Good morning. Thank you for inviting me to talk. And so I'm going to give you my perspective on spine injuries. Okay. Okay. Here we go. The first thing you have to do is really talk about bench research and how we've come to these conclusions. I'm just kidding. This is based on 27 years of experience dealing with coaches and agents and players, their parents, general managers, et cetera. And more importantly, the surgeons in the lounge. And so I'm gonna try to give this to you in 15 minutes. Everybody here has treated some high profile athletes and what I've learned is that when you treat a high profile athlete, it's like work comp, but it's with an audience. You know, they're not getting a second opinion, they're getting a thousand opinions, right? Everybody and their brother wants to chime in on what's going on with them. So you know, you guys are going to be here for, I don't know, three days. You're going to learn a million things. From my talk, really you'll need to learn three things. So I'm gonna give you three lessons that I've encountered, three kind of take homes. And if you stack that to every 15 minute talk, you'll probably leave this meeting with, you know, 150 new things. So lumbar disc herniation, pars or stress fractures, and cervical disc herniations. And so all these three things that I'm about to talk to you about, I got brain burn on them. And brain burn is when an event happens and it's so impactful, it singes your cerebral cortex and you never forget it. It's like maybe the first time your dad spanked you or, you know, the first time you saw a really important athlete and you had a big problem and it just burns into your brain. So the first one is a lumbar disc herniation or HMP, herniated nucleus pulposus. So here's a classic showing of an actual view of L5-S1 and this area is the disc herniation. And that is a big disc herniation. So this is a pretty common problem in our athletic groups. Size and location do matter. The bigger they are and where they are really make a difference in whether you can treat this operatively versus non-operatively. The key thing here is discern between contained and extruded. That's the lesson I'm going to give you today. The extruded disc herniation has very little contact with the disc. I mean, it's outside the mothership. It doesn't have a source of hydration. It's out. And it has an excellent chance of resorption. So here are two slides. One on the left is contained. And if you look at the disc herniation, you can see where it's right there at the level of the disc. You can see a nice little capsule around the top. So it's a capsule or pseudocapsule. So that's just the annulus that's just barely holding on to it. So think of it like a jelly donut. And so there's still part of the donut that's holding the jelly in. Now the one on the right is an extruded disc. And this disc herniation goes all the way down to there. It's in what we call the lateral recess, which is a really tight quarter. And then it's going out into the neuroframing of the level below. So when you have a disc extrusion, it's typically the most painful disc herniation you're going to have. You have to have a fairly significant injury for it to extrude. And there's significant chemical neuritis inflammation. It is a prostaglandin and leukotriene party. If you have a contained disc herniation and you have a little bit of the annulus just hanging on to it, you're not getting this chemical seep through that pseudocapsule as much as if you have an extruded piece of disc material, it is chock full of leukotrienes and prostaglandins. And it's just pissing off the nerve. And so if you can get the inflammatory response under control, you got a chance. So here's that same MRI with the extruded disc on the left. Once again, here's the extrusion. And when you look at the STIR sequences, look at the levels above. You can see the black dots are the nerve roots. See them? You see them? All you see here is high signal. So when you see that, you know that there's a very good chance that if you can get the inflammation under control, that they're going to get better. So here's my vignette. So all pro-guard. The guy's never missed a game. He gets injured training camp. First week. He has severe back pain, right low extremity pain, abnormal spine mechanics. What does that mean? In their language, they say jacked up, you know, can't bend. You know, you do a supine straight leg raising, his hemipelvis comes off because he's protecting it. His tibialis anterior, his dorsiflexor is weak. His EHL is weak. The EHL is not critical. You know, I've operated on NFL running backs with near drop foots from a 4-5 disc herniation. They'll get their tibialis anterior back and they'll never get their EHL back and they go back and perform. So the EHL, although it's indicative of what the injury is, it's not a functional problem, but it does lead you down the right path. So we're out at training camp. First thing he gets is a MedDraw dose pack, very effective, calmed it down, came back pretty quickly. As soon as it came off the pack, got an MRI, the MRI showed that disc extrusion that I showed you. So we do a targeted selective nerve root block, SNRB, selective nerve root block. And so there's, you have to be careful with your pain management docs. Everybody has their own kind of little bit of lingo, but if you work with someone or your spine consultant works with somebody, they usually have a go-to guy that can do these injections. And I've had someone doing mine for 28 years. So started doing serial examinations. He was getting better. His strength was slowly getting better. It certainly was not digressing. Put him on a core strengthening program. The athletic trainers are working with him. And never forget, the guy's a beast, right? He's not like you and I. I mean, he's a great jungle cat. We think we're like them, but we're not. So he missed the entire preseason, started the opening game September 8th, 38 days later, the guy started in a football game, maybe 36 days. He played the entire season. And so after the season, we got another MRI. And so once again, on the left, here's his extruded disc. And on the right, he's got this little bitty blip here. And so the take-home lesson of this is you have to discern between, is it extruded? And if it is, it has a great chance of being reabsorbed. You got to get them over the inflammatory aspect of it. You treat them very aggressively in a targeted fashion. Identify the nerve that's at risk. Make sure you're doing serial examinations. But the knowledge that, look, this is an extruded disc guy, and there's a pretty good chance if we can get your pain under control and you're not losing any strength, that we can get you through this without any surgery. It's factful information that's helpful for all involved and helps you make decisions on injury list, et cetera. Lesson number two, stress fracture in lumbar spine, new versus old. So par stress fractures, 4% to 6% is found in the general population, probably 15% in a athletic adolescent population. For two years when I started in baseball, we took x-rays of everybody on the 40-man roster for the Texas Rangers, and about 20% of the 40-man roster had old, unhealed stress fractures in their back. That's how common it is. So here's a Jackson's maneuver. Some people call it the Stork maneuver, and if I did my research right, I believe the Jackson's maneuver is actually named by Douglas Jackson, who is a sports medicine guy that worked with Leon Wiltsy, who is a very well-known spine guy in Long Beach. And so this one-legged hyperextension, this is the best test for a stress fracture. It produces focal stress on the PARs, and it's very specific and it's very sensitive. Usually gives ipsilateral pain that comes off the chart. What you have to be careful about is when you're doing the serial examinations, they know what you're looking for, and so I always look at their eyes, and so if I see them once and they say, oh no, it doesn't hurt, I know they're lying to me. What x-rays do I get? I get five U's. What I don't get is obliques. If it's in a chronic fracture, okay, you're going to see it on a lateral, and you're really going to see it on a flexion lateral. If it's an acute fracture, you're not going to see it. It doesn't matter whether it's an oblique or not. So I'm more interested in getting flexion extension films and seeing whether there's an instability than I am getting an oblique. So here's your classic spondylolisis, a little fracture through the PARs of L5. Currently, an MRI is probably the best test to get for this, and so on your left, what you see in the, this is the L5 pedicle, and you see all this edema, okay, and that's first where it shows up, even though it's in the PARs interarticularis, the first place it shows up is in the pedicle. And then on the right side, this is a STIR image, and you can see this white signal that's indicative of a stress fracture. So we don't know whether it's a stress reaction. We don't know whether it's a stress fracture. You know, it's a continuum, and what I tell my patients, it's like a paperclip that you unfold and you're bending it, okay? If you touch it where you're bending it, it's hot. It's going through some metal fatigue, okay, that's a stress reaction, and if you keep on bending it, it's going to break, and that's a fatigue fracture or a stress fracture. So we're not exactly sure where we are in this particular thing. You can get a CAT scan if you want. Most parents, teenagers, don't want to have that. College and pros, you can do whatever you want. So how do I treat them? If it's an acute fracture, it's usually a three-month time frame. I feel it's incumbent upon me as a doctor and a team physician and a parent that if someone's got a stress fracture, I want them to heal it, okay? Because if they don't heal it, there's about a 5% chance sometime later in their lives they're going to develop spondylolisthesis that's going to require an operation. So four to six weeks of rest. I don't put them in a brace, typically. I ask them to just limit their activity. See them back. Once their exam normalizes, meaning the Jackson's test is negative, then we start them on an isometric core program and some non-impact cardio, and then at three months, we start them on sport-specific exercises and get them back to play. If you looked at all these in a year, probably only about 50% of the stress fractures at L4 and L5 heal, but about 95% of them don't hurt. Treatment of a chronic fracture is a little bit different. You need to confirm the chronicity of it, and that's pretty simple because if someone comes in, you're going to get an MRI, you're going to see whether they have high signal. Most of their pain is coming from their PARS fracture, and so if you look at the histology of a PARS fracture, there's actual neural invasion into that fake joint. You can inject the pseudoarthrosis site or the PARS site and give them some lidocaine and some steroid, and typically they'll get a pretty good response to that. You can also go back and do what's called a rhizotomy, or medial branch radiofrequency ablation, but that works pretty well as well. It's not going to give them long-term relief, but it is going to get them through a season. Once again, rehab, rehab, and more car rehab. About five cases a year, I see where someone comes in and it's pretty clear they've got a chronic defect, and they're hurting, and you get an MRI, and sure enough, let's say they have a bilateral L5 fracture, and then at L3, they have a new stress reaction. So don't get misled by what you see just on the plain film, because it occurs. So the surgery, you can do the direct PARS repair. There's several techniques. I've never done one. I've never had to, and time and rehab work. So these people that are, I hate to sound disparaging against my SPON colleagues, but some of them will operate on anything, and operating on these things, in my viewpoint, is totally unnecessary. You know, you operate on them, and they're out six months. Well, shit, man, if you set them down for six months, they're going to get well anyway, and you know, you save them an operation. Here's my vignette. It's hard to know what you can play with. So here's a major lead catcher. He comes to you for clearance. He's got L3 and L5 PARS defects. He's got a herniated disc at L3-4. You can see his degenerative disc at L2-3. I mean, he's got a scallop out at the top of his disc space, I mean, the bottom of his disc space there. He's got some instability here at L3-4, right? But the guy's a beast, does a lot of core, and you say, should we sign him? Should we not sign him? Well, what if I told you this guy went on and did this? So there's the value of core stability. And so some of these, even though it looks terrible, it's amazing how functional they can be with these PARS defects. And so you just got to be, you just have to have a perspective that allows you to look at it that way. So the take home is it's pretty common in teenage athletes. MRI is the best test for both chronicity and for acuteness. Rule out an acute fracture at another level. Don't operate, or at least don't let your spine consultant talk you into it. And lots of core exercises. So lesson three, the occult cervical disc herniation. This was the massive brain burn I got early in my career. So cervical disc herniations are best imaged on MRI. And so the neuroframing vessels are already in the vein, coarse out, and they create what's called a signal void. And so that flow artifact obscures disc herniations out in the neuroframing. So I had a professional shortstop. I'm at an away game in spring training, and I get called down to the clubhouse. And this guy's left arm is weak. His triceps is discernibly weak. Okay, it's four over five, and that's his lead arm. And it just so happens he's the highest paid athlete in the world at this point in time. So it was owner of the team, it was a GM, it was an agent, it was a shit show. And so we fly back to Dallas, get an MRI, and the MRI is totally normal. I mean, cold normal, right? And so it's like, there's no way. This guy has got a C7 radiculopathy. So we look for the foramenal disc, and we get an IV contrast CT scan. So you're looking in the foramen, so you want to fill the foramen up with some type of contrast. And so sure enough, he's got a left C7 disc herniation. So just follow me here. So vertebral body, okay, spinal cord, neuroframing on the right. You can see the dye, this white is the dye going out in the vessels. Over here on the left side, you see this little ellipse right here? And there's no dye? That's where the foramenal disc herniation was. And so we got the diagnosis, steroid injections, physical therapy. This guy had a weak triceps all year. I'd go in and examine him, I could just push him back. So it just goes to show you that, hey, he did need an operation, okay? He was very functional, and he won an MVP that year. So the take-home lesson there is, IV contrast CT or mologram and CAT scan for unexplained radiculopathy, it's a much better assessment for the neuroforamen. And as my boss, Bob Watkins, told me, never let a test stand between you and the diagnosis. So the three things, a lumbar disc herniation, assess for extrusion and high signal intensity, have great chance of reabsorption. Stress fractures, discern whether it's new or old. Symptoms you can manage and play very well with, and beware of a fracture at a new level in the setting of an old fracture. And occult cervical disc herniation, if someone has a clear-cut radiculopathy and a negative MRI, you need to get a contrast CT scan. Thank you guys.

spine injuries

lumbar disc herniation

stress fractures

occult cervical disc herniation

treatment options