CF 152: Spinal Instability Clinical Pearls & Degeneration and Facets
Today we’re going to talk about Spinal Instability Clinical Pearls & Degeneration and Facets
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OK, we are back and you have found the Chiropractic Forward Podcast where we are making evidence-based chiropractic fun, profitable, and accessible while we make you and your patients better all the way around. We’re the fun kind of research. Not the stuffy, high-brow kind of research. We’re research talk over a couple of beers. I’m Dr. Jeff Williams and I’m your host for the Chiropractic Forward podcast. If you haven’t yet I have a few things you should do.
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You have found yourself smack dab in the middle of Episode #152
Now if you missed last week’s episode , we talked about chiropractors integrating into a medical setting. Make sure you don’t miss that info. Keep up with the class.
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On the personal end of things….. We shall see if we are climbing back after the three day ice storm and the resurgence of COVID has hit us in the last two weeks. We are starting the week, I’m writing this on a Monday….with 120 on the schedule. Of course, we haven’t filled in all of Wednesday or Friday appointments….we have fresh injuries that will see us all three days so those will fill in quite a bit more and I’m hoping to at minimum get back up to the 145 mark that has been our average since Rona began.
Which is way down from my weekly appointment average of 182 from last year. But 145 is decent and I can roll with that until people are more comfortable in getting out and going into public spaces and businesses. Right now, they just aren’t. And that’s understandable.
Many of you live in places where there is widespread mask use and they take social distancing seriously. Well, Amarillo, TX would not be one of those places. We have some of the kindest and most giving folks on the planet here in Amarillo but there is a reason we’re number 2 on the New York Times list of places that are about to go through a bad time with the Rona.
People here just don’t want to wear masks and by golly aren’t going to be told to wear them either. It’s disappointing. For example, just today, my wife and I went to a restaurant we know is not typically busy and we have a little table we can usually sit in where nobody else is around us. That table for the first time was not open today. But there was a table I could see that had nobody near it.
We go to this restaurant often enough that the servers know us and they know we are taking the Rona very seriously. So they sit us away from everyone. We are sitting there eating and when we’re about to finish up, they sit a group of about 7 dudes one table away from us. Not a damn one of them come in wearing a mask. I couldn’t get out of there fast enough. I was disappointed that they didn’t make a choice to wear the masks and I was disappointed that the restaurant didn’t enforce the state mandate to wear them. I was also very disappointed that they chose to sit them next to us. But….while I love my town and I love my people, that’s this area of the country for you.
It’s frustrating as hell. Our hospitals are full. FEMA is here helping us. They’ve brought in over 750 helpers from outside of our area. Our hospitalization rate is almost 40% right now. Yeah….that bad. And we still have people walking around like it’s a hoax and not wearing masks. It’s insane to me.
It’s spiking out there everywhere though. Not just here in Amarillo. Stay safe people. Stay vigilant. It’s our responsibility not only to ourselves and our families but to our elderly and immunocompromised patients and our staff. You may be young and athletic yourself but if you get it, even if all you have is a low grade temp or a minor headache and that’s it…..you still have to stay home and lose income for two weeks minimum.
Be smart. Don’t be one of these vitalists out there thinking they’re freaking superman because they got their adjustment this week. That’s the most insane of all. Sorry vitalists. It’s true.
Yes….dammit….I’m a bit gripey today!! Why do you ask?
I’m just done with it honestly. I’m over it. I’m over the election. I’m over everyone being offended about everything. I’m over riots and violent protests. I’m over so much these days and I can’t imagine that you’re any different.
We’ll get through it. Just hold on. Be kind and be brave. Be kind and be brave. We don’t need much more than that do we?
This one is called “Relationship Between Endplate Defects, Modic Change, Facet Joint Degeneration, and Disc Degeneration of Cervical Spine” by Lee et. al(Lee S 2020). and published in Neurospine on June 30, 2020, and it sizzles as it sits!!
Why They Did It
The “disc degeneration precedes facet joint osteoarthritis” hypothesis. in cervical spine degeneration, the multifactorial analyzes of disc degeneration (DD), Modic changes (Mcs), facet degeneration, and endplate degeneration (ED) is still limited.
How They Did It
Retrospectively recruited 62 patients from 60-70 years old
They evaluated the following:
- disc height,
- segmental angle,
- ossified posterior longitudinal ligament,
- endplate degeneration,
- facet joint degeneration,
- uncovertebral joint degeneration,
- disc degeneration,
- spinal stenosis,
- Modic changes, and
- cord signal change
What They Found
- The interrelationship of degenerative parameters showed close relation between uncovertebral joint degeneration, spinal stenosis, disc degeneration, ossified posterior longitudinal ligament, Modic change. endplate degeneration, and cord signal change has partial relation with degenerative finding.
- Facet joint degeneration only has relation with uncovertebral joint degeneration and Modic changes.
Wrap It Up
They conclude, “Our results may indicate that facet joint degeneration that occurs independently, rather than as a result of other degenerative factors.
This one is called “A Screening Tool for Patients With Lumbar Instability: A Criteria-related Validity of Thai Version” by Chatprem et. al.(Chatprem 2020) and published in Spine Journal on November 1, 2020, the roof, the roof, the roof is on fire.
Why They Did It
The aim of this study was to examine the performance characteristics and validity of an existing lumbar instability questionnaire as a screening tool for lumbar instability among chronic low back pain (CLBP) patients.
How They Did It
Lumbar instability screening tool responses and x-ray assessments were reviewed from a sample of 110 patients with CLBP (aged 20-59 years).
What They Found
- Fourteen (12.73%) patients had radiological lumbar instability. These patients reported a higher mean lumbar instability questionnaire score than those without radiological lumbar instability.
- A questionnaire score of at least 7 had a sensitivity of 100% and a specificity of 26.04% for detecting lumbar instability when compared with x-ray examination.
- A lumbar instability screening tool total score of at least 7 was ruled out lumbar instability in CLBP patients. This cutoff score may be used as a marker of conservative treatment response.
Now just to expand on that idea a bit here; many chiropractors have a mental block when it comes to spinal instability.. What I mean is that many are so subluxation-minded that they do not understand that spinal instability is not good and that adjusting too much too often can actually be the cause of spinal instability.
If I’m speaking to a vitalistic, philosophy-minded chiropractor, I’m going to say, “You’re not always slaying subluxations, Mr. Vitalist. Many times, you’re so eager for the almighty dollar and the awesome sound of pops over and over again that you create the very problem that you hoped to fix in the first place.
That is the reason our profession has developed scaled back guidelines for treatment. Have you ever encountered a neck self-adjuster? I used to be one when I was kid. It starts off pretty darn difficult to adjust your neck. Then, with repetition, it gets more and more loose to the point that all you have to do is turn your head and it starts popping.
That is essentially what many vitalists are doing with patients when they see them repeatedly time and time again month after month, year after year. What the hell else would you expect.
Then the instability causes chronic pain that they think just needs more adjustments which actually cause more instability and more chronic pain. The cycle is perpetual and the vitalist chiropractor isn’t smart enough to figure out why they can’t get this patient feeling better. After all….isn’t it all about the mighty subluxation?
Why do they fuse spinal segments? To reduce the movement in order to reduce the pain. Doesn’t it seem there are patients that benefit more from exercise and support than from adjustments?
It turns out there are. Those that are hypermobile on the Beighton Scale and those that have instability. Just to update your knowledge on spinal segmental instability, the smoking gun of spinal instability would be
- Vertebral body anterolisthesis
- Broad-based disc bulging – flat tire vs. aired up
- Facet joint enlargement
- Ligamentum flavum hypertrophy
- Possible Modic changes.
Facet pain can often get confused with instability as well. A good example is when a patient has pain just to the left of the lumbar spine, over the facet. You push on it and it hurts. You can provoke facet pain by poking on it. But, you can provoke instability by poking on it as well.
There are a couple of general ways to focus in on what’s going on there and differentiate the two. You can have the patient stand and extend at the waste, the perform extension rotation both ways. If this doesn’t bother the patient, it’s almost certain it’s not a facet issue. Extension rotation is that accurate.
If when prone, poking on the facet hurts, you can stabilize the low back region temporarily by have the patient perform a super man / reverse plank type of a position and then, while they’re in the position and those low back muscles are good and tight and supportive, poke on the sore spots again. If the reverse plank position helps that pain, there’s a good chance it’s instability.
Also, if the low back commonly hurts when they roll over in bed, that’s could be a sign of instability as well. You don’t want to adjust instability folks. You want to strengthen it. Make it solid. In my office, we start that by doing McGill’s Big 3, the side plank, modified curl up, and the bird dog exercises.
Did you learn something? I hope, if you were lacking in this, I was able to shed some light on it for you. If you have any questions on this feel free to email me at firstname.lastname@example.org so we can discuss.
Alright, that’s it. Y’all be safe. Keep changing our profession from your little corner of the world. Keep taking care of yourselves and everyone around you. Tough times are upon us but, the sun will shine again. Trust it, believe it, count on it. Let’s get to the message. Same as it is every week.
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I want you to know with absolute certainty that when Chiropractic is at its best, you can’t beat the risk vs reward ratio because spinal pain is primarily a movement-related pain and typically responds better to movement-related treatment rather than chemical treatments like pills and shots.
When compared to the traditional medical model, research and clinical experience show us patients can get good to excellent results for headaches, neck pain, back pain, and joint pain to name just a few.
It’s safe and cost-effective can decrease surgeries & disability and we do it through conservative, non-surgical means with minimal hassle to the patient.
And, if the patient treats preventatively after initial recovery, we can usually keep it that way while raising the overall level of health!
At the end of the day, patients should have the guarantee of having the best treatment that offers the least harm. When it comes to non-complicated musculoskeletal complaints…. That’s Chiropractic!
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We can’t wait to connect with you again next week. From the Chiropractic Forward Podcast flight deck, this is Dr. Jeff Williams saying upward, onward, and forward.
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About the Author & Host
Dr. Jeff Williams – Fellow of the International Academy of Neuromusculoskeletal Medicine – Chiropractor in Amarillo, TX, Chiropractic Advocate, Author, Entrepreneur, Educator, Businessman, Marketer, and Healthcare Blogger & Vlogger
- Chatprem, T., Puntumentakul R, Boucaut R, Wanpen S, Chatchawan U, (2020). “A Screening Tool for Patients With Lumbar Instability: A Criteria-related Validity of Thai Version.” Spine (Phila Pa 1976) 45(21): E1431-E1438.
- Lee S, S. D., Lee JS, Sung SK (2020). “Relationship Between Endplate Defects, Modic Change, Facet Joint Degeneration, and Disc Degeneration of Cervical Spine.” Neurospine 17(2): 443-452.