1 Spinal Longevity Clinic Care for appropriate candidates suffering with: Chronic neck and back...

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Spinal Longevity Clinic

Care for appropriate candidates suffering with: Chronic neck and back pain, sciatic

pain, herniated discs, and failed back surgery pain.

Dr. Alan Sinner

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"... Forge every sentence in the teeth of irreducible and

stubborn facts.”

William James

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They found no abnormalities on CT or MRI

examination in the cervical spine…• In microscopic analysis, however, they found discrete

injuries to the lower cervical facet joints including,• hemarthrosis, • avulsion of capsular attachments, • muscular hemorrhages,• contusions of the synovial folds,• and discrete fractures extending from the deep cartilage

through the subchondral plate to the underlying cancellous bone with associated bleeding.

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Alan Sinner, D.C.Curriculum Vitae

Education • Chiropractic Medicine Magna Cum Laude 1984

Certification•Motor Vehicle Crash Forensic Risk Analysis (MVC-FRA)•Whiplash and Brain Injury Traumatology•Spine Research Institute of San Diego (SRISD)

Education Interests•Currently completing a 384-hour post-graduate Orthopedics program leading to recognition as a Board Eligible Chiropractic Orthopedist.

Professional Affiliation•Ameican Back Society•International Traffic Medicine Association Aur

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Our Purpose Today…

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Kyphoplasty—For painful progressive

vertebral body collapse/fractures (VCFs)—AAOS, 2005.

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Kyphoplasty

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KyphoplastyOriginal vertebral body collapse

Height restored and final cement

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Red Flag Diagnoses—Cauda Equina Syndrome (CES) Surgical Emergency

• 1 : 2500• Severe &/or progressive

neuro deficit, weakness often bilateral

• Saddle anesthesia• Retention w/ overflow

incontinence is characteristic

• Fecal incontinence w/ anal sphincter tone

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CES— “a rare disorder affecting the bundle of nerve roots (cauda equina) at the lower (lumbar) end of the spinal cord—AAOS, 2001”

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CES— Causes:

-Ruptured disk

-Tumor

-Infection,

-Fracture -Stenosis-Violent impact-MVC-Fall from height-Penetrating trauma—gunshot or stab-Children may be born with it

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CES— w/o fast treatment to relieve the pressure, CES may cause permanent paralysis, impaired bladder and/or bowel control, loss of sexual sensation and other problems.

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CES—Although treatment is needed early to prevent permanent problems, CES may be difficult to diagnose—AAOS, 2001.

Symptoms vary in intensity and may evolve slowly over time.

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Red: L5 pain zone for 75% of the population

Yellow: L5 pain zone for 50% of the population

Green: L5 pain zone for 25% of the population

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Red: S1 pain zone for 75% of the population

Yellow: S1 pain zone for 50% of the population

Green: S1 pain zone for 25% of the population

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Radiculopathy—Saggital MRI view

Contained disc extrusion uplifting PLL from bone (blue arrows)

Thecal sac (red stars)

Ligament flavum (green stars)

L5 DDD ( hydration)

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Regions & Zones

Central

Paracentral / lateral recess

Infraforaminal / subarticular

Extraforaminal

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Axial CT myelogram

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Radiculopathy—axial view

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24 y/o male doing fairly well: 9mm L5 disc herniation compressing the (R) S1 nerve root against the lamina. Note the compressed thecal sac.

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Axial CT myelogram—to look for filling defects

compression upon the nerve root will NOT allow the contrast material to 'fill' into the nerve, hence, no bright white nerve root—(R) S1.

Disc tissue outside the posterior vertebral body (ring apophysis)

= ‘Bulging'.

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“Motion Segment”

Disc Anatomy

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Risk for acute injury—rear impact MVC:1) Female sex. 2) Females weighing less than 130 lb in frontal crashes.3) History of neck injury.4) Head restraint below head's center of gravity (males and females); large topset.5) History of CAD injury.6) Poor head restraint geometry/tall occupant (e.g., 80th percentile male).7) Rear vs. other vector impacts. 8) Use of seat belts/shoulder harness (i.e., standard three-point restraints). 9) Body mass index/head neck index (i.e., decreased risk with increasing mass and neck size). 10) Out-of-position occupant (e.g., leaning forward/slumped).11) Non-failure of seat back.12) Having the head turned at impact.13) Non-awareness of impending impact.14) Increasing age (i.e., middle age and beyond).15) Front vs. rear seat position.16) Impact by vehicle of greater mass (i.e., 25% greater).17) Crash speed under 10 mph.18) For rear struck occupant, when the bullet vehicle has a motor that is longitudinally mounted.

* Always wear your seat belt. It can save your life.

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Risk for late whiplash—rear impact MVC1) Female sex (119,1160,1276,1290,1345).2) Rear vector impact vs. other vectors (1276).3) Body mass index in females only (1240).4) Immediate/early onset of symptoms (i.e., within 12 hours) and/or severe initial symptoms 5) Ligamentous instability.6) Initial back pain (799).7) Greater subjective cognitive impairment (386,797).8) Greater number of initial symptoms (386).9) Use of seat belt shoulder harness (125,1154)*. For neck (not back) pain (1240); non-use had a protective effect.10) Initial physical findings of limited range of motion (242,1292).11) Neck pain on palpation (1454).12) Muscle pain (1454).13) Initial neurological symptoms; radiating pain into upper extremities (242,1454).14) Past history of neck pain (243) or headache (797).15) Headache (1454).16) Initial degenerative changes seen on radiographs (136,242,243,249).17) Loss or reversal of cervical lordosis (455).18) Increasing age (i.e., middle age and beyond) (243,386,799,1240,1290,1329).19) Front seat position (243).20) Occupants of vehicles manufactured in the late 1980s to early 1990s (OR=2.7 vs those in early 1980s vehicles) (1276). This is relevant for rear impact crashes only. Other data suggest this relationship holds

for all 1990s vehicles.* Always wear your seat belt. It can save your life.

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NMSP—Vascular disease

AAA

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INTERNAL DISC

DISRUPTION (IDD)

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Mechanical Spine Pain—DiscProduce, reduce, & turn it on and off

rapidly during evaluation.

Pain 2° to stress on annulus

ability to straighten up

Posterior nucleus migration

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Disc Nutrition: As we start the day our discs, like squeezing out a sponge, compress and dehydrate due to the axial loads of gravity and physical activity. Healthy disc will shrink some 20%, which in turn decreases our height by 15 to 25mm.

Then as we sleep and decompress our spines, our discs swell with water plus nutrients and expand back to their fully hydrated state. This tide-like movement (diurnal change) of fluids in and out of the disc helps with the movement of nutrients into the avascular center of the disc.

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Internal Disc Disruption (IDD)• Just because a MRI is deemed "normal" does NOT

always mean that back and leg pain are not coming from problems within that very disc—this is especially true if the MRI demonstrates bulging and/or a 'Black' appearing disc. Milette PC, et al. Am J Neuroradiol 1995

• IDD prevalence w/Chronic LBP patients is estimated between 30 and 50% Scwarzer AC, Spine 1995

• Unfortunately, only concordant LBP 2° provocative discography and a normal neurological examination (DTR, motor, sensory) are diagnostic.

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IDD-MRI may be read as “normal”

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Possible IDD discogenic pain to:

Low back

Buttock

Groin

Thigh

Leg

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IDD—mother nature tries to heal the breach w/scar tissue

OCM helps this process

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IDD Study

• 84% of patients that complained of lower limb

pain, which passed the knee were found to

have concordant pain on provocative

discography and either grade 2 or 3 IDD.

Ohnmeiss DD, et al, Spine, 1997

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IDD• IDD diagnosis accepted by the North American Spine

Society (NASS)—Spine, 1988

• “IDD is the m/c cause of chronic LBP and may be often over-looked by the treating physician—Nikolai Bogduk

• IDD occurs when the disc develops a full thickness radial annular tear that allows communication between the center (nucleus pulposus) and the nerve-infested outer region of the disc (annulus fibrosis).

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Radial Tears

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SPONDY

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Mechanical Spine Pain—Extension

• Hx: sports, reaching overhead, arching back, lying prone, rear end MVC

• Aggravated by: lying prone, arching backwards, standing, walking, looking up/side (neck)

• Tissues stressed: facet joints, pars (adolescent spondylolisthesis)

• Diagnosis: facet syndrome, adolescent spondylolisthesis

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Spondylolisthesis—

The most common

X-ray identified

cause of LBP in

adolescent athletes

is a vertebral stress fracture.

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Adolescent Spondylolysis

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Adolescent Spondylolisthesis

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MPS

TrPts

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Treatment of CAD

• CMT (60,61)

Fixated segment imposes excessive motion at injured segment

Motion normalized at injured segment

Fixation reduced with CMT

Increased motion at injured segment

CMT

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LBP Natural History – Old Testament, 1990

• AAOS Orthopaedic Knowledge Update, 1990

• 90% of patients pain free within 3 months

• Up to 90% improve within 1 month, AHCPR, 1994

• Inaccurate prognosis led to disappointment, anxiety, anger, & ineffective management

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Homer Simpson to Chiropractor• On January 17, 2001 it was chiropractic’s turn for some of Matt Groening's acerbic wit in his most successful prime-time series on TV (if longevity is the yardstick). Sub plot: Homer's visit to the MD for back pain. • • MD: Your spine is more twisted than Sinbad's take on marriage. • • Homer: So, just give me some drugs and surgery. • • MD: I'd love to, but to be honest, modern medicine has a lousy record of treating the back. We spend too much time on the front. • • Homer: Yeah, there's some neat stuff on the front. • • MD: I'm going to send you to my chiropractor. • • Homer: Hey, I thought real doctors hated chiropractors. • • MD: Well, that's our official stance, but between you and me and my golf clubs, they're miracle workers.

• Homer goes to Dr. Steve the chiropractor, lies down on the adjusting table and immediately falls asleep. Dr. Steve awakens him: • • Homer: Less yackin,' more crackin.' • • Dr. Steve: We don't actually crack backs. It's merely an adjustment...OK, you're going to hear a loud cracking sound. • • Homer: Hey, it feels a little better. • • Dr. Steve: I thought it might. Now I need to see you three times a week for many years. • • Home again, Homer hurts his back racking leaves and complains that Dr. Steve didn't help his back. Bart, his son, asks if he had been doing the exercises Dr. Steve prescribed. Homer, of course, hadn't followed the DC's instructions.

• Meanwhile, Homer falls backward over his trashcan and dents it. The fall relieves his pain. • • Bart: The trashcan must have unkinked your back. • • Homer: That's not a trashcan, it's Dr. Homer's miracle spine-o-cylinder—patent pending.

• Homer opens a clinic in his garage, treating patients, mostly friends from the local tavern, with the spinocylinder. • • Patient: You think you can fix my sciatica? • • Homer: I don't know what that is, so I'm going to say "yes." • His bedside manner is unorthodox. He tells the patient to go "limp." As he pushes the patient over the trashcan, which is on its side, he intones: • • Homer: One, two, better not sue. • • Patient: Hey it worked! My searing leg pain is now a gentle numbness.

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POST TRAUMATIC HEADACHE National Headache Foundation—

• “Headache is a common result of head injury and it might persist for months or years following even mild head trauma.

• “Although it is most frequently associated with a variety of symptoms such as dizziness, insomnia, difficulties in concentration and mood and personality changes, headache dominates the clinical picture.

• “There appears to be no relationship between the severity of injury and the severity of post- traumatic headache.

• “The most frequent cause of chronic headache after trauma is muscle contraction, specifically sustained contraction of the muscles of the neck and scalp.

• “Another type is characterized by vascular changes that may give rise to a vascular headache that can pulsate. These headaches often take on the characteristics of migraine.

• “Head pain generally responds to the non-narcotic analgesics while the emotional reactions may require the short-term use of tranquilizers or antidepressants.

• “Physical and manipulative medicine may also have a useful role in the treatment of chronic post-traumatic headache patients.

1 Spinal Longevity Clinic Care for appropriate candidates suffering with: Chronic neck and back...

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