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Hi, I am Dr. Mark Studin and welcome back to part two. MRI spine interpretation first, again, I’d like to thank ChiroSecure for giving me the platform for sharing this information. It’s critical to our profession, it’s critical to your practice, and let’s get right to it. So where we left off, um, last time in part one is sharing with you the normal anatomy, uh, of the spine.
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So right now I wanna start talking about disc bulges. A disc bulge is just that this is a normal lumbar spine, and we know it’s lumbar because we see the cord down here. There’s no solid spinal cord, and it’s not the, the, the, the convexity of the, the concavity, I apologize. Right here. It’s popping in. So when it bulges out, it pushes out that concavity to be a convexity.
And we know it’s a disc bulge. Because there’s nothing sticking out. It’s kind of smooth. It’s all the way around. Um, and usually a disc bulge is a minimum of 50% if it’s degenerative and, and usually actually closer to a hundred percent. But in reality, you can have a disc bulge at less than 25% if it’s a directional bulge, which you don’t see often unless the patient is positioned in the tube improperly.
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Or it’s a scoliosis or there’s a high end ligament tearing, which is causing a short curve, um, scoliosis in the spine. So, but the overwhelming majority of the time, a disc bulge is degenerative. Now again, let’s just do a little bit anatomy. Here’s your disc, and you could see the high intensity zone, HIZ, which is the nucleus pulposus.
The low intensity zone or low signal, which is the annulus fibrosis, and you don’t talk about lights, darks, you say high signal, low signal, high signal, low signal, and this is normal. So what we also see here, these are your neural canals. Here is your thecal sack. The circular thing. Circular thing, holding in the quarter.
A equina. It’s like a sock on the foot. These are your nerves. This in the back is epidural fat, taking up the space. Between the ligament and flava and the thecal sac. Here’s your facets. Very clearly defined. And this is a bulging disc. So the bulging disc has lost its normal concavity, and that’s degenerative usually.
So we just discussed this, the red arrow points to where it bulge from going con concave to convex. Now when we look at a disc degeneration, which again is a minimum. De degenerative disc is a disc bulge synonymous, so when there’s degeneration, it’s a minimum of 50% of the circumference. And when you look at it, typically the hallmark is, you look right here, the neural canals here and here equally, they’re usually closed in, but what occurs is is the disc is wearing thin like sandpaper on wood, and the disc walls collapse.
So nothing is sticking out here. You have nothing sticking out. It’s cut. It’s pretty much uniform all the way around, and it’s a minimum of 50%. Now, when we look at a herniated disc, conversely a herniation is a tear in the annulus, a tear in the uh, um, uh, annulus where the nucleus osis goes from the inside out.
So when the nucleus goes from the inside out, that’s a herniation. It could sit on a nerve root. It could sit on the the corta. It could sit the thecal sac affecting the nerve roots on the inside. It could sit on the spinal cord, it could sit anywhere inside the canal. And again, I’ve given you the reference for all these definitions.
Now, when we look at a herniated disc. It’s broadly defined as a localizer focal displacement of the disc right here, beyond the limits of the vertebral or intervertebral disc space, meaning it’s beyond the limits of the bone above and the bone below the disc material may be the nucleus, cartilage, fragmented physeal bone, annular tissue, or any combination there above it might bring the bone with it, and I’m gonna show you an image of that later on.
The disc space is defined. Cranio cord data above or below the vertebral body, um, uh, the end plates and preferably by the outer edges. So when you get to focal or broad based, I’m gonna not read this, I’m going to show you pictorially. So when we look at a herniation, you see, we showed you before it was straight across.
That was a bulge. This is sticking out. I’ve gone through the effort of colorizing. The actual lesion for you, showing you, in this case it’s in the quarter, a equina. This is the lumbar spine and it’s really, it’s compressing the corta a equina because it’s pushing the quarter back into the ligamentum flower.
So it’s pushing on top and the bottom. So this would be defined as a central, as a large central herniation, which is s stenosing, the central canal by about 40 to 50%. And it’s compressing the fecal sac, um, uh, between the herniated disc and the ligament of flava. And it’s catching, you see the screen line here on the right?
Um, L five. It’s catching the L five s one nerve root as it’s exiting. It’s very simple. You get to see all these things and see why this is on the right side. MRI is read right and left. It’s reversed and on every image you’ll see right and left. But you get to see why your patient’s in pain and you’ll be able to understand it and help them better.
Um, and you get to make a clinical decision of how you want to treat this patient. I mean, I know how I would do it, and it really doesn’t depend upon the image. If they have serious motor loss or sensory loss, I’d want to co-manage this. I might not want to deliver an adjustment. I don’t know if I’d want to get in there and decompress it.
I’m not sure. It really depends upon the patient. I might, I might put ’em on SOT blocks, I might ice ’em, I put ’em on bedrest. It all depends on the patient, and you get to make those decisions knowing what’s going on with your patient. Now we’ve got a focal herniation, which is zero to 25% of the circumference or broad base, which is 25 to 50% of the circumference.
Which one is worse? Well, the arbiter between good and bad of space, occupying lesions with respect to the spine is that which compromises the neurological element the most, and in this case. Which is counterintuitive is the focal herniation versus broad base, because focal usually sticks out further and catches the nerve.
So the nerve neurosurgeons all tell me focal is usually a lot worse, even though more disc material can come out in the broad base scenario. Now, here’s what it looks like. Here’s a focal herniation. Again, I’ve colorized it for you. Here’s what it looks like on the sagittal side view. Here’s what it looks like on the axial top down view.
This is a focal herniation. Now I’m gonna throw a couple of other things in there at you. This is the posterior longitudinal ligament. All this under is an epidural vein, and this is called a varix or inflamed epidural vein. But this is focal. This is also focal extruded, but I’m gonna talk about that in just a few minutes there.
And here’s your phylum terminality. I can’t see where this almost appears. This is not like the court’s coming down, the conus, meis. It just seems a little low. It might be, but I can’t tell in this sequence. So here’s your bone, here’s your disc. High zone, low zone. There’s line going through. It is normal.
It’s a little bit darker. It’s desiccated. Desiccated means drying out. This is not an indicator of age. Because all it says is the water went from here to here on the outside. That’s what it means. So the inside got dark ’cause the water run on the outside. Um, and the water’s also the same color as the inside.
So this is a relatively new herniation. Here you’ve got a schmorl’s node, and I can’t tell on this sequence if there is a bone edema, which is called e modic change. We’ll get to that in a different time. But there’s a lot you can tell from just these limited sequences. As we report this, we get a little bit more funky, and we’re going to say Mrs.
Smith’s lateral, uh, uh, side view. This is a, there’s a reference on here. Yellow ellipse is the, uh, thecal sac. Then the green ellipse is the cord aqua being compressed between the pink, uh, posterior canal and the. Which is green. So I’ve actually colorized this to make it a little bit more understandable to the reader.
You’ve got a herniation. You’ve got the fecal sac, which is the uh, red here. Actually, this is the, I said, I just said that wrong. The orange is the depth of the herniation. The red is the outline of the herniation. The yellow is the fecal sac, the green is the neurological element, and here the pink is the epidural fat.
So we’re getting to CDs from two different things, and this is how I report things so people can understand, and it’s really important to understand. If you look at the lesion and look at the opposing view here, it really gets quite in depth. So there’s a lot going on. So when we look at this and we look at a focal herniation, and I know I just got a little esoteric with you, but I want you to see it.
Let’s just look at, here’s a T one weighted image where water is dark. Here’s your herniation. I’ve colorized it for you. Here’s your herniation, I’ve colorized it for you. It’s less than 25% and you need two views to conclude an accurate diagnosis. And this is obviously, um, in the cervical spine because we see a spinal cord.
We see a spinal cord and the nerves lining up to exit over here, and these are your neural canals. It gets a little bit crazy, but it’s easy. Now we’ve got a C six seven broad base herniation. 25 to 50% and I’ve colorized it for you here. Here is the opposing sagittal view. It gets a little crazy, but once you see it over and over and over again, and if we colorize the whole thing right here would be the whole outline of that herniation.
But here it is causing a compression of the spinal cord because you see a little bit of CSF here, you see none all the way around. So this is compressing the spinal cord. I don’t think I would touch this patient. Why? Because when you deliver a high velocity, low amplitude thrust, you create in increased intrathecal pressure, you’re increasing the size of this herniation where it’s gonna thump that spinal cord.
And I don’t want to do any damage to the court. You’re doing boom, each time to a spinal cord. That’s very problematic. So you might wanna wait a couple of weeks or a month or so. You might want to co-manage with, with a different type of provider. Depending upon the patient’s clinical presentation. Do they have serious motor loss areflexia?
You have to know how long it’s been there. Are we looking at cord edema? It looks like there is a little bit of cord edema going on here ’cause the cord’s swollen. The next step from that is mylo is, is, um, myelomalacia, the cord’s gonna start to die. So I want to get this decompressed quickly. This person might not have the, the, the, the liberty or the leeway of waiting so much time.
And that delay can cause permanence, spinal cord damage. And we’re talking for the rest of their lives. And by the way, if it’s early on and you want to treat it or, or, or, or take a, a gamble, that’s okay. But that’s your clinical decision. Me, I see cord edema. I’m getting ’em to a surgeon. Uh, immediately.
Immediately, because that spinal cord’s gonna die. I could adjust them and I could wait and I can put ’em on decompression for 4, 6, 8, 10, 12, 15 weeks until it comes down. Uh, put laser on ’em. I’ll do whatever I want. Symptoms might ease up, but if this is not fixed, this is gonna die. Literally die, and it’s just not gonna come back.
You know, that’s a clinical decision you have to make. I’ve made my decision and my decision is I want to get ’em after that part is fixed and it’s decompressed. It’s a little bit too far gone from my comfort level. This is a bi lobular herniation in a broad base scenario, and you see how crazy jagged it is.
It’s not like a a perfect ellipse. This is a sack of jello going in every different direction. So here’s what it looks like here, but. Here’s what it looks like here. And the sagittal will help clearly define what’s going on. No one image is going to give you your picture. Everything has to define what’s going on.
So then we look at a protrusion versus an extrusion. A protrusion is like a pyramid, okay? And an extrusion is like a mushroom. So protrusion is where the base is wider than the apex at any plane. And an extrusion is where the apex is wider than the base at any plane. So here we have a protrusion. The base is wider than the Apex base is wider than the apex.
Here base is wider than the apex. We have a protrusion and here we go again, base wider than the apex. These are protrusions. If we look at it here, here’s the base, here’s the apex. That’s a protrusion and it’s, and it’s, um, sing the neural canal. And I’ve colorized things to make it easier for you. Then we’ve got an extruded disc.
An extruded disc can be migrated, or common unit meaning attached or fragmented or sequestered. They’re both extrusions. So here is an ex, here’s an extruded disc. Here’s the bone, here’s the bone, here’s the disc, here’s the herniation, the extrusion type herniation. So here’s your disc level. You see these little dotted lines.
This is telling you your disc levels based upon the anatomy. So if the disc material comes out. Go Cephalad or Caad above or below this disc level. That’s an extrusion. Simple. It’s an extrusion. So when we look, this is a huge extrusion here. Here. We look at it, it’s extruded. We outline it, and then I give you the lines.
So now you understand how to identify that. Again, a different one. Here’s an extrusion. This is a huge extrusion. Look at it. Come down. Here’s the line of the disc, the opening of the disc. This disc material has gone well, cephalad, this is an extrusion. This patient had a subsequent trauma, and this literally got cut off and fell down into the neural canal.
This poor woman’s in exquisite pain, and the radiologist missed it, and the orthopedic surgeon missed it, and the pain management doctor missed it. And, and, and Dan, well, guess what? We didn’t miss it. We found it, and we helped her get it fixed. She’s had exquisite pain for I think maybe a year, year and a half.
No one knew why it was absurd. So this is a huge extrusion, and I’m not going to go through language with you. I’m gonna take, um, it’s just a little bit too crazy. I’m not gonna get into that right now. But everything we do is referenced everything. Here’s another extrusion that goes above and below, above and below.
And here you could see it sits. The central canal and lateral recess and a hundred percent stenosis net. Neural canal, a hundred percent. This was missed by a general radiologist in Nebraska who refused to talk to my chiropractor, who I trained, and I got the guy on the phone and I told him, I found it, got him to the surgeon, and I prevented his license from being lost.
So here’s a huge, huge, huge extrusion and it’s problematic. Now, here we have a fragment. When you have a disc piece that comes out and breaks off. It breaks off and it breaks off. This is a fragment. Okay. It’s an extruded material that is displaced away from the side of the extrusion. Um, despite of the continuity of this may be called migrated, but once it is away from the body of the disc, it’s sequestered or fragmented.
It’s, it’s, it’s still extruded, but it, it can never be a protrusion. It’s an extrusion and it’s sequestered. So here’s what it looks like. This disc material. Here it is. It fragmented into the canal, and you could see it down here fragmented. In fragmented. See that right here? This big pieces of fragment.
There’s no continuity with the disc. There’s a lot going on back there. Not a little amount, a lot amount. So chiropractors we can handle, most of us can handle a protrusion, chiropractor, can handle about, and this is not evidence in the literature, this is my opinion, uh, can handle about 80% of extrusions that are migrated, a common unit or attached.
Uh, pain management may be about 30% of the time and neurosurgeons 5% of the time. Once that’s fragmented off, don’t touch, don’t touch right to the neurosurgeon. Patient’s gonna be in exquisite pain. That’s an easy triage. It’s easy, easy, easy. Folks, this isn’t hard. This isn’t easy. It just takes a little bit of a focus.
If you wanna learn, take your camera out, take a picture of that QR code, go look up your, your academic choices. They’re all. Um, uh, co-taught and professor through Harvard trained neuroradiologist, stonybrook trained, I mean, all over the, all over the, all over the country. You get, and you got a lot of great chiropractors training as well.
So we’ve got a lot of opportunity for you to learn because this is easy, but it’s not easy. You need to see it. But you need to understand it. And if you ever have a question, just call me. So folks, I’d like to thank ChiroSecure again for giving me the opportunity to do that, to do this, and we’ll see you on the next show.
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