There we go. First thing we're going to do is start off with some bench research that we kind of do the basis of all the stuff that we're going to talk about. That's really bullshit. This is really based upon 28 years of doing this, okay? And so you can talk about all the bench research that you want, but the reality of it is when you're in the trenches and you deal with it on a day-to-day basis, that's a completely different animal than the academic research. And so this is based on a bunch of years of dealing with players, their agents, their GMs, their parents, their doctors, and then all the guys in the surgery lounge. So one of the things that I learned a long time ago is treating a high-profile athlete is work comp with an audience. Okay? You're not getting one opinion. It's in the newspaper. There are a thousand opinions, and you start getting phone calls about the best way to do it. And so quite simply, we're going to do – there's kind of three take-homes from today. Lumbar disc herniation, stress fractures or PARS fractures, and cervical disc herniations. Lesson one is about lumbar disc herniation and how to discern some things that you can play with and can't play with. And so here's just a picture of a lumbar disc herniation, and here is the disc herniation, okay? The normal outline is across here, and these are the neural elements that are being compressed, and this is an axial. And so, you know, it's pretty common. I'm sure every one of you guys have seen it. Size and location do matter. I've seen big ones that don't hurt. I've seen small ones that are killing you. And so it's kind of like real estate. It's location, location, location. One of the things that I'm going to try to teach you today is discern between what is an extruded disc and a contained disc, because they're two different animals in the way they play out and the best way to treat them. The extruded disc is kind of, think of the disc like a jelly donut, okay? You push down on the jelly donut, out it comes, right? And so sometimes the jelly is just a little bit out, but sometimes the jelly is all the way out and has no attachment to the mothership, and that's extruded. When it doesn't have attachment to the mothership, it has a great chance of being reabsorbed by the body, whereas the one that's partially contained or still has a stalk that's reaching into the disc space, it's still getting communication and it can hang around for a long time. And so here is an MRI, the difference between a contained disc herniation and extrusion. So can you see my pointer? Oh, great. So this is a contained disc herniation here, okay? And then over here to the right, if you look, this is L4-5. You see this disc herniation comes all the way down and trails out the back. You see this? Whereas this one is just... So this herniation has come out of here and then has traveled caudally, all right, and really has almost no connection to the disc. So disc extrusions are incredibly painful, okay? And the reason that is it takes a lot to have an extrusion. I mean, it's a blowout, right? So just like what I tell my patients, it's just like having an ACL tear, okay? ACL tear, a guy comes into the clinic, you know, his knee's big, red, hot and swollen, okay? And that is not the size of the ligament tear. That's the chemical inflammation associated with it. You know, that's going on in the spine, but it's that far below the level of the skin. You just don't see it. So there's a very powerful chemical neuritis that's going on along with the mechanical problem of this disc pressing on the nerve. So it's salt in the wound essentially. And so your goal is to try to get the inflammation under control. So there's a chemical irritation and then there's a mechanical problem. And so you can't really do anything about the mechanical problem, but you can certainly knock down the chemical problem with an anti-inflammatory. And so one of the ways to discern this is, so this is the injury. Once again, this is the extruded disc herniation here. And on the STIR signals, which really highlights inflammation, you can see how bright it is here. That means it's got a lot of water content in it, and that means it's all the way out. And those are the ones that have the best chance of being reabsorbed. So here's a little clinical vignette. So here I'm dealing with this guy, and he's a really good football player. He gets hurt in training camp August 3rd, okay? So, you know, if you're familiar with NFL season, it's quickly approaching. And he shows up with back pain and right lower extremity radiculopathy or leg pain. He's got some weakness in his tibialis anterior, his foot dorsiflexor, okay? Somewhat important when you're playing offensive guard. His EHL is weak, and, you know, having a weak EHL means nothing, but it does indicate what the problem is. So how do we treat this? So we're going to knock down the inflammation. So we give him a MedDRAW dose pack, and that quiets it a little bit. And then we say, you know what, we're going to really knock it down. We do a SNRB, which is Selected Nerve Root Block. And so it's the Willie Smith comparison. So Willie Smith is a famous bank robber, and they ask Willie, why'd you rob the bank? His response is, that's where the money is, okay? And so if all the inflammation is right there at the L5 nerve root, we'll put the medicine there. That's going to give you the best chance. So we start doing serial exams because we want to make sure he's not getting weaker, okay? And start him on a core program. And you've got to remember, he's not like you and I. He's a different breed of cat. So he missed all the preseason. The opening game was September 8th, and he played the entire season. So on postseason imaging. And so I know this, and I treat him like this because it was an extruded disc, and I know that if I could get him over the inflammation and make sure he wasn't getting weaker, there's a pretty good chance he could progress. And so once again, this is the preoperative imaging here, or preseason. And then postseason, all that's gone. All he has is this little remnant right here. And he did great. He played the entire season, went to the Pro Bowl, the whole nine yards. So the take-home here is figure out whether it's contained or extruded. Know that the extruded disc has a great chance of reabsorption. You know, aggressively target it, okay? Where's the problem? We're going to treat the problem. Make sure you're doing serial exams, and then obviously counsel the player. Lesson two, stress fractures. You guys see probably lots of stress fractures. What do you do about it? And so in general, you know, 4% to 6% of the population has a stress fracture. Rolling around out there, they don't even know it. Those are old ones. Those are the ones that are kind of, you know, that happen naturally between age 9 and 15. But in the athletic population, the young, about 15% of kids will get a stress fracture. And in Major League Baseball, probably 20% of a 40-man roster has an old, unhealed stress fracture because that's just part of the game. You know, it's like having your elbow injury or your shoulder problem. It's very common in baseball. So how do you look at it? So this is a Jackson's Maneuver right here. This is the best examination to realize if they have a stress fracture or not. Stork test, Jackson's Maneuver, whatever you want to call it, but standing on one leg, arching back with ipsilateral pain. If it's really hot, both left and right side will give you whatever side it is. And so it's a very specific test, and it's one that you should do when you're looking at it. So what x-rays do I get? I don't get obliques. Obliques are hard to take. Obliques are hard to look at. And if it's an old fracture, you're going to see it on a lateral film, particularly a flexion and extension film. And if it's a new fracture, you're not going to see it because it's really a stress reaction or a very subtle fracture. So here on the lateral, you can see that little line that goes through. And so once again, you don't need obliques to see that. And so on an MRI, you're looking for edema. And so what you see over here, this edema shows up in the pedicle. That's a first sign of a stress reaction or stress fracture. And on the STIR images, you see how bright this is in the pedicle? That's indicative of a stress reaction or a stress fracture. So it's a fracture, okay? No matter what you say, you've got to treat it like a fracture. And so the only way to really immobilize them effectively is ask them to immobilize it. No one's going to effectively immobilize L4, L5. You have to put them in a LSO with a thigh cuff or a Spica. No teenager's going to do that. I mean, it just doesn't work. So you just ask them to immobilize themselves and then re-examine them about 4 to 6 weeks. If their exam normalizes, at that point, you can start them on some aerobic conditioning and you can do some spine-neutral core stuff. And then at 3 months, okay, and once again, it's a fracture, so you've got to let it try to heal. At 3 months, you can start them on a graduated program. And if you look at the literature, probably only 50% of L4 and L5 will heal. 95% don't have a problem at a year, even whether it healed or didn't heal. But as a doctor and a parent, you know, you want to give that kid the best chance for that thing to heal because if it doesn't heal at age 41 or 52 or 63, he may develop a slip that requires some type of surgery. So you want to confirm the chronicity. Sometimes we inject in old PARs with steroid. Sometimes we'll do a nerve ablation to try to treat it. That works well and work on your core. So I see probably five cases a year where someone has a chronic fracture and it just kind of gets blown off. You get an MRI, so they have a chronic fracture at L5, but they have a new fracture at L4 that you have to treat. So make sure you get an MRI to at least evaluate that. Sometimes you need to get a CAT scan. And so can you treat it with surgery? Sure you can. I've never done it, and I've been doing this a long time. So rehab works, okay. There's no reason for someone to have surgery for a PARs defect. It's just not necessary. And it's hard to know what you can play with. Here's another vignette. This is a major league catcher that I took care of for a long time. Bilateral defects, L3 and L5, a disc herniation or an H&P at L3-4, and a degenerative disc at L2-3, okay. I mean it's a shit show of what he's got going on in his back. So what happens to him? Seven silver sluggers, 13 gold gloves, MVP, catches more games than anybody in the history of major league baseball and goes in the Hall of Fame. And you would never guess, given those radiographs and MRIs, that you can do it. But this guy was very diligent about doing his core. We managed it, and he was able to do it. So the key here is identify the problem, manage it, and just progress him. So the take-home comment to kids, do an MRI, rel at the acute fracture versus a chronic fracture, don't operate on it, and work on the core. Here's the last vignette, the occult cervical disc herniation. So cervical disc herniations are best seen on MRIs, but there's some MRIs or there's some herniations you can't see on an MRI. Out in the neuroforamen, the artery and the vein are coming and going, so there's a flow artifact, and so sometimes that can obscure the disc herniation. So I saw this professional shortstop. I get called, he's got new weakness in his left arm. He's right-handed, lead arm in a swing, and at the time he's the highest-paid athlete in the world. So there's a little bit of stress involved, about 1,000 second opinions. So we fly home from spring training, we go get an MRI, and the MRI is nothing. I mean, but I'm telling you, this guy's weak, right? So looking for a foramenal disc, I get an IV contrast CAT scan. Intravenous, okay? Dyeing the veins and the arteries, right? And so what you're doing is you're looking at the contrast as it goes out the neuroforamen. If there's no contrast, that means there's something sitting out there blocking it, okay? And sure enough, that's what he has. And so you can see just a little blip of tissue right there that shows he's got a foramenal disc extrusion. So same thing. Targeted some steroid injections, did some physical therapy. The guy had a weak tricep. He was angry with me because I'm big enough to where I have good leverage, and so I'd see him in the training room and I could still bend him back and check his triceps. But the guy had a great season, won his MVP, has gone on and had a great major league career. So the take-home lesson here is if you have what you think is a cervical radiculopathy, the MRI is clean, get an IV contrast CAT scan or a monogram and a CAT scan. And the other take-home lesson is never let a test stand between you and the diagnosis. So in review, lumbar disc herniation. Look for an extrusion, okay? Stress fracture, MRI. Occult cervical disc herniation. If you have a negative MRI, get a contrast CT scan. One of the last things that Giat wanted me to talk to you about, and I'll just mention it briefly, is cervical disc arthroplasty for people with a herniated disc. And in the NHL, four players have gotten it. And my stance on it, that's crazy. You know, I've stood on the sideline for 20 years watching football injuries, covered professional bull riding, professional rodeo. The forced couples that are created on a football field and in rodeo are not you can't recreate that in a lap. There's no way a cervical disc arthroplasty can hold up to that. So we're in the process of generating a white paper. So if one of your athletes that's in a collision sport is thinking about having an artificial disc, I would say no. And one of my things is never ignore a visceral reaction. After standing on the sideline for that length of time, if I'm sitting there and I'm covering a game and that guy's got a cervical disc arthroplasty in, my stomach hurts, okay? And so I would tell you emphatically I would not do that. Thank you very much.

athletes' injuries

practical experience

lumbar disc herniation

stress fractures

occult cervical disc herniation