Fact or Fiction?
If you want an excuse to operate on a pitcher’s throwing shoulder, just get an M.R.I. World's foremost sports surgeon, Dr. James Andrews after doing shoulder MRI's on 31 healthy big-league pitchers visiting him for other reasons, and then finding that 90 percent of them had both cartilage and Rotator Cuff abnormalities.
Like Dr. Andrews in the quote above, many of you have found out the hard way that MRI examinations are not all they're cracked up to be. Oh; most people already realize that x-rays will not show a Disc Herniation. But they are typically under the impression that an MRI will show anything and everything that might be wrong with you. But if you have followed my DAY TO DAY BLOG, you are aware that this is frequently not the case.
Spend any significant time researching Disc Herniations, you are likely to have heard of "Asymptomatic Disc Herniations". Buckle your seat belts and hold on to your hats because this is going to start getting interesting. Depending upon whose research you believe to be the most accurate, between 35% - 75% of the adult American population has Asymptomatic Disc Herniations. What does this mean? Only that the majority of U.S. adults are walking around with Disc Bulges / Disc Herniations ----- but have no idea because they do not have back pain or leg pain (SCIATICA).
FUN FACTS ABOUT DISC HERNIATIONS
- Herniated Discs are not necessarily painful --- in fact much of the time they are "asymptomatic".
- The majority of Herniated Discs are asymptomatic (they cause no pain).
- Surgery is rarely needed to fix most cases of Herniated Disc.
- SPINAL SURGERY frequently means poor outcomes for Herniated Discs.
- Herniated Discs do not typically get "more herniated" with time (however, they do end up DEGENERATING).
- Although the pain may go away after a period of months or years, Herniated Discs do not resolve on their own.
- Herniated discs cannot be seen with an x-ray.
- Herniated Discs can happen without an overt injury.
- Herniated Discs can happen due to compensation caused by an abnormally rotated pelvis.
- Medical treatment is not necessary for most herniated discs.
- Many disc-like conditions are misdiagnosed (i.e. PIRIFORMIS SYNDROME)
In fact, according to the research I am about to show you, if I rounded up 100 people with an average age of 45, with no history of low back pain; and were to do MRI's of the lumbar spine on all of them, the results would be as follows.
- 35% - 75% would have Disc Bulges
- Just under 40% would have Disc Protrusions (Disc Herniations contained within the Annulus)
- Just over one in ten would have Disc Extrusions (Disc Herniations where the Nucleus Pulposes is actually leaking out of the Annulus) --- severe Disc Herniations.
How do I know all this? Not only have I learned a thing or two over the two plus decades I have been taking care of patients, but there are numerous scientific studies on the subject that encompass nearly six decades. Let's take a couple of minutes to look at just a few of them. I want you to note that some of the variations between studies has to do with the fact that there are no hard and fast definitions for terms like Disc Herniation, Disc Bulge, Disc Rupture, etc. These terms are often used interchangeably with each other and have the potential to create some confusion.
ASYMPTOMATIC DISC HERNIATIONS
Six years later, in the March 1990 edition of the American Volume of The Journal of Bone and Joint Surgery, renowned orthopedic surgeon Scott Boden, also working at GWU Medical Center, followed up with a paper titled, "Abnormal Magnetic-Resonance Scans of the Lumbar Spine in Asymptomatic Subjects. A Prospective Investigation". In it he said that, "We performed magnetic resonance imaging on sixty-seven individuals who had never had low-back pain or sciatica. The scans were interpreted independently by three neuro-radiologists who had no knowledge about the presence or absence of clinical symptoms in the subjects. About one-third of the subjects were found to have a substantial abnormality. Of those who were less than sixty years old, 20 per cent had a herniated nucleus pulposus. In the group that was sixty years old or older, the findings were abnormal on about 57 per cent of the scans: 36 per cent of the subjects had a herniated nucleus pulposus and 21 per cent had spinal stenosis. There was degeneration or bulging of a disc at at least one lumbar level in 35 per cent of the subjects between twenty and thirty-nine years old and in all but one of the sixty to eighty-year-old subjects." At least 35% abnormalities in asymptomatic individuals.
1994 saw yet another study published on this topic. Dr. Maureen Jensen's "Magnetic Resonance Imaging of the Lumbar Spine in People without Back Pain" published in the July 14 issue of the New England Journal of Medicine. In this study we learned that, "Thirty-six percent of the 98 asymptomatic subjects had normal disks at all levels. 52 percent of the subjects had a bulge at at least one level, 27 percent had a protrusion, and 1 percent had an extrusion. Thirty-eight percent had an abnormality of more than one intervertebral disk. On MRI examination of the lumbar spine, many people without back pain have disk bulges or protrusions. Given the high prevalence of these findings and of back pain, the discovery by MRI of bulges or protrusions in people with low back pain may frequently be coincidental. " Over 50% of asymptomatic individuals had Disc Bulges.
In 1995, Volvo's 'Clinical Sciences Study of the Year' (The diagnostic accuracy of magnetic resonance imaging) was published in the December issue of Spine. The present study has presented evidence that.... asymptomatic patients show a high incidence rate of disc herniations (76%). Individuals with minor disc herniations (i.e., protrusion, contained discs) are at a very high risk that their magnetic resonance images are not a causal explanation of pain because a high rate of asymptomatic subjects (63%) had comparable findings. I must make note of the fact that this study also found that a whopping 85% of the asymptomatic subjects had class 3-5 DISC DEGENERATION on MRI as well. At least 75% of asymptomatic individuals had Disc Herniations.
A few years later, a group of prominent Swiss researchers, led by Dr. Weishaupt of Zurich's Orthopedic University Clinic's Department of Diagnostic Radiology, got their hands on 60 hospital employees with no history of back pain. The research team ran all of them through MRI's of the lumbar spine. Even though the paper's conclusion infers that MRI is a wonderful tool for diagnosing back pain in the under-50 crowd, reading between the lines leads one to a different conclusion. 40% of the volunteers had "Disc Protrusions" even though they did not have back pain. Even more amazing was that almost 1 in 5 of the test subjects had a "Disc Extrusion" (severe Disc Herniation). The results were published in the December 1998 issue of the journal Radiology. Almost 20% of the asymptomatic individuals studied had 'severe' Disc Herniations.
*In Y-2K, Dr. Michael Raskin (M.D. / Attorney) got into the mix with a paper he published in Applied Radiology. In the paper, whose topic pertained to the difficulty of accurately diagnosing personal injury clients, he exposed one of the dirty little secrets that hundreds of thousands of people on SSI Disability have known for years --- essentially that back injuries are easily faked. "Asymptomatic individuals with "abnormal" MRI--Recent literature has shown that many anatomical abnormalities of the back, including disc bulges and disc herniations, are quite common in people without back pain. Even prior to magnetic resonance imaging (MRI), the high incidence of disc abnormalities in the lumbar spine of asymptomatic individuals was quite well known. In 1956, a study using postmortem examinations of the entire spine showed a 39% prevalence of posterior disc protrusions. In 1968, a study using myelography in 300 asymptomatic individuals demonstrated lumbar disc abnormalities in 24%. Using computed tomography (CT), a 1984 study reported the prevalence of herniated discs in asymptomatic individuals to be 20% in those under the age of 40 years and 27% in those over the age of 40. Since MRI became a clinically available diagnostic imaging tool in the mid 1980s, multiple studies have confirmed that more than half of adults without symptoms have significant disc bulges or disc herniations. Furthermore, the prevalence of [asymptomatic] disc herniations increases with age." We have known that there is a huge prevalence of asymptomatic Herniated Discs since 1956.
A study published one year later in the journal Spine came to similar conclusions. According to the University of Washington's Department of Radiology, "Back pain is the second most common symptom-related reason for clinician visits in the United States. Up to 84 percent of adults have low back pain at some time in their lives." But despite this, as well as the incredible numbers of MRI's being done here in the United States, the authors concluded that, "Many MR imaging findings have a high prevalence in subjects without low back pain. These findings are therefore of limited diagnostic use." Read the previous two sentences.
And what if you are one of those people who has already had a back surgery? The scientific literature speaks to you as well. Just a little bit over a year ago, a group of six researchers working at Vanderbilt University Medical Center in Nashville, Tennessee, concluded their study on post-surgical asymptomatic Disc Herniations by saying that, "Nearly one-fourth of patients undergoing lumbar discectomy demonstrated radiographic evidence of recurrent disc herniation at the level of prior surgery, the majority of which were asymptomatic..... Clinically silent recurrent disc herniation is common after lumbar discectomy. " Their findings were reported in the December 2011 issue of Spine. This was not new information.
A 1995 offering, this time by Dr. RD Fraser and his team from South Australia's Department of Orthopedics and Trauma, Royal Adelaide Hospital, had this to say in that year's March edition of Spine. "The findings of this study indicate that long-term improvement of a patient's symptoms after treatment of disc herniation may occur with or without resolution of the herniation. This and the similar findings in the different groups is consistent with the 10-year clinical results after the treatment of disc herniation reported by Weber." This was the conclusion after looking at groups that were treated in various ways for herniated discs, and noticing that after a decade, 37% of the people in the study still showed herniated disc on MRI. Interestingly enough, there was no rhyme or reason for who hurt and who did not simply by looking at their MRI. Between 25% - 37% of post-surgical asymptomatic patients showed Herniated Discs after their surgeries.
BUT WHY DOES IT MATTER?
Let's say that you start having all the SIGNS OF A HERNIATED DISC. After trying several things that did not help you, you had an MRI. The MRI showed that you have DJD at three levels of the lumbar spine and two with DISC HERNIATIONS. Your doctor wants you to do CORTICOSTEROID INJECTIONS, and when that doesn't work, he wants you to visit a Spinal Surgeon. Even if you do not happen to be the sharpest knife in the cupboard, you know one thing ----- you know that people that have SPINAL SURGERIES don't usually do worth a flip. All you have to do is ask them.
BE WARNED: If you do not realize what it really means that most Disc Herniations are asymptomatic, and that it is often quite difficult to correlate one's symptoms with what the MRI shows, you will be taken advantage of. How do I know this? For starters, look HERE. Because there is big money in Spinal Surgery, it is not hard to grasp the fact that astounding numbers of people are having surgeries for problems that are not even the source of their pain! This is one of the reasons that before I start Spinal Decompression on anyone who's Sciatica originates in the butt / hip instead of the low back, I make good and sure that they are not dealing with PIRIFORMIS SYNDROME first.