Questions

What presentations are true emergencies?Any patient that presents with loss of bowel bladder control, or rapidly progressing motor deficit is an emergency. These patients should be admitted to the hospital for immediate diagnostic testing. These tests may include CT’s, MRI’sand plain radiographs.
The immediate concern is for a so call cauda equina syndrome, or significant neural compromise.The differential diagnosis may include fracture, large disk herniation, severe spinal stenosis, neoplasm, and infection. In patients on anti-coagulant therapy, the concern is for an epidural hematoma. In certain obese patients with concomittant diagnoses including rheumatoid disease, Cushing syndrome, or exogenous corticosteriod drug therapy, the cause for cauda equina syndrome can also include Epidural Lipomatosis.
What is degenerative disk disease?The natural process by which your intervertebral disks dehydrate and wear away. When you are a young child, your disks are well hydrated (full of water). As you age, the disks begin to dry out. The forces of the water in the disk (hydrostatic pressure) decrease, and the structural integrity of the disk walls (the annulus) are compromised by this lack of pressure. The analogy is that of a car tire, that loses its air pressure, the side walls of the tire bulge out, and the loss of air pressure increases wear of the tires, allowing fissuring. Eventually, the car tire gives out. In this same manner, the disk bulges out, potentially irritating nerves, and with a blow-out of the disk, there is the so call disk herniation.Go to Spine Animation to find an animation on Degenerative Disk Disease.
How often do people get disk herniations?Disk herniations is expected and found in the supra-majority of people. There has been multiple studies looking at the incidence of disk herniations, and it is accepted that by the time your age in in the mid-40’s, most people will have evidence of disk degeneration and protrusions. It does not mean that these findings are symptomatic. But, if we perform diagnostic tests such as MRI’s or CT scans on this population, we will find evidence of disk changes in the majority of this population. What does this mean? Your back pain and leg pains may or may not be from the findings on your tests. You and your physician need to take a detailed inventory of your complaints, to determine whether the findings on your tests correspond to your current medical presentation. As prudent physicians will tell you, we treat your conditions and medical complaints, not your imaging studies.
Does every disk herniation need surgery?The answer is an emphatic NO! The vast majority of disk herniations resolve without surgery. Statistics are on your side. Even with great big hernations, as long as you do not have progressive neurologic deficits, or loss of bladder and bowel function, you can wait to see if the pain subsides. Statistically, greater than 98% of disks resolve without surgery. You already know this is true. We all know many people who decided against elective disk surgery and resolved their pain over time. If the statistic is that over 50% of patients over the age of 45 has disk herniations, then if all of these need to be treated with surgery, we would be operating on more that half the population. There would not be enough surgeons, operating rooms, nurses, and hospital beds to accommodate this. Fortunately, only a small fraction of any of the herniated disks ever need surgical management.
When should a MRI/CT be ordered?For patients with neck or back pain, without any neurologic deficit, and without any history of potential fracture, neoplasm or infection, diagnostic testing such as an MRI or CT scanis usually not necessary during the initial 4 to 6 weeks of treatment.Also, as long as there is no progression of a neurologic deficit, some clinicians will choose to wait before an MRI is performed as a majority of radiculopathies also resolve or lessen within that 4-6 week time window.If there are any concerns about the need for further workup, a consultation with a spinal specialist may be beneficial.In regards to CT scans, one should also consider the Radiation exposure to the patient, before ordering this test for general screening.
When should X-rays be ordered?In adults, the true benefits of x-raysfor general testing in patients with neck and back pain are limited.With a history of trauma, x-rays are necessary to rule out a fracture. Surgeons will sometimes use x-rays as part of their pre-operative planning.But for primary clinicians, x-rays have limited value, although, your patients usually demand one.Usually, if there is a significant x-ray finding (fracture, neoplasm, infection), a clinical history will be more valuable in the diagnosis than the x-ray.
Patients with osteoporosis can have fractures with very trivial forces. If the clinical exam is suspicious for fracture, an x-ray may be helpful.