I don't know if Julie Ducey's out there. I need to update my industry relationship. Typically, I'm probably the only spine surgeon in America that doesn't have any industry relationships. But I think sometime late last night, I became the official spokesperson for Casamigos Reposado. So I just wanted to add that in. So now that I have your attention. So I want to talk to you guys about some lessons I've learned in treating athletes. And so I wanted to start off with some bench research. I'm just kidding. Not my strong suit. My strong suit is 30 years of experience. And that's dealing with all the same things that most of you guys deal with. And that's the players, and their parents, and their coaches, and GMs, and trainers. And as my good friend John Conway told me, the difference between seeing a pro athlete and a high school athlete is five phone calls. And so one of the things that I've learned in my time in treating high-profile athletes, which is work comp, but the only difference is it's work comp with an audience. The entire world gets to know what you're doing. For instance, some guy with a hand injury goes to Los Angeles. Well, what happened? Well, he went and saw Dr. Shin. And so the entire world knows, well, he showed up. Well, the entire sporting world knows he showed up on a Tuesday to see Dr. Shin. He was told he had this injury. And so everybody's sitting there wondering, well, when's he gonna come back to play? So it is an audience that you're dealing with, so be prepared for that. So today, I just really have three lessons I wanna impart upon you and common things that you'll see during your coverage. And it's a disc herniation, how to deal with stress fractures, and cervical disc herniations. So the first lesson's about disc herniations. And all right, here we go. Here's a big disc herniation. This is L5-S1. And the disc herniation is this big glob right here. And so I always talk to the players about disc herniations and try to break it down in simplistic terms. And my analogy is a jelly donut. And you push down on a jelly donut, and some of the jelly comes out. You know, you can say slipped out, it ruptured out, it herniated out, it protruded out, extruded out. They all mean the same things. Like, it's semantics, which they don't know what that word is. Then I say it's like saying lawyer or attorney. And so what I'm gonna impart upon you today is trying to figure out this third thing, trying to discern whether it's a contained disc herniation or an extruded disc herniation, because it makes a difference in your treatment. And the reason is once it's extruded, okay, you have a better chance of this thing reabsorbing. And so when you think about extruded, think about the jelly donut. You've pushed on it, the jelly's come out, and it's past the donut part, right? There's no stalk connecting it to the rest of the disc. So in essence, it's left the mothership untethered and doesn't have a supply, okay? Whereas contained disc herniations still have a stalk that goes into the disc space and to some degree is not completely out and has a stalk of nutrition. So here's an MRI. This is a lateral view of an MRI. Down here at L5-S1, you can see a disc herniation, all right? It looks very much like the disc there, right? So, and it's got a nice rim around it. That looks contained. And then here, this is at L4-5, you can see this, excuse me, right back here, you see this thing that kind of teardrops down from the disc space, and you have this pretty high signal here. So this thing is out and extruded down behind the body. So contained, extruded. So these disc extrusions are pretty painful. There's two things that happen when you have a disc herniation. There's a mechanical pressure where you have something pushing on the nerve and then you have the chemical neuritis associated with it. And the explanation I tell the players is, you know someone had an ACL tear, right? And their knee's this big. Well, that's not how big the ligament is. That's the chemical inflammation associated with it. And that's going on inside your body, five inches below the skin, so you just don't see it. And so sometimes once you get the inflammatory response under control, the pain gets a whole lot better and they can live with the mechanical pressure. So when you look at an extrusion with high signal, here's the T2 image, okay? So you can see it here, right? I showed you that earlier. And then on the STIR sequence, you look at it and see how high the signal is compared to these areas here, right? Compared to the, you know the nice thing about the spine is you have multiple levels that you look at. I mean the spine is very simplistic in that it's a repeating unit. It can get very complicated at times, but incessant, it's just a repeating unit. So what this is showing is that you have really high signal in this disc herniation, which is represented on the T2 image here. And so the case presentation is an all pro guard and a really good player. Never missed a game before. He has an injury in training camp, August 3rd. And so not much time before the season. You know, his evaluation showed that he had abnormal spine mechanics and he was weak. You know, your tibialis anterior, that's the beginning of a foot drop, if you will, four to four plus over five. And his EHL is quite weak, extensive hallucis, which is not a critical muscle if you're playing football. So what did we do? Well, we're gonna try to control the inflammation. I gave him a MedDraw dose pack. Okay, very simplistic. And then he was still having symptoms. We targeted the L5 nerve root, which is what's being affected. And then I was doing serial exams on him. You know, when serial exams, that's like every two or three days because you don't wanna see this thing progress in terms of a bigger motor deficit and you wanna make sure he's doing better and have him on a core strengthening plan. So he missed the entirety of pre-season and a month later, he started the season. I played the entire season, did really well, was all pro again. And then we did some post-season imaging just because we can, right? And so here is his pre-season MRI, T2, and here's the disc herniation. And post-season, here it is, it's gone, all right? And so it's a good example of identifying that it's an extruded disc, try to get the pain under control and then monitor him. So lesson two, stress fractures. And so very common, I see kids come in, you get an MRI and they have a stress fracture. Stress fractures, when I'm telling them, it's pretty common in the adult, I mean, in the teenage and young 20-year-old population. For two years, when I was covering the Texas Rangers, I was allowed to X-ray all of the people on the 40-man roster. And during that time, about 20% of a major league roster had old, unhealed stress fractures. So it's pretty common. That's like saying, you know, my shoulder kind of hurts in baseball. It's just part of it. So here's some simple tests, the Jackson's Maneuver. Some people call it the Stork Test, where you stand on one leg and you arch backwards. And it creates a focal stress right on the parser and inter-articular errors. It's quite specific and quite sensitive. That's a very young Drew Dossett right there. I've still got a patch of hair right here at the top. So when I get some X-rays, I just get five views. I don't ever get obliques. I think, personally, I think that's a waste of time. If they have an old stress fracture, something that's been there and it's chronic, you're gonna see it, allow an X-ray and you're gonna see it on flexion and extension. And so instead of getting obliques, I would tell you, get flexion and extension films. That's gonna give you more information than an oblique will. So if you're getting five views, those are the five to get. So here's the, you can see, here's the stress fracture that's seen on the spot lateral. And so on an MRI, the T2 signal, so axial here is edema within the pedicle and the pars. And on the sagittal view, you see it here. And what you can't really discern here is that just a stress reaction or is that a stress fracture? And so it's a continuum. And the analogy I use is a paperclip. Unfold a paperclip, start bending it. Okay, it gets a little bit warm. The metal's starting to fatigue. That's a stress reaction. You keep bending it, it breaks. That's a stress fracture. And they seem to understand that, at least while they're sitting in front of you. So how do you treat it? So look, it's a fracture. That's just, there's no question about it. It's a fracture. And so it takes about three months to adequately heal it. And so most of the time you're dealing with 13 to 17 year olds, right? And it takes four to six weeks of rest before the pain gets under control. Once the exam normalizes, meaning this Jackson test or the Stork test doesn't hurt anymore, you can start them on a cardio program and a spine neutral program. You still wanna keep them from bending the paperclip. So you gotta keep them in spine neutral. At L4 and L5, I never brace them. Studies have shown that in order to effectively brace that, you gotta put it across the hip in a Spica type fashion. And no teenager in the world's gonna do that. And only about 50% of them heal at L4 and L5. So that treatment's a little bit different than a chronic fracture. You need to confirm chronicity, which you can do on an MRI. There won't be any signal there. I've treated these with injections into the PARS fracture itself. It's truly a pseudoarthrosis. You get neural invasion, you get synovial cells, and it's a source of pain. I've actually even done rhizotomies there, where, I don't do this, the pain management guys do, where they kill these nerves. And then core rehab and more core rehab. And that's been very effective. So about five times a year, someone will come in and on the plain films, they'll have a clear PARS defect. And then I'll get an MRI, and what you'll see is they have the PARS defect at L5, and at L4 they have a stress reaction. So it's important to keep that in the back of your mind that they can occur together. So how do you fix this? There's several different ways. PARS repair, but I've never done one. 30 years of doing this, never fixed one PARS, okay? People that fix PARS, that kid's out for six to nine months. Let me tell you something. You're out six to nine months, it's gonna quit hurting whether you fix it or don't fix it. And so don't subject them to the rigors of surgery and the complications. And it's hard to know what you can play with. Here's a great case. So this is a major league catcher, okay? This is what you see on his x-rays. L3 and L5 PARS defects that are old. He had a herniated disc on MRI at L3-4. He has a degenerative disc up here at L2-3, okay? At L3-4, he's got this kyphosis, right? And you're thinking, holy smokes, Batman, how's this guy gonna do it? Well, let me tell you how he did it. He worked on his core, and this is his stats, okay? And so it's hard to know what you can play with, and core stability exercises work. So the take home in that, it's very common in teenage athletes. The best test for chronicity is get an MRI, make sure you don't see edema at a different level. Do not operate on it. Don't let any of your spine consultants talk you into saying, hey, we're just gonna do a direct PARS repair. I think that is a total waste of time and puts the kid at risk. So the last thing I wanna talk to you about cervical disc herniation. And so when you're looking at a cervical disc herniation, the best way to image it is on an MRI, but there are signal voids that get created on an MRI. We think that the MRI is the end-all, be-all test, but it's not. It's got its fallacies as well. And so the vessels that course in and out of the neuroforamen, okay, the nerve channel, the artery and the vein, they create a signal void. And so sometimes you can have a disc herniation in the neuroforamen that, frankly, you just miss. Even when you look back at it after you've identified it on a different test, you just can't see it. So I was asked to see one of our players. He's a shortstop, had new onset pain in his, during spring training. His triceps was weak and it was his lead arm and his batting, and at the time, he was the highest paid athlete in the world. So nothing like work comp with an audience. And so we went back to Dallas from training camp or spring training and got an MRI. And the MRI is stone cold normal. I mean, normal, normal. And yet this guy's got, you know, a frank C7 radiculopathy. So how do you look for a foramen disc herniation not seen on an MRI? Well, you get a contrast CAT scan. So you even get an IV contrast CAT scan or a myelogram and a CAT scan. And I chose this IV contrast CAT scan. And so what you see is, this is an axial image. So let me just get you guys situated here. Here is the spine's process and the lamina. Here's where the vertebral body and the disc is. Here are the neuroforamins. This is the cord, okay? The white stuff you see here is the contrast. Those are the vessels, right? And so in the left, excuse me, the right neuroforamen, here are the vessels coming out, all right? All this white. And over here, here's some of the white, right? And all of a sudden, you got this ditzel right there. And that's it. That's the foramen disc protrusion not seen on an MRI. So steroid injections, once again, trying to get the inflammatory component under control. Physical therapy played well that year, despite he was weak the entire year. He was just a fraction under my height. I'm 6'5", and he was probably 6'3 1⁄2". He was pissed all year that I could break him when I checked his triceps. But, you know, look, proof's in the pudding. He did great. So the take-home lesson here was if you have an unexplained cervical radiculopathy, you have an MRI that's negative, get an IV contrast CT scan. And so I probably see this eight to 10 times a year, which is pretty high. And as my boss that I did my fellowship with, Dr. Watkins, said, never let a test stand between you and a diagnosis. So what did we learn? Lumbar disc herniation. Figure out if it's an extrusion by looking at the high signal intensity on the STIRS. These have the best chance for resorption. And then aggressively manage the inflammatory cascade. Stress fractures. Try to figure out if it's new versus old. The MRI's the best for that. Takes about three months when it's new. Old, you can manage and play with well with different things, steroid injections, rhizotomies, et cetera. But also recognize that even though you have an old fracture seen on x-ray, that you could have a new fracture at a different level. And then in a cold cervical herniation, make sure you do a contrast CT scan if you can't see it on MRI. Thank you guys. Thank you.

Dr. Julie Ducey

lessons in treating athletes

disc herniations

stress fractures

cervical disc herniations