Disc Pathology: Herniations vs. Bulges vs. Protrusions vs. Extrusions

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Hi, I’m Dr. Mark Studin. First. I’d like to think ChiroSecure for the opportunity to be able to share with you. And today’s topic is going to be MRI, spine interpretation and triaging the engine now, and you can put the slides up. Now. I don’t want you to think or be presumptuous that in 30 minutes, I’m going to teach you how to interpret Mr. But what I’m going to do is give you the basics of understanding, uh, some pathology, some anatomy, some general information to give you a springboard, to understand how to do that. And then at the end of the program, I’m going to give you a place to go, to really start to learn. Now my credentials, uh, other than, um, I teach at various levels in three chiropractic colleges and two medical schools, I’ve earned a mini fellowship in neuro radiology, MRI spine interpretation.

Um, I teach this, uh, through SUNY Buffalo, the state university of New York at Buffalo school of medicine at the graduate medical level and at the university of Bridgeport school of chiropractic in the classroom at the doctoral level. So I’ve been doing this quite a bit, um, around the country and it’s a lot of fun. So the first thing you need to understand is the, is the, is the evidence in the literature. And it says in spine journal in 2017, that there is a 43.6 error rate for a general radiologist, not neuroradiologist. And a neuroradiologist is a radiologist who spends an extra year and a half to two years studying only brain and spine. But in a general radiologist, there is a 43.6% error rate in reporting this pathology, herniations, bulges, extrusions, et cetera. And according to Robert Peiser, who’s a Harvard trained radiologist who actually was my professor who taught me.

He finds a 95% error rate in reporting this pathology from general radiologists. I find that 85% error rate and magni Shadi, who’s a neurosurgeon and a neurotrauma fellow doesn’t even waste his time reading the general radiologist report. He says they never, right. So just remember you as a chiropractor are delivering a high velocity thrust into someone’s spine. If there is a potential pathology, when there’s an MRI, when at best there almost a 50% error in that. So it is really incumbent upon you to understand the basics of what you’re looking at and that’s important. So what we’re going to do is we’re going to really look at the anatomy and anatomical pathology. Now, remember there are structural or biomechanical pathology, and we’re not looking at that right now. We’re looking at anatomical pathology, fracture, tumor infection, herniation, bulge. The anatomy is not correct. And we, you have to be able to identify that because when you’re triaging your cases, it will, it can grossly change your diagnosis, prognosis, and treatment plan.

Now, the first thing you have to understand is terminology. There’s so much outdated stuff there. And by the way, far, don’t wrote an article and we’ll get to that in one second, in 2014, by the way, called lumbar nomenclature version 2.0, which still is the standard, but act by the American society of neuroradiology, the American college of radiology, um, and it’s widely accepted in the industry. But if you’re using interchangeably terms like disc prolapse, slipped, disc disprotrusion, disc bulge, and you, you interchange your outdated, no different than the coin phones, the rabbit ears on the TV and the hot and tech typewriter. So you’re outdated. So you have to understand the difference. And by the way, there’s no such thing as a prolapsed disc, that language has been put to rest years and years ago. So I’ve given you the citation here, which is the far don’t article, um, protruded disc Carnegie, disc bulging, disc extruded, the sequestered disc fragmented this migrated common unit radial line.

You’ll have Fisher transfer, Samuel efficient, circumferential, annular, fissure. That’s what we’re going to cover today. You need to understand what those definitions mean. If nothing else that interpreting the reports that you’re getting and to interpret that you need to understand what the evidence says. Now, the other thing that’s really important to understand is the neurology of the desk. And if you look at the image on the right, you’ll see the red arrow it’s coming off the spinal cord, and you’ve got the interior and poster your, there you go. And that little itty-bitty nerve coming out is called the recurrent laryngeal nerve. Now that recurrent meningeal nerve, which you used to be called the sinew vertebral nerve, they renamed to the recurrent laryngeal nerve. If you look at the top left image, the arrow pointing to it, that intervates the outer one third of the annulus.

So the annulus fibrosis is the outer portion of the desk. And the gelatinous substance in the middle is called the nucleus pulposus. And if you look at the left bottom image, you will see the red arrow shows those recurrent laryngeal nerves actually goes in. And invaginates the, uh, inner one-third of the disc circumferentially, uh, throughout the entire desk. Now, the reason that’s important, look at here, I would just enhance that for you. So you can see where I drew in those red lines, all inside the outer portion of the disc. They all also feed no susceptive letters, which picks up a tremendous amount of environmental inf uh, information through neuropeptides, which I’m not going to get into today. But then that feeds into the lateral horn. It goes up into the brain and the brain does its thing. And that’s really important to understand. So when we’re looking at things like disc bulges and a disc bulge, if you look on that left picture, when the arrows going out all the way around a disc bulge has to actually go a minimum of 50% of the circumference to be considered a bulge.

And if you can see the middle picture, which has a lot of blue on the inside and the dark band around it, that dark band does the disc bulging circumferentially. Cause it usually goes much more than 50%. It’s usually about 95 to 100% and it expands all the way around. And that’s really important because that’s actually degeneration. So when you see a disc bulge, which is a minimum of 60 or 50% of the circumference, it’s like sandpaper on what it starts to whittle it down. And if you look at the bottom, right, picture the walls on the outside, get thin and the bone above and below pushed down a little bit and it pops out circumferentially all the way around. Kind of like if you had an Oreo, when you push down real hard, that white cream would pop out all the way around circumferentially, if there was equal pressure.

So when you have a disc bulge, the overwhelming majority of them, almost all of them are degeneration. And the disc bulge is degenerative. It takes approximately one year post-trauma for enough of that disc to degenerate to start to bulge. So if your patient was in an accident two weeks ago, and you did an immediate MRI and it showed a disc bulge, most likely that was not from the accident two weeks ago. It’s been there for quite some time. Now what we’re looking at again, when you have that disc bulge, it’s what we talked about before, when you have a disc bulge, those nerves that, that recurrent meningeal nerve, what happens is degeneration stimulates something called the nerve growth factor. And if you look at the image on the right, those nerves grow in to the annulus fibrosis, and it goes all the way into the nucleus as well, and it creates chronic inflammation and pain.

So if you have someone with a disc bulge, based upon the nerve growth factor, you’re going to have a chronically uncomfortable or chronic pain in that disc based upon the recurrent laryngeal nerve and all those free nerve endings exposed. It’s kind of like you could chop down on a cavity, it’s going to be sore. Or if you break your leg before it heals, you walk on it, it’s going to hurt. So your patient potentially is going to be uncomfortable for a lifetime. Then if you see a disc bulge with those nerves that are exposed and potentially can be activated, and if you’re adjusting and delivering high velocity thrust into that region, you potentially can increase the pain in that patient. Now, if we look at again, this is the same thing or what I just shared with you. And I put three citations up there, which explain this.

It’s very, it’s been around a long time. It’s been known for a long time and everything I’m sharing with you is evidence-based. Now, if we go on to the next step, we look at a disc bulge from trauma. So if you have approximate less than 50%, approximately 25% of the circumference, there’s no nucleus pulposus material on the outside or high signal. We’ll get to that in a little bit. That can be a disc bulge from trauma. You don’t often see that, but what it’s caused from it’s caused from ligament tear. So if you look at the left picture, you will see that void between the spinosaurus and that causes the vertebra to tilt tremendously in angular, deviation, and or translation. And in order to have the mantra of evidence, you need to have really digital x-ray digitizing is your best area for demonstrative evidence showing that that vertebra is malaligned to a degree where it’s pathological there’s technology out there called some verdict.

If you contact me, I’ll share it with you, uh, which can help do that. There there’s not too many other platforms that can, but you need to verify that demonstrative like show and tell folks that’s the key, which it looks plain why you’ve got the traumatic disc bulge, but then it’ll turn into a degenerative disc bulge over time. And I know I’m going through this really, really, really fast. And I apologize, but again, I’m just giving you concepts right now. Now when we look at, um, okay, this is the suburbia, which I just shared with you, the green line, I’m not concerned with the red line. The red line is full impairment, but the green line in that technology shares with you when pathology starts by abberant positioned vertebra. So it’s actually very specific. There is no such thing as non-specific back pain, which is a topic for a whole entire different conversation. But back pain is very specific. Where does bulges come from? A very specific where there’s biomechanical failure, secondary to connective tissue. Pathology is very specific topic for another conversation.

What we’re looking now was annular fissure, okay. This used to be called an annular tear and there were three kinds concentric radial and transfer a transverse concentric. It means it goes in circles around the spine and that’s traumatically. And that’s the generation. I’m sorry. Um, what’s the first one I have up here. Now I have tra radial Fisher transverse. So if you look at the left picture, transverse or radial are actually identical in, in what they’re looking at. W they both emanate from the nucleus and it goes out, but it doesn’t tear the outer shell. If you look at the right picture, you see it comes out, but doesn’t tear the outer shell. That’s what a Fisher is. Once it tears the outer shell and the nucleus pulposus material can go from the inside to out. Then it’s a herniation. So radial versus trans versus the same thing, it’s just the location of the slice.

But now when you get to circumferential, you look at the right picture. It’s almost going all the way around, uh, this, the picture depicts about 50% and just like the disc bulge, it needs to be about 50%, but that sharing that sharing with you, that it’s Fisher and concentrically, and that’s a bulge. And again, that goes all the way around the spot of the desk. I’m sorry. And if you look at the arrows, you will see that there is white or high signal on the left image, which is a T2 weighted image, were water images, white. And if you look in the desk, you’ll see a little white, um, blip, but it doesn’t break through the poster, your portion of the desk, where the arrow is showing. And that’s really important to understand, because if it did break through, that would be called a herniation.

If you see high signal on the outside, and when that occurs here, look right here. Here’s an annular. It should be called an annual a Fisher. Uh, that’s an older slide I had, but you will see it’s coming through. But on the outside, there are still a layer of anular of annular material intact. It’s still intact, but sometimes a drop leaks out. And if that drop leaf, so then what could occur is that drop can go on a nerve. Are there a nerve root or the spinal cord? And that nucleus pulposus material, even one drop is neurotoxic. And you get chemical ridiculousness, which can cause exquisite pain going into the arm or lender even locally. And by the way, it’s very challenging to treat that. And that’s again, a topic for a whole other conversation, but that’s what chemical ridiculousness sets. Now let’s look at our herniated disc or herniated disc is a tear or rent in the annulus fibrosis.

As you can see in the top, right where the inside comes out and it’s actually, it could put pressure on the cord or the root. So if we look at it a little closer in the bottom, right, you could see the inside comes out, it’s sticking out. And in the left picture, you could see the nucleus proposed. This material has to go from the inside to the outside and be demonstrable and how actually the nucleus proposes material by definition has to go beyond the vertebral endplate, which is the bone above and or bone below by definition to be considered or herniation. Now, when we look at this, there’s a myriad of types of classifications or any Asians, but focal herniation is zero to 25% of the circumference. As you can see on the left and a broad base herniation is 25 to 50% of the circumference.

As you could see on the right now, even though more material potentially could come out of the nucleus and broad base, typically a focal is more egregious because the Arbor between good or bad is how much of the nuclear content is effecting a neurological element. And in this case, it could be a spinal nerve or the, or the court. So therefore, when you have a focal herniation, it usually sticks out further. It takes up more of the focal real estate, and it affects their neurological element. And when you speak with neurosurgeons and I speak with hundreds of thousands of them nationally, and I teach them, I speak with them, I interview them. They always say, the focals are much more egregious as a rule than the broad base. Now, why don’t we go and further define here’s a Fogel twenty-five percent. So if you look at the top picture ski magically on the left side, which is actually the right of the patient and MRI, you’ll see it’s less than 25% sticking out.

And that’s on the nerve root. If we look at the bottom picture in between those two arrows, the disc is sticking out and that’s less than 25% of the circumference of the disc. Now, if we look at the, and if it’s more than 25%, it could be 25 to 50%. It’s broad base. Now we look at the definitions of protrusion versus extrusion. A protrusion on the left is like a pyramid when the base is wider than the apex and an extroversion is like a mushroom. When at any given point or any plane, the apex is wider than the base. So you have a pyramid. The base is wider than the X. The base is wider than the apex is the protrusion and extroversion is where the apex is wider than the base. And it’s really easy to see that when you’re looking at it on image.

So when we look in the bottom picture on the right, you shall see the poster, your portion of the, of the desk, um, uh, up that’s the cord. We’re going to go above and to have someone else working the mouse for me right there, that’s the desk. And then you have the UN it’s like a pyramid. The base is wider than the apex. Now, if we look at the next one and we look at an extrusion, oh, here we go. Extra to desks. Aren’t could be either migrated or common unit. We’ll look at a picture in a minute, a migrated, common human means the same thing it’s still attached, or you could have an extruded disc that’s sequestered or fragment that meaning it’s detached. So the first thing we’re going to look at is it’s attached. So if you look at the right picture, those two dotted lines that I have, one dotted line is the inferior in play to the bone above.

And the lower dotted line is the, is the superior end plate of the bone above a bone below. Now, if you look at the right arrow, that points up and down, you can see that the disc is actually going below that bottom line. And that’s the key it’s migrating. So it kind of looks like a mushroom head right there. That is a, um, a towel or what’s, what’s a hallmark of an extruded desk it’s going above and or below the disc space kind of looks like a mushroom if you turn it sideways. So therefore, the next thing we’re going to look at is right here, this is called formally what I call a big extrusion. And this is also why you need to understand this stuff. And again, I’m not being presumptuous to think that you’re going to understand that in a short 30 minutes, it was, I’m blowing through this stuff fast.

You really should watch this over and over and over again, to understand it. And then we’ll give you tools and places to go to learn more. But if you look at that right arrow, and you could see that huge disc coming out and on the left side of the dotted line, it’s actually filling in the entire lateral recess. It’s, it’s, it’s very significant. This is from the brassica and a radiologist diagnosis is a disc osteophyte complex chiropractic go with just the way and the chiropractor who I trained, looked at this centered over. And I said, my God, you just said, this person, there’s a good chance. They might end up being a paraplegic. I mean, you can really screw up the quarter to quantify a lot of bad things going to occur. This patient need to be in a needs to be in a neurosurgeon’s office immediately.

There’s, there’s no room there to treat that patient. So this is really important. This is one huge extrusion, and this is just a disaster waiting to happen because the general radiologist had very little training in spine and wrote a wrong report. It’s a matter of fact, I just got five minutes ago, uh, before we started a report from someone in Texas where the general radiologist missed a pars fracture on an MRI, just missed it. Thank God that I trained this guy. He called me up and said, mark, I just need a reality check on my, my, my eyes deceiving me. I mean, that could have been a quadriplegic waiting to happen if, and it was a Frank, a fresh fracture. You could see bone a demon in there. It was a mess right off to the neurosurgeon. So it’s really important to understand this stuff.

Then we look at a fragment and if we look at the green arrow on the left, that little blip behind bill three is just a free floating, fragment, exquisite pain because it’s nuclear proposal material and a form of chemical, ridiculous, a lot more than a drop. And in the right picture, the red arrow is showing the fragment hectically drop all the way down all the way down in the neural canal, almost down to the following term anally. And that’s just sitting and floating there. So when that happens, folks right off to the neurosurgeon do not pass out. So when we look at triaging the protrusion 99%, we can manage no big deal extrusion or migrated common unit. We treat about 80%. We co-treat about 30% with pain management and neurosurgeons 5%. And the arbiter is not the image of your clinical evaluation. If the patient has experienced severe motor weakness or severe sensory aberration, um, right off to the surgeon, do not pass go.

And if you’re not sure right off to the surgeon, and if there’s an extrusion, do not pass go no pain management, right to the neurosurgeon and not an orthopedic surgeon, I will never, ever, ever, ever, ever refer a spine patients with general orthopedist. If they’re a spine orthopedist evidenced on their CV by a, um, a fellowship in spine, then that’s okay. But other than that, only, only, only, um, uh, only, only, only so a neurosurgeon. And that’s it. How do someone just pop up a question, but I’m going to try to get to those later. Um, and the worst usually are hospital-based radios, no general radiologist, um, because they just cherish them and burn them. You know, except if it’s a general, uh, let me rephrase that. If it’s a teaching hospital, um, you get a neuroradiologist, you’re fine. And you should demand only a neuroradiologist look at your image.

And I haven’t even talked about ordering protocols because ordering protocols matter tremendously. So now we have annual Fischer mandated with a herniated. Okay. If you ever heard any in a desk, it has to have an annual efficient, there is no question because there’s a fissure there. You need a portal for that nucleus, the closest material to come out. Um, um, I don’t want to do that right now. It’s gets a little bit too crazy. Um, well, there you go. Now let’s look at nerve root compression. You see, on the left side, there was a line, that’s a reference line. That’s where we’re looking or taking our sequence right in that, not the neuroforamen that means hole, but there is a canal there where the nerve goes through. And on the right image, I’ve got a white arrow and red, big arrow that white arrow shows the disc is, is, is herniated. But the red arrow shows the nerve root, which is being compressed in that canal. So in this particular case, you’ve got a left because it’s reverse red left and right or reverse. You’ve got a L you’ve got a left herniation, which is compressing the nerve in the left neural canal, which would explain your patient’s pain on the left side.

This is, we’re looking at, you have a concept of abutment versus compression. So if you look at that, that red line and that herniation above that, you see black and front. And if you go above a little more, you see black in front of the court in black and back of the court. But at the level of the herniated disc, the court is pushing against the back of the canal. There is no black in front which represents CSF and no black and back, which record CFF that is a cord compression. If in fact, I could still see black and back, that would be a court abutment. Both are displacing the spinal cord and gives you spinal cord, a symptomatology for being impaired. And that’s really important to understand conceptually. So if you look at the image on the right, cause that’s the one people most used to looking at, you’ll look at the reference line and red, there is no space, zero between the, uh, the spinal cord and the desk, but in the back of the cord, it appears to be space.

If you look in the axial view, the one you’re not used to looking at the one on the left, the top arrow shows the front of the cord. There is no space between the spinal cord and the, and the, um, and the desk. But in back, there is no space between the read the back of the canal and the desk. So this really is a true cord compression. And if you have a cord compression within suing neurological deficit, distal to the level of, of lesion, that can be called in myelopathy. And if you have a patient with a myelopathy immediately, well after the neurosurgeon do not delay because what’s going to happen is you can get myeloma Malaysia, which is softening or damage or degenerate to the spinal cord. And that’s right. Really important. You have to decompress that are also spinal cords, literally dying a little at a time.

And sometimes it doesn’t come back. Actually a lot of times it doesn’t sometimes it does, but you have to have a relationship with a neurosurgeon who understands chiropractic, who understands what you’re doing, but you have to understand what they’re doing and how to interpret this stuff and how to treat it your case. Now, when we look at, um, here, here’s another compression, by the way, you see there’s no S in the left view, there’s no space in front of the court or in back of the court. And then the right view. There’s no space either in front or back. And that’s really important to understand that as a true court compression. Now, um, if you want to learn MRI spine interpretation, just go to university dot, teach doctors.com. This is the, uh, this is the site to go to. There is an MRI spine interpretation course it’s approved for CE and every state that allows online CE, but more importantly, you also get a category.

1:00 AM a, uh, C M E credits through the state university of New York, Buffalo school of medicine and biomedical sciences. Why is that important? That doesn’t do anything for your license, but it’s a perception when you’re dealing with the courts. If you don’t even have the minimum of this course specifically, then I can’t guarantee you’ll be able to opine with attorneys when you’re dealing with medical specialists or medical primaries. And you’re going to have a level of communication with them. The first thing they’re going to say, where were you trained? Listen, I love Cleveland university. I love life. I love national. I love Parker. I love all these schools. They’re wonderful, but when you’re dealing with a world in medicine and you want to work collaboratively with a medical doctor, I get to say the state university of New York of Buffalo school of medicine. Now you’re trained through medical academia, just like them.

And instantly you go from a lowly technician below that of a PT to that of a peer. And it matters tremendously. In addition, in New Jersey, which used to be the bellwether state, unless you were had this course specifically, the court’s rule that you were not allowed to opine on MRI. And now in Georgia, there was a doctor, which is now the new bellwether state that in fact, even with this course was not allowed to Alpine and said, no chiropractor could opine in the state of Georgia, uh, because all they could do was, is adjust exam and x-rays, and that’s it. The doctor who went there actually took a mini fellowship in neuroradiology. Not only has this course, but has an MRI qualification, which is part of what we do as well, but it’s taken dozens of courses. And the judges overturned that and allowed him to opine.

Without that he wouldn’t be able to have a relationship with attorneys. He also probably gets three or four referrals a week from medical specialists. So he gets to talk to them at appear as many doctors do, because this tool for my practice management perspectives gives you the opportunity to build your practice based upon clinical excellence and my entire platform for my entire career in consulting and teaching is clinical excellence will drive the success of your practice on top of that. The other person that loves it as Cairo secure, because there’ll be less claims against you when you’re starting to treat patients with a higher level of knowledge of what’s wrong with them and understanding whether there’s almost a 50% error rate, as I share with you in the evidence on front. So, listen, this has been a blast. I look forward to working with you in the future. Um, next week I have Janice Hughes coming and speaking, uh, you should, uh, uh, sign on and watch and, um, I will be back shortly and we’ll be doing this a whole lot more. If you have any questions, give me a general, thank you so much and have a great day.