“He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.” William Osler, Canadian Physician, 1849-1919 Chiropractic Management of Lumbar Disc Derangements Lecture notes William E. Morgan, DC, DAAPM, FICC, LLD (hc), FIM Copyright © 2013 Bethesda Spine Institute Text by William E. Morgan, DC All rights reserved. No part of this book may be reproduced in any form or by any electronic, mechanical, or other means without prior permission in writing from the publisher. Editor: Clare P. Morgan, DC Disclaimer The views expressed in this book are those of the author and do not necessarily reflect the official policy or position of the Department of the Navy, Department of the Army, Department of Defense, nor the U.S. Government. Nothing in the presentation implies any Federal/DOD/DON endorsement. The information within this guide represents the views of the author at the date of publication. Due to the rapid increase in knowledge, the author reserves the right to update and modernize his views as science uncovers more information. While every attempt has been made to verify the information, the author cannot accept responsibility for inaccuracies or oversights. Any perceived disrespect against organizations or individual persons is unintentional. The author makes no guarantee or warranty pertaining to the success of the reader using this material. The Cost of Piracy The ability to rapidly share information is part of what makes living in the twenty-first century so extraordinary. So extraordinary that many people forget that much of what is passed from person to person is protected by copyright. Reproducing copyright protected electronic literature is illegal and is, in a word, stealing. Reproducing copyright protected material is morally wrong and illegal. But more disturbing than the legality of piracy is the fact that doctors and students continue to steal the intellectual property of others. When a doctor or student bootlegs intellectual property, it costs them. It costs them their integrity; it costs them their self-respect; it costs them their honor. Our patients deserve to be treated by doctors who have retained their integrity. Contents Chapter Page 1 Expectations and Way Finding 1 2 The Natural Course of a Disc Herniation 9 3 Outcome Measures 14 4 When to Refer 23 5 The Lumbar Spine 28 6 Disc Herniation 45 7 Clinical Presentation of Lumbar Disc Derangements 50 8 Differential Diagnosis 54 9 Principles of Orthopedic Neurology 68 10 Orthopedic Neurology: The Examination 79 11 The Examination: Practical Application 86 12 The Role of Advanced Imagery in Evaluating Lumbar Disc Lesions 89 13 Introduction to the Systematic Interpretation of the Lumbar MRI 94 14 Anatomical Atlas of the Lumbar Spine on MRI 108 15 The Lumbar Disc on MRI 124 16 Classification of Annular Tears 157 17 Inflammation and Disc Injuries 166 18 Creep 171 19 Lifting and Load Bearing 175 20 Activities of Daily Living 183 21 Physiological Factors in the Management of Disc Derangements 198 22 Extension Exercises 218 23 Exercises to Avoid To Protect Your Disc 234 24 Strengthening the Core 243 25 Nutritional Considerations 259 26 Chiropractic Management of Herniated Discs 268 The Appendices 292 Appendix 1: Piriformis Syndrome 293 Appendix 2: Sciatic Nerve “Flossing” 299 Appendix 3: Glossary 302 Appendix 4: Centralization and Peripheralization 306 Appendix 5: Gallery of Lumbar Disc Derangements 308 To return to this page from any chapter in this book click this icon: Expectations and Way Finding 1 What are Realistic Expectations? No book, course, or instruction is able to fully impart all the information to make the reader an expert. This book was created to provide clear, pragmatic information and instruction, offering realistic goals that can be imparted through this particular medium. The goals of this course are: • Understand the anatomy and function of the disc, the types of disc derangements, and the lexicon for describing disc lesions • Identify probable disc derangements through history, observation/examination, and imagery • Determine the safest course of management • Understand the concept of evidence-based practice • Learn the mechanism of injury for disc herniations • Learn to perform an efficient and meaningful orthopedic/neurologic exam • Learn to identify disc lesions • Learn how to conservatively manage a disc derangement • Learn when to refer Chiropractic Management of Lumbar Disc Derangements 2 Fine Wine or Sour Milk The passage of time is both friend and foe. Time allows grape juice to mature into wine, but it can also turn milk sour and cause bread to become stale. Time can create master clinicians or in the case of chiropractors who do not remain current in their knowledge, out-of-date chiropractors. Time can make us wise or just make us older. There is a general belief that physicians become better with time and experience. Most of us have believed that physicians accumulate knowledge and skill with the passing of years and become better doctors. However, research does not support this belief. Surprisingly, a recent systematic review of 62 studies revealed that in 70% of the studies there was a negative association between length in practice and several measures of quality care. Doctors who have been in practice longer are at risk of providing lower quality care and should be targeted for performance improvement interventions. (Of course this meta- analysis evaluated trends in medical doctors and not chiropractors, but the possibility that this trend could apply to chiropractors should cause chiropractors to take note.) Unless you deliberately commit yourself to remain current in scientific trends and modern standards of practice, you will most certainly be left behind. If you do not continually seek to improve the quality of the care that you provide, then it may be indicative of the low value that you place on your patients. It takes effort to remain current and relevant, and unfortunately most of us are resistant to change. It is easier to reject guidelines and outcome measures than to take the time to understand why we need them and how they are created. Figure 1:1. While it is a common belief that physicians become better with time, there is compelling evidence that as years pass, physicians actually provide lower quality care. Choudhry NK, et al. Systematic review: the relationship between clinical experience and quality of health care. Annals of Internal Medicine 2005; 142: 260–273. Chiropractic Management of Lumbar Disc Derangements 3 It