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By Judy Dennis
When a patient has a back injury, it is sometimes difficult to tell from the report what the doctor has really found and whether or not it is significant. It is also difficult to know what is congenital, what is natural aging, and what findings are traumatic in origin. Since these differences can have a major impact on the setting of proper reserves, it is important to gain a full understanding of the realm of back injuries.
DEGENERATIVE CHANGES: These are often associated with aging, however, they can also be seen in people who have worked at hard labor. They can develop as a result of injury, but take years to do so. If a recently injured patient has degenerative changes, the changes would not be due to that injury. These changes usually include spurring, osteophytes and other bony changes. This can lead to osteoarthritis. To determine how the changes occurred, one needs a history of injury, occupation and the patient’s age. If there are significant degenerative changes in a young person, it can be assumed that these changes are traumatic, either from the wear and tear of labor or from a prior injury.
DISC BULGE, PROTRUSION, HERNIATION, RUPTURE: These are terms doctors use interchangeably. The disc is a cushion between the vertebrae. When it bulges, it protrudes beyond the edge of the vertebrae. The center of a disc is the nucleus pulposus. Generally, a disc is not considered herniated unless the bulge involves the nucleus pulposus. A bulge and a protrusion are essentially the same; a herniation is similar to a bulge but involves greater protrusion, whereas a ruptured disc involves actual spillage of the disc contents. An extruded fragment is a section of disc that is no longer contained by the spinal column. A bulge is not significant unless there is impingement or narrowing of the spinal canal. Impingement means that the disc is pressing on something. If it is pressing on a nerve root, there are generally specific leg or arm symptoms corresponding to the disc level and the side on which the bulge occurred (if it is not central). A disc is generally not felt to require surgical intervention unless there is nerve root impingement affecting the extremities. This can be confirmed with electrodiagnostic studies such as EMGs and NCVs. Epidural injections are one way of relieving the symptoms without surgery. There are various surgeries that can be done in this situation, depending on the general stability of the spine and the likelihood of repeat herniation. Disc bulge results from improper body movements. One can simply be picking up a paper clip, but if done wrong, a disc herniation can result. Of course, lifting heavier objects can increase the likelihood of disc injury. Disc bulging can result from trauma or from normal activities. Bulges of 1-3 mm are not uncommon, especially in people over 40.
FRACTURES: When people see spinal fractures, they start thinking of big insurance dollars. Some fractures are significant and others are not. Some fractures result from certain activities only, and it is useful to know if the fracture could result from the mechanics of the accident and if it is current. In the neck, at the higher level vertebrae, one can often have congenital lines through the vertebrae. It is difficult for a doctor to tell if it is a fresh fracture or one that has always been there, just on the basis of an x-ray. If such a fracture exists, it generally is not significant unless it is displaced; otherwise it is simply a crack in the bone. Compression fractures are just that; the vertebral fracture results from activities such as jumping, falling and landing on one’s feet. It is rarely the result of lifting or similar activities, which generally do not cause any type of spinal fracture. Stress fractures result when the muscles normally supporting a structure become fatigued from overuse. People can have spinal fractures without realizing it. To determine the age of a fracture, a bone scan is usually done. This involves injecting radioactive material into the patient. It is absorbed into recently-injured areas to a greater extent than into old areas. If there is no absorption, either an injury has fully healed, or there is no injury in that area. When a fracture occurs from a fairly mild trauma, consideration should be given to an underlying disease process such as osteoporosis or multiple myeloma.
MECHANICAL BACK PAIN is usually the result of degenerative changes of spondylosis, spondylolisthesis or spondylolysis.
SPINA BIFIDA can be a very serious condition in which the spinal cord pushes through the vertebrae, which does not fully close. When it is occult, there is some failure to close but the spinal cord does not push through or herniate. This is usually just a finding on x-ray and not significant.
SPINAL STENOSIS refers to narrowing of the spinal canal. This can be the result of a congenitally-narrowed canal, bony overgrowth of the vertebrae, disc protrusion or a tumor. This is significant when it results in pressure on the spinal cord.
SPONDYLOLISTHESIS, SPONDYLOSIS, SPONDYLOLYSIS and SPONDYLITIS:
These can be confusing because of the length and similarity of their names. In researching them, I found that my sources did not always agree and therefore it can be expected that the doctors will use them differently. Spondylolisthesis is the slipping of one vertebra on another, usually L5-S1. This is often congenital or degenerative and may not be symptomatic until there is an intervening event such as an accident. Spondylosis is degenerative change in the vertebrae, due to aging or long-term wear and tear, such as hard labor. It is found only in the cervical spine. Spondylolysis is the breakdown of a vertebra, usually a pars interarticularis stress fracture. This can occur along with an existing spondylolisthesis. It may be congenital or developmental and also may not be symptomatic until there is an intervening event. Spondylitis is an inflammation of the vertebrae, often due to some form of arthritis. For example, ankylosing spondylitis is an inherited condition resulting in a virtual inability to move the back. It is generally diagnosed with a specific lab test and x-ray findings.
SPRAIN/STRAIN: This is the tearing (sprain) of the ligaments or muscles, or the overuse (strain) of them. This can result in bleeding at the site and inflammation. Treatment is with physical therapy and anti-inflammatories. Often, the area becomes healed with scar tissue and there is stiffness and increased risk of injury in the future. This is why exercise is often suggested, to keep the area limber and reduce the likelihood of injury.
SPECIAL SPINAL STUDIES: There are various tests that can be done to determine what is going on in the spine. If the injury is just a sprain/strain, it is difficult to verify objectively, other than by the presence of muscle spasm (which can be faked). X-rays can tell if there are bony changes such as fractures and degeneration. Narrowing of the space between the discs can be seen, indicative of possible bulging or degeneration. MRIs are best for analyzing disc changes. CT scan is better for bone changes, and can also help visualize the discs. A bone scan is useful in determining the age of injuries and on-going inflammatory processes. EMGs and NCVs are tests of the nerves and muscles. They can determine if there is damage and often pinpoint the source (eg: carpal tunnel syndrome or a cervical spine injury). A myelogram involves injecting a contrast material into the spinal area. It can best delineate the extent of disc bulging and the impact on the spinal cord. Because it is invasive and has side effects, and because we now have the MRI and CT scans, the myelogram is not done as often as it used to be.
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