth.  These injections are performed in the surgical center and are done using an intra-operative X-ray machine to make sure that the medication is injected in the same area where the nerve root compression is occurring.  In our experience, nerve root blocks are very helpful for patients.  They will often result in a sufficient reduction in pain so that physical therapy is tolerable.  The block may also interrupt the “cycle of inflammation” to the point where the symptoms are manageable and surgery can be avoided indefinitely.

 

Why you should avoid narcotics

In our experience, using narcotic pain medications on a daily basis for the treatment of the pain associated with a spondylolisthesis is a bad idea.  Because spondylolisthesis is a condition that tends to worsen with time, most people who start taking narcotics find it very difficult to stop.  The use of narcotic pain medications for an open-ended diagnosis is dangerous.  This is because there is not a defined point in the future when we know that the pain will spontaneously resolve.  For example, if a patient has a fracture, we know that the pain will subside once the fracture heals.  However, with a spondylolisthesis, because there is not a possibility of spontaneous correction, the patient will continue to perceive a need for narcotics on a regular basis.  This quickly leads to tolerance as the medications become less effective with time and their routine use becomes habit forming.  For more information on my philosophy about the use of narcotic pain medications, click here.

What the establishment says about non-operative care for spondylolisthesis

The North American Spine Society’s consensus statement on non-operative care for spondylolisthesis is a follows: The majority of patients with symptomatic degenerative lumbar spondylolisthesis and an absence of neurologic deficits will do well with conservative care. Patients who present with sensory changes, muscle weakness, [or a short walking endurance] are more likely to develop progressive functional decline without surgery. Progression of slip correlates with jobs that require repetitive anterior flexion of the spine. Slip progression is less likely to occur when the disc has lost over 80% of its native height and intervertebral osteophytes have formed. Progression of clinical symptoms does not correlate with progression of the slip.

Surgery for spondylolisthesis: do you need it?

Here is what the North American Spine Society has to say: Surgery is recommended for treatment of patients with symptomatic spinal stenosis associated with low grade degenerative spondylolisthesis whose symptoms have been recalcitrant to a trial of medical and interventional treatment.  In our clinic we agree with this statement.

What this means to us is that patients who have symptoms that can be clearly attributed to their spondylolisthesis should first be educated about their condition.  Next they should consider physical therapy and lifestyle changes that we believe are associated with improvements in back pain.  If they continue to have pain they should consider a selective nerve root block to temporarily reduce the inflammation in the nerve roots — as long as this is seen as a bridge to making physical therapy more tolerable.  Surgery should only be considered when the patient has continued symptoms that do not improve with physical therapy or medical management.

Our technique for the surgical correction of spondylolisthesis is designed to achieve four goals

1. relieve the nerve root compression that is causing pain and numbness in the legs

2. stabilize the unstable spinal segment that is slipping, only if necessary

3. improve the alignment of the spinal canal

4. provide the patient with a durable solution that will improve their quality of life for years to come.

While there is a great deal of debate about the best surgical technique for the treatment of spondylolisthesis, the NASS clinical guidelines do state that surgical decompression with fusion is recommended for the treatment of patients with symptomatic spinal stenosis and degenerative lumbar spondylolisthesis…and that …decompression and fusion is recommended as a means to provide satisfactory long-term (greater than 4+ years) results for the patient.  For example, on a recent Spine Surgery Board Certification Examination administered by the American Academy of Neurological Surgeons, the following question was asked: A 47 year old dentist presents with a 5 year history of intractable low back pain refractory to several courses of physical therapy and numerous medications.  He has recently developed bilateral L5 radiculopathy.  MR imaging demonstrates grade II anterolisthesis of L4 on L5 with resulting L4-5 central canal stenosis and bilateral neuroforaminal stenosis. The BEST treatment option is:

  1. dorsal column stimulator
  2. anterior lumbar interbody cage fusion
  3. laminectomy and pedicle screw fusion
  4. epidural steroid injection
  5. laminectomy with facetectomy

The correct answer, according to the AANS, is #3.  Here is their explanation: This patient has failed reasonable attempts at non-operative management and has an anatomical abnormality that corresponds to his clinical symptomatology.  Surgical correction is the best option.  Decompression alone in the presence of spondylolisthesis in a relatively young patient is associated with a high incidence of progressive listhesis and worsening pain.

Here’s where I disagree.  I think that it in carefully selected patients, a microscopic decompression with meticulous physical therapy and rehabilitation can result is excellent clinical results.  When I am able to alleviate someone’s leg pain so that they can go back to working out and keep their core strong, they are happy.

I’d be happy to give you second opinion if you are interested in whether or not a fusion is necessary in your case

In the meantime, here is a series of pictures from our operating room during correction of a spondylolisthesis of the spine using a traditional approach…

surgery for spondylolisthesis  intraoperative image spondylolisthesis  decompression for spondylolisthesis  size of incision spondylolisthesis surgery  drain connected to reservoir  rolling the patient back into a supine position

Here are a series of x-rays that demonstrate the correction of spondylolisthesis with a decompression and fusion of the slip performed in our clinic in Monterey, California.  You can click on each of these Xrays to enlarge them to full size.

L4.5 degenerative spondylolisthesis repaired with an L4.5 lumbar decompression, instrumented fusion, and reduction of spondylolisthesis.

L4.5 grade 1 spondy AP preop  L4.5 grade 1 spondy lateral preop  L4.5 spondy postop AP  L4.5 spondy postop lat

 

L5/S1 isthmic spondylolisthesis repaired with an L5/S1 lumbar decompression, instrumented fusion, and reduction of spondylolisthesis.

L5.S1 Grade 2 spondylolisthesis AP  L5.S1 Grade 2 spondylolisthesis lateral  L5.S1 Grade 2 spondylolisthesis extension  L5.S1 Grade 2 spondylolisthesis extension  L5.S1 grade 2 spondylolisthesis post op AP  L5.S1 grade 2 spondylolisthesis postop lateral

 

I’ve also got a large number of patients that haven’t needed  a stabilization.  Instead, I’ve done a microscopic decompression for them, especially if they only have pain and numbness in one leg.  If they are able to decrease the chance of future progression of the spondylolisthesis with lumbar spine strengthening exercises, they are delighted with the opportunity to live without a fusion every day.

If you’ve already had an MRI scan and are intrested in discussing your options, I will review your MRI scan for and tell you whether or not I think a microscopic decompression rather than a fusion will work in your case.

To learn more about your options for non-fusion treatment of spondylolisthesis, click here: MRI review.

axial plane for MRI scan

MRI Scans: Where Abnormal Findings Are Normal

An Introduction to MRI scans

The very first MRI scan of the human body was performed in 1977. Prior to this, we were basically making educated guesses about what was wrong with the spine. Today, the modern practice of spine surgery relies heavily on the interpretation of MRI scans.

MRI scans slice the human body into thin sections

Magnetic Resonance Imaging creates thin section images of the inside of the human body. This technique allows us to visualize anatomic structures from any angle and direction. The two most common slices that we look at on MRI scans of the spine are the sagittal and coronal slices. The saggital plane sections the human body lengthwise. The axial plane creates a cross section of the human body.

MRI axial planeMRI sagittal plane

An MRI image looks like a photograph, but it is actually a computerized image of the nuclear magnetic resonance of molecules inside the human body. These images are superior to CT scans and X-rays. The resolution and clarity of the images is better, we can see more fine detail, and this test uses harmless radio waves instead of ionizing radiation.

MRI scans as a medical tool

Magnetic Resonance Imaging is an amazing tool that allows us to see deep inside the human body with a degree of clarity that is absolutely amazing. We can visualize the tiny details of normal and abnormal human anatomy. We can clearly see the intervertebral discs, spinal cord and nerve roots. In addition to normal anatomy, we have also learned to identify a number of findings that may cause neck and arm pain or back and leg pain. The list of abnormal findings that we can see on an MRI scan include the following:

disc desiccation

disc degeneration

disc bulging

disc herniations

annular tears

spinal stenosis

neuroforaminal narrowing

We are going to look at examples of each of these conditions. However, before we do, it is important that you understand that after the age of 30, essentially every MRI scan of the human body is abnormal.

Every MRI scan after the age of 30 is “abnormal”

These two pictures explain why. The natural aging process causes changes to every structure of the human body. The spine is no different. If we were to look at the skin of the gentlemen on the right with a microscope, we would see evidence of degeneration, loss of elasticity (which is called elastosis), noncancerous skin growths (called keratoacanthomas), pigment changes such as liver spots, and thickening of the skin. These findings would all be described as “abnormal”.

MRI scans reveal a natural aging process

However, we could describe the skin on the right as “normal for age”. We only describe it as abnormal when we compare it to the image of the baby on the left.  Most people, even if they don’t have any back pain, will still have evidence of abnormalities on MRI scans.  Disc degeneration, bulging disks, and herniated discs occur very commonly and they may not be causing symptoms of pain. For example, in a paper published in the journal radiology, the researches found that approximately 90% of people WITHOUT any history of back pain in the last 6 months still have evidence of annular tears, disc degeneration, and disc bulging at one or multiple levels.

Therefore, the critical task when it comes to interpreting MRI scan is CORRELATING the findings on the MRI scan with the patient’s complaints and with the physical exam.

What a normal MRI scan looks like.

This is an MRI scan of a 40 year old male. There are 5 intervertebral discs in the lumbar spine. We are going to start with a normal level which has a normal intervertebral disc. Each disc separates two bones called vertebrae in the spine. In this case, this is the L3-4 disc. Above the disc is the L3 vertebral body and below the disc is the L4 vertebral body. The center of the disc, the annulus pulpous is relatively white. The front and back of the disc, the annulus fibrosis is dark black, thick, and is not bulging into the spinal canal. The spinal canal is filled with white fluid, called cerebrospinal fluid (CSF).  Inside the CSF is the spinal cord and the nerve root that go down to the legs.

normal saggital MRI scan lumbar spine

On the axial image, the neuroforamen are wide open and there is plenty of space available for the nerve roots.

normal axial slice MRI lumbar spine

Disc dessication

Using the same MRI scan, let’s look at a dessicated disc. Desiccation is the state of dryness, or the process of drying. The theory here is that when we are young, and our discs are young, our discs have a high water content.

MRI scan lumbar disc dessicationWhen we are young, the center of the disc, called the annulus fibrosis, has an electrical charge that holds onto water very well. The disc is viscous, elastic, and is a good shock absorber. With time, the center of the disk loses water content and the disk starts to “dry out”. I tell patients that all of our intervertebral discs start out as fat plump grapes and eventually end up like raisins. Just like us.

MRI reveals disc dessicationDisc Degeneration

Disc degeneration is a more advanced form of disc dessication. In addition to the nucleus pulposus drying out, the disc starts to collapse.  Bone spurs form around the edges of the intervertebral disc. Disc degeneration is the same thing as degenerative arthritis. This condition is inevitable. It’s just as certain as death and taxes, and it will happen to everyone if they live long enough. The one thing that predicts whether or not you will have degeneration of your discs is the number of birthdays you have had. The more birthdays, the more evidence you are certain to have of disc degeneration.

MRI scan shows disc space degeneration

Disc bulging and herniations

Disc bulges and herniations come in all sorts of sizes and shapes. As the disc starts to degenerate, it can bulge out towards the spinal canal and the nerve roots. This first example is described by the radiologist as a “herniation”.  This herniation is still contained by the annulus.  As such, it is probably more accurate to describe this as a disc bulge.

MRI scans focal disk herniation

In contrast, this example shows a really large disc herniation.  In this case, the nucleus pulposus has herniated completely through the annulus and there is a large free fragment of disc material filling the neural foramen and completely obstructing the normal path for the exiting and traversing nerve roots.

 MRI scan large disc herniationAnnular tears on MRI scan

Annular tears are a particularly interesting finding on MRI scans. They represent a partial disc herniation where only a few of the fibers of the annulus fibrosis remain. Here is a short video illustrating the typical findings in an annular tear.

 

Spinal Stenosis and neuroforaminal narrowing: what that looks like on the MRI scan

The end result of all of these changes is spinal stenosis. Stenosis mean “narrowing”.  The process of disc bulging, degenerative disc disease, and the development of arthritis of the spine all cause narrowing of the space available for the nerve roots. Here is a short video where I review the MRI scan of someone with two level severe spinal stenosis and illustrates this process.

Making Sense of your MRI scan

Recently, it has become much more common to give the patient a copy of the MRI and report from the radiologist.  Unfortunately, this often creates a lot of confusion and concern.

I have been practicing spine surgery in Monterey, California for more than 12 years.  About 4 or 5 years ago, ObamaCare mandated that patients be given a health care summary document when they finished seeing the doctor.  This applied to MRI scanners as well.  Now, it is very common for the patient to see the radiologists report, usually before they see the doctor who ordered the scan.

By the time that a patient sees me, they usually have had the opportunity to read their own MRI report which typically sounds something like:

  • “disc dessication is prominent at L5/S1.”
  • “There is broad based disk bulging at L4/5 and L5/S1 and degenerative disk disease at these two levels.”
  • “Complete disc space collapse with prominent osteophytosis is noted at L5-S1”

Patients love Google.  After an hour or two of typing the words they don’t recognize on their MRI report into the Google search bar they are scared.  They arrive in my office CONVINCED that there is something dramatically wrong with their back.

I begin by explaining that these findings can be considered a normal part of aging and that they frequently occur in patients without back pain or sciatica.

While there is a healthy debate about what constitutes an abnormal versus a normal MRI scan of the spine, there are a few key findings that reveal a problem that we know will require surgery.

If your MRI scan does not show evidence of severe stenosis, spondylolisthesis, neuroforaminal narrowing, or a large extruded disk hernation, chances are that you can probably get better without surgical treatment.

However, the opposite is also true.  If you MRI scan shows that you have a large disk herniation, a free fragment, severe neuroforaminal narrowing, severe spinal stenosis, or a severe spondylolisthesis, chances are, you may need to have an operation after all.  The important thing to do is make sure that you have the right operation.

I specialize in non-fusion, outpatient, microscopic surgery for herniated disks, spinal stenosis, spondylolisthesis, and sciatica. If you think you may be a candidate, I will review your MRI scan to see if we can help you.

If you are interested in having me review your MRI scan, you can follow this link:

[button url=”https://sohrabgolloglymd.com/upload-mri/” target=”_blank” color=”blue” size=”large” border=”true” icon=”MRI review”]MRI review[/button]

I have also prepared a short video explaining some of your options so that you can make the right decision about spine surgery.

the way i see it

the way I see it

starbucks coffee cup -- the way I see itI perform spine and hip surgery and I see patients in consultation in my office in Monterey, California.  I have written this guide so that you will know in more in advance about my practice philosophy.  I am a direct and open communicator and I strive to educate patients as completely as possible.  I use the medical literature as a guide towards treatment decisions — what we refer to as evidence based medical practice — but please understand that I do have my own biases and opinions.  I am presenting those biases and opinions here so that you may decide in advance if we are likely to form a constructive doctor-patient relationship.

 

If we examine the causes of disability in the United States of America, we find that arthritis and back and neck pain is identified as a cause of disability in 30% of the population and this is more than all of the other major causes of disability in the US combined.  These are copies of slides from one of my talks on common causes of back pain…click on the thumbnail image to enlarge the slide.

spinal disease and arthritis causes the majority of disability in the united states  80 percent of people have an episode of back pain during a year  only 10% require an operation

When someone with back or neck pain is referred to a spine clinic, reasonable guidelines suggest that 100% of those patients need to be educated about their condition, 80% would probably benefit from physical therapy, 20 to 30% may need some sort of a minor medical intervention such as an injection, and less than 10% of patients should require operative intervention.  In my practice, it is quite common to see a patient who has had a 1 to 2 month history of low back pain with an MRI scan of the lumbar spine that is described as showing disk bulging and degenerative changes.  This patient is often taking narcotics on a daily basis and states that he or she has tried physical therapy a few times and “failed”.  They are now seeking answers and further care.  Often, this patient is obese, sedentary, and from the perspective of someone who lives in coastal california, leads a relatively unhealthy lifestyle.  This type of patient is often unhappy with the results of their consultation with me because they have unrealistic expectations about how medical science can help them.  Let us examine each of these elements so that we can understand why….

The four things that everyone with back pain should know:

  1. The MRI scan is normally abnormal
  2. Narcotic pain medications are not a great idea for open-ended diagnoses
  3. PT involves more work than you think
  4. Lifestyle choices have a huge effect on back pain
Nora-Volkow

Narcotic pain medication — too much of a good thing?

Many patient who see me in consultation have been prescribed narcotic pain medications for their back pain.  In my experience, this is often the beginning of a slowly developing disaster.  Typically, the patient is initially offered a prescription of anti-inflammatory medications by their primary MD which has a modest effect.  However, if the patient still perceives that pain is present, if they have taken a painkiller for some other problem in the past, or if they simply ask for something stronger, they are often offered a prescription for a narcotic.  Examples of narcotic pain medication include Norco, Vicodin, Oxycodone, and Lortab.  These are opiate medications that are in the same class of molecules as Heroin and Morphine and their effect upon the brain is still incompletely understood.  Recent research suggests that one of the effects of taking these drugs is an increase in levels of neurotransmitters — tiny little molecules that buzz around our brains and effect how we feel — such as Dopamine that are associated with generalized feelings of satisfaction, accomplishment, and meaning.  After taking these medications for a short period of time, the patient experiences the opposite emotions if the drug is not taken regularly.  This typically results in an increase in feelings of anxiety, depression, lack of purpose, and more PAIN.  For a fascinating discussion of this area of research, click here for a recent interview with Nora D. Volkow, the scientist who is in charge of the National Institute of Drug Abuse. (http://www.nytimes.com/2011/06/14/science/14volkow.html)

Nora Volkow a general in the drug war

The first image in the next sequence of pictures is from the marketing campaign for a new narcotic pain medication.  In my mind, there is not much difference between the first image and the second.  Both are using advertising to deceptively suggest that a substance has less risk than it really does.  One thing is certain, the rate of narcotic pain medication consumption is skyrocketing.  The Drug Control and Access to Medicine Consortium, which is based at the University of Wisconsin, tracks world wide per capita opiate use.  The consortium publishes a fascinating interactive map and chart of world wide per capita opiate consumption online.  Click here for the DCAM web site.

nucynta opiate poster  marlboro man annual opioid consumption oxycodone use in 1995  oxycodone use in 2007  opiate consumption as a function of GDP

 

These charts speak for themselves.  The United States has the highest rates of per capita opiate consumption and the largest year upon year increases.  For example, in 1995, each citizen in the United States on average consumed about 10mg per year of Oxycodone, but by 2007, this rate increased to 140 mg of Oxycodone use per year per person.  This represents a staggering increase.  Some of the factors contributing to this increase include aggressive marketing by pharmaceutical companies, increased expectations on behalf of the patient, and increased permissiveness on behalf of physicians.  Narcotic pain medications are important tools and they are indispensable in the management of fractures, post-operative pain, pain caused by cancer, and other ailments.  IN MY OPINION, the use of narcotics for the management of back and neck pain without nerve root impingement is inappropriate.  Back pain is typically an open ended experience — meaning that there is rarely a defined point in the future when we know the pain will diminish.  This is unlike the situation faced by a patient who has a fracture or post-operative pain, for example.  If someone has a fractured bone, with reasonable certainty we know that the fracture will heal within 6 to 8 weeks and the pain will typically subside.  I have no problem giving someone with a fracture a prescription for narcotics because it is likely that the pain will subside within a reasonably short period of time and the patient will stop using the narcotics before they become “habit-forming”.  However, if someone starts taking narcotics for back pain, I frequently them, “When will you know that its time to stop?”  If they answer is, “When all of my pain is gone”, then this is a very unrealistic expectation and is likely to result in a long period of narcotic use which in turn leads to narcotic addiction.  While there are many doctors and patients who believe that narcotics are a reasonable drug to use for the management of neck and back pain, I do not.  I respectfully acknowledge that there are many medical experts and patients in this country who believe that pain is still being under-treated in the US but I do not provide the service of ongoing narcotic based management of pain.

 

Take home message #2: if you are not a candidate for surgical treatment, you will not be offered narcotic pain medication.

next topic: physical therapy involves more work than you think

SG-sliderSS1

Sohrab Gollogly, MD is a board-certified orthopedic surgeon and Fellowship-trained spine surgeon who also performs scientific research and participates in several volunteer surgical organizations.

Dr. Gollogly completed his undergraduate education in biology at Reed College in Portland, Ore. He earned his medical degree from the University of Washington School of Medicine.

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