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September 2017 Archives

Rear-End Accidents at Moderate Speed

Injuries After a Rear-End Accident

Your client was rear-ended five months ago at moderate speed.  She has been seen in the Emergency Room, by her PCP, by her chiropractor, by a physical therapist, and by a neurologist.  Plain films and a cervical MRI revealed only minor information about her status, and she is telling you that in addition to frequent headaches and neck pain, her head still “doesn’t feel right,” and it’s affecting all aspects of her life.  She’s been given a different story about her case at every step along the way, and she keeps saying, “I just wish I knew what’s wrong with me.”Contrary to popular opinion, the ability of a spinal MRI to identify the degree of ligament damage in the neck is fairly limited.  Fortunately, there is a diagnostic study available which can provide objective proof of permanent ligament injury in the spine.  It’s called digital motion x-ray (DMX).For decades now, we have known what happens at each joint, including the spinal joints, when a person moves.  It’s pretty simple:  Joints are formed when two bones come together.  The bones are held in place by strong, non-elastic connective tissue structures called ligaments.  When your clients are involved in car crashes, strong forces travel through their bodies and up the spine to the neck and head.  The ligaments in the upper cervical spine are the most brittle ligaments in the body, and they were never meant to withstand these forces.  As a result, they are abruptly stretched, and when they are stretched, they never regain their original length, so there is slack in the ligament, and now the joint is unstable.  These are not “self-limiting injuries.”  Because of the close proximity of the central nervous system- the brain stem and the spinal cord- this is absolutely critical to the health of the rest of the body.  When bone bangs into spinal cord, bad things happen.A DMX study records the motion of the spine as it moves in all directions, and what the interpreter looks for is unusual and excessive gapping between the bones, which indicates that the ligaments have been stretched out and injured.  There are 22 major ligaments in the neck, and all of them can be visualized in this way.  The medical literature is full of reference articles which address the abnormalities which can be found in ligaments.  Ligaments have fairly specific pain referral patterns, and when a torn ligament is found which matches up with pain in a specific area, then a definite cause-and-effect relationship can be established.While the DMX study is very good for identifying ligament injuries, it is useless for detecting injuries to the intervertebral disc.  If damage to most of the ligaments at one level can be identified, then medical necessity for a cervical MRI can be established.  It’s hard to believe that if serious trauma damages most of the ligaments at one spinal level, that the disc got away unscathed, because, after all, it’s actually just a highly specialized ligament.  By the same token, the MRI is not capable of doing a credible job in detecting ligament injury.  So the two diagnostic studies are not contradictory, but complementary.

Identifying ligamentous injury after a car accident

Identifying ligamentous injury is not only essential in formulating a patient’s correct diagnosis so that they can get proper treatment, it has the effect of increasing the cash value of a personal injury case.  The computer programs used by the insurance industry (Colossus and its knock-offs) place a higher value on the diagnosis codes which describe ligament injury than they do for disc injury, and so does the universally accepted medicolegal textbook, the AMA Guide to Evaluation of Permanent Impairment, 6th Ed., in terms of impairment rating and resultant disability.  This is not artificially inflating the case by manipulating the codes; rather, it is just a case of accurately presenting the truth concerning the severity of a person’s injuries.  It is fair to say that before DMX studies were available, whiplash victims have been grossly under-diagnosed.  About 1 million people get whiplashed each year in car crashes, and the most conservative estimates tells us that about 33% of them end up with chronic pain, despite their doctor’s best efforts.  Most studies indicate that the percentage is a lot higher than that.  And these people are your clients.

Using DMX to Diagnose Injuries

Digital Motion X-ray of the Spine

Recently, a Defense Medical Examination was performed on a patient on whom I had done a cervical spine digital motion x-ray study.  The examiner, Zoran Maric, MD, went out of his way to trash my report, complete with his biased opinions and cherry picking from National Enquirer level articles he found on the Internet to support his suppositions.  I could probably write an article about each one of them, but the one which really caught my eye was a Medical Policy position paper written by unknown authors for Anthem Blue Cross/Blue Shield about the use of “Dynamic Spinal Visualization (including Digital Motion X-Ray and Cineradiography/Videofluoroscopy,” dated 10/4/2016, which he used to establish his contention that any dynamic visualization technology was worthless.The position of the authors was that “dynamic spinal visualization, including, but not limited to, digital motion x-ray of the spine, with or without digitization of spinal x-rays and computerized analysis of the back or spine, is considered investigational and not medically necessary for all indications (emphasis theirs).”  Their rationale?  They stated that the current literature on the subject was “limited to a few studies involving very small numbers of participants,” so “further evidence from large controlled trials is needed to demonstrate that the results have significant impact on clinical care and are superior to currently available alternatives.”  They went on to state that, “the data is insufficient to support the use of digital motion x-rays, or cineradiography/videofluoroscopy of the spine for any indication (emphasis mine).”  This is simply not true.Fluoroscopy was invented by Thomas Edison in 1896, one year after the invention of the first x-ray machine, and by the mid-1920’s, researchers were trying to record fluoroscopic images of the spine on 16 mm film.  As the years went by, more and more evidence was piled up, and I have 600+ pages of medical archival literature from the early days to prove it, along with close to two hundred more recent articles which I have collected over the past 5 years while I have been learning about dynamic imaging.   And I don’t have everything.  In fact, the Anthem BC/BS position paper cited six sources from the literature to support their rejection of the technology, and I was only familiar with one of them.  But I was really surprised to see it there, as I was very familiar with it, and I knew it was very pro- motion x-ray.  So, naturally, I requested the other five from the librarian at Cleveland Chiropractic College- Kansas City (my alma mater), and proceeded to read them to see if they supported the thesis of Anthem BC/BS.  The short answer is…. they didn’t even come close to supporting it.One of the basic tenets in writing research papers is for the authors to list any biases, any conflicts of interest, and any perceived weaknesses in the finished product, for the purpose of getting “out in front” of any criticisms from the rest of the professional community, so as to appear as objective as possible in reporting the facts discovered by the research project.  If you will notice, this is done in every research paper routinely, and the same is true about the six research papers which I reviewed.  Each of the papers has in common a statement concerning any shortcomings in the research design, as they should, and unfortunately, this is what the unknown authors (I picture these guys as sitting at a conference table with paper bags over their heads, with eye holes cut out) chose to highlight as the focus of the literature.  No direct footnoting is done, but the implication of listing the articles is that they somehow support the supposition of the Medical Policy paper, which is that digital motion x-ray is useless.  But if you really want to see what a research paper is all about, the place you go to is the end of the paper, where you will find the “Discussion” section, followed by the “Conclusions” section.   The Anthem BC/BS Medical Policy paper is a sham of a professional publication, just junk science, masquerading as the real thing.  Here’s the evidence from the literature they themselves cited:Harvey S, Hukins D, Smith F, et al.  Measurement of Lumbar Spine Intervertebral Motion in the Sagittal Plane Using Videofluoroscopy.  J Back Musculoskelet Rehabil. 2015 Sep 25. [Epub ahead of print]What’s funny about this one is that the first statement in the paper is this:  “Static radiographic techniques are unable to capture the wealth of kinematic information available from lumbar spine sagittal plane motion.”  Geez, where have I heard that before?  I’m tempted to stop right there, but this is a study which has a very small patient sample size, and they came to no conclusions- because they intended this study to be a mere pilot study, contemplating a much bigger and better study in the future.  Note that it is extremely recent (2015).Hino H, Abumi K, Kanayama M, Kaneda K.  Dynamic Motion Analysis of Normal and Unstable Cervical Spines Using Cineradiography.  An In Vivo StudySpine (Phila Pa 1976). 1999; 24(2):163-168The authors studied ten healthy subjects and 12 patients with unstable cervical spines by recording and analyzing, under videofluoroscopy, the entire range of motion from full extension to full flexion.  The pathological spines exhibited a different order of onset of segmental motion; in other words, the unstable segments moved first!  “Cineradiographic motion analysis is a valuable adjunctive technique, especially in the diagnosis of conditions that cannot be identified by conventional radiographic examination.”Lindgren KA, Leino E, Manninen H.  Cervical Rotation Lateral Flexion Test in Brachialgia.  Arch Phys Med Rehabil. 1992; 73(8):735-737In this study, the authors studied 23 patients with brachialgia and thoracic outlet symptoms under videofluoroscopy and with the cervical rotation lateral flexion test (CRLF) in order determine the role of fixation of the first rib in their symptoms.  The videofluoroscopy was performed in order to confirm the physical findings of the two examiners, who determined that 25 of the 56 ribs tested (that’s what the article said- shouldn’t that be 46 ribs?) were fixated.  The intermethod reliability between the clinical and the radiologic tests was found to be excellent (K score= .84).Okawa A, Shinomiya K, Komori H, et al.  Dynamic Motion Study of the Whole Lumbar Spine by Videofluoroscopy.  Spine (Phila Pa 1976). 1998; 23(16):1743-1749This study observed the act of lumbar flexion from the standing position under videofluoroscopy in a control group (n=13) and a group of 8 patients with degenerative spondylolisthesis and a group of 8 patients with chronic low back pain.  A significant number of those with degenerative spondylolisthesis exhibited abnormal biomechanics, while the differences in motion between the normal controls and those with chronic low back pain (without spondylolisthesis) were felt to be insignificant.  The authors had some doubts about their data analysis and their methodology, but bottom line, it is a fact that they were analyzing a video and it yielded valuable kinematic information.Teyhen DS, Flynn TW, Childs JD, et al.  Fluoroscopic Video to Identify Aberrant Lumbar Motion.  Spine 2007; 32(7):E220-229This is the one I was already aware of, and I have been using it in my seminar.  The authors studied 20 healthy controls and 20 patients with low back pain under videofluoroscopy while moving from standing neutral to full flexion.  They used eight kinematic variables to quantify the rate of attainment and magnitude of intersegmental angular and liner displacement, and found that those with low back pain demonstrated aberrant motion during the mid-range of motion as compared with the controls.  The statistical analysis proved to be 96% accurate in identifying those with low back pain!  “DFV (Dynamic fluoroscopic video) was useful for discriminating between individuals with and without LBP based on kinematic parameters.  Disruptions in how the motion occurred during midrange motions were more diagnostic for LBP than range of motion variables.”Wong KW, Leong JC, Chan MK, et al.  The Flexion-Extension Profile of Lumbar Spine in 100 Healthy Volunteers.  Spine (Phila Pa 1976). 2004; 29(15):1636-1641The purpose of this study was to contribute to the already present data base of research on what constituted normal lumbar motion (as cited by the first ten sources in the bibliography, some of which involved large cohorts for study).  The subjects were recorded using an electrogoniometer and videofluoroscopy through the full range of motion in flexion and extension.  They established differences in range of motion between those who were under 50 years old and those who were over 51 years old.  Not exactly earth-shaking information.  The fluoroscopy was used to establish a data base which “is useful to assist the diagnosis of spinal instability in the future.”All of these articles cite the need for more research, which is the prudent thing to do when you are researching.  Not doing so would imply that all questions about the subject have been answered, which common sense tells you doesn’t happen in anyone’s research.  But the authors of the Medical Policy paper jump the gun and state that all of the research is inconclusive, and that there needs to be more done, so in the meantime, let’s ignore any and all information which can be gleaned from any form of dynamic radiography.  Any objective reader of these articles, and all the rest of my personal collection, can see that motion x-ray is essential in the determination of spinal instability.  But the insurance company is dead set on being blind to the facts, as demonstrated by the list of exclusions they included in the paper.  All the CPT codes for motion x-ray, including the one I use (76496) are included on their list of procedures which are ”Investigational and Not Medically Necessary.”  Then, to emphasize that there are no indications for which the technology may be useful, they list every ICD-10 code they can come up with, from M40 to M99, then Q76, and then everything (almost!) from S12- S33.The American Academy of Professional Coders (AAPC) bills itself as “the nation’s largest medical coding training and certification association for medical coders and medical coding jobs.”  I found an interesting opinion piece on their website, dated 10/27/2008, written by attorney Michael D. Miscoe, who at the time was the President-elect of the AAPC National Advisory Board, concerning the use of the correct CPT code for billing for DMX studies.  The confusion arose because in 2000, an article appeared in the AMA CPT Assistant that equated videofluoroscopy with videofluorography/cineradiography, when subsequent to that decision, the FDA determined that “videofluorography/cineradiography and videofluoroscopy devices are substantially different, and diagnostic purpose (in terms of anatomic structures evaluated and conditions that can be diagnosed) of each is also substantially different.”  Videofluoroscopic devices are classified as “image intensified fluoroscopic x-ray systems” while cineradiographic and videofluorographic devices are classified as “cine or spot fluorographic x-ray cameras.” He concluded that the only code which should be used for a DMX study was the one I use, which is 76496 (unlisted fluoroscopic procedure –eg diagnostic, interventional) because of the use of the descriptor “diagnostic.”   There are two other codes, 76120 (cineradiography/videoradiography except where specified), and 76125 (cineradiography/videoradiography to complement routine examination), which describe the recording of the use of fluoroscopic devices when they are used for procedures such as placing cardiac catheters or needles into injection sites.  The difference between the two is the use of the device for diagnostic purposes, rather than a procedural purpose.   The Anthem Blue Cross/Blue Shield arbitrarily decided to lump all three codes together, and excluded the use of all three.  Once again:  “Based on what?”You know why they do this.  The sole purpose of Managed Health Care is to save insurance companies money by limiting access for services.  And it’s pretty much guaranteed that the diagnoses of greater severity result in more money being spent on health care.  That would be a  ”reverse ka-ching” for the insurance industry.  Digital motion x-ray studies up the ante on the diagnosis severity by identifying ligament injuries which are permanent, progressive, and painful.  This is in no way “padding the bill” in order to get greater reimbursement; it is merely reporting the truth.For the record, before medical machines can be used on the general public, they have to be approved for use by the Food and Drug Administration.  The digital motion x-ray machine that I use, the Visualizer 2000, was approved by the FDA in 1994 as a Class B Medical Machine.  The definition of a class B medical machine is that it is “non-experimental.”   I have the original paperwork in my possession and can make it available to anyone who wants to see it.  The National Clearinghouse Guidelines, which you can find on the website for the Department for Health and Human Services, which is a Cabinet level government office, lists videofluoroscopy (a synonym for digital motion x-ray) for the diagnosis of ligament injuries under the section outlining the accepted standard operating procedures for Whiplash Associated Disorders (WAD), including it in the same sentence in which it also approves of plain film x-ray, MRI, CT scans, and diagnostic ultrasound.   The National Clearinghouse Guidelines also has a Chiropractic Subluxation Practice section, in which it reiterates the use of diagnostic videofluoroscopy for doctors of chiropractic.  Jeff Cronk, DC, JD, of Spinal Kinetics, put on the first two seminars for Bill Gallagher’s Motor Vehicle Injuries course, and one of the many points he made several times during his presentations was that doctors need to know the professional guidelines under which they practice; if they cannot articulate them, they are open to criticism, medicolegally.  From a medicolegal standpoint, the use of the machine has passed the Daubert challenge (November 28, 2007) in Federal Appeals Court in a case entitled Graftenreed vs. Seabaugh.  The judge accepted the DMX technology into evidence and opined that he was doing so because it was not a new technology, but an improvement on older, previously accepted technology. In addition, the injuries I regularly diagnose with DMX studies are attested to and described in the AMA Guidelines for Evaluation of Permanent Impairment, 6th ed., in Chapter 17, Table 17-2 (Cervical Spine Regional Grid: Spine Impairments), page 564, under the section which describes Alteration of Motion Segment Integrity (AOMSI).  Our profession affirmed the use of the digital motion x-ray technology for the purpose of assessing ligament injury in a position statement written by the American Chiropractic College of Radiologists (ACCR) in 1989, and ratified by the International Chiropractic Association (ICA) soon after.  And, more locally, I have been approved by the State of Arizona Board of Chiropractic Examiners to teach a continuing education course in interpretation of digital motion x-ray.  I can provide you with all the documentation you need concerning the efficacy of digital motion x-ray studies. At this point, if someone is still of the opinion that DMX is experimental and investigational, I am ready to argue, “Based on what?”  If someone has peer-reviewed literature which categorically states that digital motion x-ray is worthless, I would be glad to look at it.  But, remember that no type of x-ray treats anyone or gets anyone well.  What this specialized fluoroscopic study does is give the clinician a more accurate diagnosis, and that in itself is instrumental in improving patient outcomes.  What the doctor who orders this test does with it is completely in his/her hands, but, if you don’t test, you’re guessing, and if you’re guessing, then the one who suffers for the willful ignorance of the doctor is the patient.  Most patients don’t want their doctors guessing about their health.  If you would put yourself in their shoes, I’m sure that you would feel the same way. Using digital motion x-rays and static motion studies are invaluable in determining diagnoses in personal injury cases, and also in just about any case in which instability of the spine is suspected.  There is a learning curve, though, for each doctor who orders a study, in learning how to incorporate the information gained from motion studies.

Modic Changes in the Spine

What are modic changes?

On rare occasions, when you receive a radiology report from one of the local diagnostic facilities, the reading radiologist may indicate that your patient has a Type I Modic change.  It’s important for you to understand the clinical implications of this finding.  If you don’t read MRI, no worries, as I will endeavor to make it clear to you.Modic changes were first identified in 1987, and then put into a set of classifications by Michael Modic, MD, thus the name.  It refers to changes which occur in the subchondral bone marrow as a result of trauma, disease, or aging, and it is closely associated with the presence of degenerative disc disease.   Type I involves inflammation and edema in the vertebral body adjacent to the disc; Type II involves replacement of the inflammation and edema with yellow fat; and Type III involves replacement of the yellow fat with bony sclerosis.  The three types are considered to be related to one another as phases in the progression of a lesion.  Since Type I involves inflammation and edema, it is important to understand it in relation to the personal injury cases you are handling.Incidentally, there is a great little book you can get from Amazon by William Morgan, DC, who was just recently named president of Parker University (formerly College) in Dallas, TX.   If you have a Kindle, you can get it for $2.99, and you cannot beat it for a concise explanation of the pathology, along with really clear reproductions of Modic changes on MRI and pictorial representations which do a great job of illustrating the lesion.  Actually, Dr. Morgan has several really good, and cheap, books available on MRI which can be very helpful in your understanding of MRI, and all of them are worth buying.

Rear-End Accidents and Subsequent Injuries

But here’s the deal: when occupants in a motor  vehicle are rear-ended, the forces which go through their body, starting at the lumbar spine and progressing all the way up to the neck, consist of two components- shear forces and axial compression forces.  It’s the axial compression forces which are the concern here, as axial compression trauma, or a series of traumas, can lead to damage to the disc, the cartilaginous endplate, the bony endplate, and the cancellous bone of the vertebral body.  The disc may herniate not only posterolaterally, as we have all been taught is the most common way for it to go, but it can also herniate intradiscally, and go right through the endplates, and form what we have always called a Schmorl’s node.  Or it may cause a number of microfractures in the endplates which lead to a disruption of the interface between the vertebral body, the endplates, and the disc, which leads to the introduction of substances into the capillary beds of the subchondral bone which were never meant to be there.  It appears that the Schmorl’s node which we have ignored all these years may not be as innocuous as once believed.The intervertebral disc is a two part structure, consisting of the tough outer annular fibers and the nucleus in the middle.  Now the textbooks teach that the disc has three parts, the two aforementioned and a third, the endplate (Bogduk N, Clinical and Radiological Anatomy of the Lumbar Spine, 5th Ed., Elsevier, 2012, p. 19-20).  The endplate is a very important organ, in that it serves two functions:  1) It separates and confines the intervertebral disc, and 2) It allows the transfer of fluids, nutrients, and waste products between the capillaries of the vertebral body and the intervertebral discs.  The mature disc does not have a blood supply, and the individual cartilage cells receive their nutrition and oxygen and get rid of their waste products via osmosis into the fluids which bathe them.  The endplate is a porous structure which functions as a selectively permeable barrier between the cartilage cells of the disc and the capillary beds which are found in the subchondral bone.  Remember, the cancellous bone of the vertebral body is filled with red bone marrow and is highly vascularized.  The exchange of the nutrients, oxygen, and metabolites is facilitated by the normal motion of the joint, which sets up a pumping action which brings the good stuff in and takes the bad stuff out.  Damage to the endplates really interferes with this exchange process, and the end result is the genesis of the inflammatory cascade.   The damage which ensues because of the pro-inflammatory enzymes involved in the process is what we see on an MRI as a Modic change.Type 2 and Type 3 Modic changes are, for the most part, not nearly as symptomatic as the Type I changes, so I’m not going to discuss them here.  But at worst, a Type I Modic change is representative of an intradiscal herniation which has displaced the nucleus, caused a fracture or fractures of the endplate, disrupted the internal architecture of the vertebral body, and introduced inflammation and edema into the area, and at best, it’s a bone bruise.  Think of this injury to the vertebral body as a bad- really bad- bone bruise.  If you have ever stepped on a rock with your heel, and gotten a bone bruise on your heel, you know what I am talking about.  If you ever were involved in sports, and have had a hip pointer, you also know what I am talking about.  Hip pointers are bone bruises, usually with enthesopathy, on the iliac crest, and they take forever to resolve.  I had them on two occasions during my wrestling career, over 30 years ago, and to this day, when I use my foam roller on my hips, I have to watch it on those spots.  If you talk to the radiologists about doing a bone scan on an area with a bone bruise to differentiate it from a fracture, they will tell you that it largely useless because the damaged area stays “hot” for a long time after the injury.  When determining the extent of a fracture, CT is much better.On a T1 weighted MR image, edema (water) appears dark, while on a T2 weight MR image, it appears bright.  Really simple.  And because a radiologist will read the study before it ever gets to you, he/she will rule out lesions such as metastasis, hemangioma, or infection as the cause of the lesion.Modic Type I lesions are not static lesions- they usually convert to Modic 0 (normal) or Modic Type 2, or they expand in magnitude.  In general, these changes will take anywhere from six to eighteen months to occur.  So if you are wondering why your patient isn’t responding to conservative treatment, stop wondering.  But as Type I progresses to Type 2, they tend to become less painful.  In one study, 73% of patients with degenerative disc disease (DDD) with Modic Type I changes had lower back pain, compared with only 11% of the DDD patients with Type II changes (Toyone T, Takahashi K, Kitahara H, et al.  Vertebral Bone Marrow Changes in Degenerative Lumbar Disc Disease:  An MRI study of 74 Patients with Low Back Pain.  J Bone Joint Surg Br 1994;76:757-64).   The same study revealed that there apparently is a relationship between the presence of a Modic Type I change and segmental hypermobility (defined as sagittal translation of 3 mm or more on dynamic flexion-extension films).  70% of the Type I patients, but only 16% of the Type II patients, were found to have segmental hypermobility, so the authors concluded that patients with chronic low back pain and Type I Modic changes had more frequent instability requiring fusion surgery than those with the Type II changes.  Another study showed remarkable results when fusion of the unstable segments was performed:  seventeen patients with chronic low back pain and Modic Type I changes underwent instrumented posterolateral fusion, and six months later, all of the Type I changes had converted, with 76.5% changing to Type II, and 23.5% back to normal, and clinical improvement was seen in all patients (Vital JM, Gille O, Pointillart V, et al.  Course of Modic I Six Months after Lumbar Posterior Osteosynthesis.  Spine 2003;28:715-21).Say you have a patient who is complaining of acute low back pain following a car crash, and the orthopedic tests for identifying sciatic tension are either equivocal or negative.  By equivocal, I mean that both straight leg raises are positive for pain, but the pain occurs at greater than 45 degrees (like 50 degrees on the right, 70 degrees on the left).  Your motion palpation of the sacroiliac joints reveals bilateral fixation, and the sacroiliac and iliolumbar ligaments are “en fuego” (that’s “on fire” for all of you non-Spanish speakers!)  There may or may not be some vague neurological signs (like an ankle clonus).   But after two or three weeks of very conservative treatment, there is no improvement, you order an MRI, and what do you know?  There’s a Modic Type I change at L4 and L5, but no evidence of any disc herniation.  Based on the patient’s case history, you know that the low back pain started as a result of the MVC, and because it’s Modic Type I, you know that it’s new.   And every time you have manipulated the patient, particularly if it involves the twisting of side posture, you have aggravated the area.  My advice?  Treat it like a rib injury and immobilize it with a brace.  Use soft tissue work for the muscular and tendinous lesions, and use ice to control the pain.Nutritionals for connective tissue support and control of inflammation are  extremely important.  I went to a Charlie Annunziata seminar last November in Phoenix at which I learned about the anti-inflammatory and scar tissue reduction properties of doTerra Essential Oils, and I highly recommend them after what they have done for the adhesive capsulitis in my hips.  Make the patient realize that this is going to hurt for a while.  Exercises?  Man, I don’t know if I like that idea, especially at first.  Anything that produces axial compression and increases intrathecal pressure should probably be avoided.  That would eliminate just about any exercise you could think of, at least until the inflammation resolves.  A follow-up MRI of the area six months after the initial MRI would be helpful to determine the progression of the lesion into other Modic types.  And when the range of motion has increased to the point at which good motion information can be obtained, then do a standing lumbar motion study and determine if there is any instability.  The above study only mentioned using translation for the evaluation of lumbar instability, but remember, the AMA Guides describe a method for evaluating angular motion for instability as well.Bottom line point?  We were always taught that Schmorl’s nodes were asymptomatic and merely an incidental finding.  But I went to school before MRI was invented, and the knowledge base has expanded greatly over the years, particularly over the last ten years.  So when these lesions are present, one should assume that they are clinically relevant, or at least have the potential to be, if they can be correlated to the patient’s complaints.
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