This article is a transcriptions of an episode of the RateFast podcast, which you can listen to by searching “RateFast” in iTunes or the iOS podcast store.
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Physicians have a number of different diagnostic tests requiring special machines, that they use to determine the severity of an injury. It’s not always necessary to throw a patient into an MRI machine when they come in complaining about back pain, however. Sometimes an effective treatment plan is enough to ensure that a potential injury gets better, instead of getting much worse.
We talked to Dr. Christian Athanassious regarding the intricate details about, and differences between, bulging and herniated discs. In our podcast, Dr. Athanassious helped to shed light on the steps that a spine specialist takes to determine the severity and treatment of discs in the spine.
Terms
Bulging disc (noun) – when the tough cartilage between vertebrae in the spine protrudes beyond the vertebrae.
Herniated disc (noun) – when the tough cartilage between the vertebrae is ruptured, pressing out the soft cartilage within.
Annulus fibrosus (noun) – the very thick, strong layer of cartilage surrounding the contents between the vertebrae.
Nucleus pulposus (noun) – the softer central part of the disc that contains the nerves of the spine.
Discogenic pain (noun) – pain coming from the spinal disc.
Annular tear (noun) – tearing of the annulus fibrosus, resulting in a herniated disc.
Reticular pattern (noun) – pattern in the form of a network, or mesh.
Cauda equina (noun) – (From Latin: horse’s tail) bundle of nerves running the length of the spinal cord.
Interview Transcription
Narrator: Welcome to the California Work Comp Report, a podcast hosted by Arun Croll and Claire Williams, featuring Dr. John Alchemy.
Arun: Hello, everybody. Welcome to the California Work Comp Report. Today is Monday, May 11th, and I’m Arun Croll. I’m here today with Dr. John Alchemy – hello, John.
Dr. John Alchemy: Hey, hello.
Arun: And we have a special guest on the show today, Dr. Christian Athanassious. Dr. Athanassious, how are you?
Dr. Athanassious: Hello, Arun. Hi, how are you? Thank you for having me.
Arun: Oh, definitely.
Dr. John Alchemy: So we wanted to talk today about some things around herniated discs and some different definitions that come up in workers’ comp in relation to that. But before we get going, tell us a little bit more about your specialty, how long you’ve been seeing spine patients, and a little bit of background about your practice.
Dr. Athanassious: So I’ve been seeing spine patients for about six and a half years now. I’ve seen them through my residency, through my fellowship and through my private practice. The patients that generally that I see are referring to having pain in the neck and the lower back, and so this pain usually will radiate to the arms or to the legs, often times this pain is due to arthritic disease, or what we call in the spine as degenerative changes of the spine, which people say are age-related, but it is the way that the back manifests arthritis within the spine.
Arun: Alright, so you work on the spine a lot. And where do you practice? Where are you based out of?
Dr. Athanassious: I’m based out of Santa Rosa, California. We have two offices, both of them located in Santa Rosa. One is located close to downtown, close to the hospital, Santa Rosa Memorial Hospital, and the second one is in just, just north of that, right off the 101, and that is very close to the Sutter Regional Hospital, right across the street, but not affiliated with either hospital.
Arun: Ah, got it. So that’s Santa Rosa, Sonoma County, Northern California. And California [crosstalk 3:46] are our specialty, specifically workers’ compensation. So you know we’re talking about herniated discs today. And the AMA Guide’s definition which is used to calculate impairment ratings and dictates the whole workers’ compensation examination, it doesn’t have a very clear definition of herniated discs, right? But it’s a word that gets thrown around a lot. So can you tell us, what exactly is a herniated disc?
Dr. Athanassious: So it’s important to understand first of all before actually getting into the definition, is that the discs are a type of cartilage that lies between the bones within the spine. The spine is made up of many bones that sit on top of one another in a column distribution. And within each one of these bones, it is not divided by cartilage in there alone, but there is fibrous tissue in the disc. The disc is kind of, you can think of it as a donut for instance, a donut that doesn’t have a hole in the center, more like a jelly donut. The outside edges of the donut are what as we call the annulus fibrosus, which is a very thick, strong layer, and this layer is what contains the central part of the disc, which we call the nucleus pulposus, or the jelly part of the jelly donut. When we talk about a herniation – there’s many different levels of herniation. There can be a bulging disc, which is often commented by radiologists on MRI reports, and they talk about a bulging disc, which means that the disc bulges out, outside the confines of where the disc normally lies, and begins to encroach upon the space where the nerves and the spine lie. Now this doesn’t necessarily mean that there is pain, or that there is pathology or disease, but simply states that the disc space is in an abnormal place, and is starting to be in a space where the nerves lie. The next classification for herniated disc is not just a bulging disc but a herniated disc. A herniated disc has to do with an actual tearing of the annulus fibrosus, which is the outside area of the disc, the thick fibrous area that does the containing of the disc. There’s a tear there, and the inside of the disc, the jelly of the jelly donut, can be pushed out and can go further into the canal, further and push on into the nerves that are there, and that often is what will cause pain. Additionally, the annulus fibrosus, the thickening area of the disc, is surrounded by nerve endings. And when this tears, this also can cause pain. A third classification or part of the classification, is an extruded disc, which also is under the umbrella of a herniated disc. But this means that not only has the central portion of the disc, the jelly of the jelly donut, pushed out of the annulus fibrosus, but no longer is there a connection between the disc from the inside to that fragment that goes out to the canal, it is separated and is lying in the canal, separate from the disc. And that’s an extruded disc. So in summary, there’s a herniated disc, and within that, there are three different levels of severity. One of them is a bulging disc, the second one is a herniated disc, the actual herniation that we talked about, and the third is an extruded fragment of disc.
Arun: Alright, so we’ve got a bulging disc, a herniated disc, and extruded fragment? Is that right?
Dr. Athanassious: Yep.
Arun: And all wrapped up in a delicious donut metaphor.
Dr. Athanassious: That’s right, it’s easier to understand, it’s easy to get an idea of that thick, fibrous component of the disc, which confines the more liquid portion that has more water content and that allows for us to have this kind of shock absorber nature when we are sitting, when we are standing, and when we are walking.
Arun: So if I were a doctor, and I was examining a patient, what would be the tell-tale sign of a herniated disc? How would I know, and how would I know how to classify it into one of those three categories that we were just talking about?
Dr. Athanassious: Sure. So I’m going to answer that question just in two parts. First, we’ll talk about how we are led on the trail to start thinking about a herniated disc, and the second part is what do we do after we have a high suspicion that we are in fact dealing with a herniated disc for one of our patients. So the first part of every exam is to listen to the patient and to hear what their complaint is. Generally, a person will come in and complain that they were out working or they were out walking, they may have twisted, they may have leaned forward, they felt a pop and they may have started having back pain, and/or some leg pain in addition to the back pain. What generally will happen, or sometimes will happen, is that the patient will have back pain and then after a while will start realizing that there is pain radiating from the buttock down the leg going to the toes with sometimes numbness and sometimes a weakness component to this. So that’s the first part of the actual history-taking part of the exam that we normally do for our patients. That would then prompt the physician to go ahead and examine the patient, and take a look. Does the patient have any weakness? Is there any numbness in the legs? Does flexing the body forward versus extending the back cause the patient to have any increase in pain? What are the positions of discomfort? Does the patient feel worse when they’re sitting down, versus standing, walking and lying down, which pushes us toward the diagnosis of a herniated disc. Additionally, there is a specific exam finding which is called a straight leg raise, and this is basically a reproduction of the patient’s pain, when the hip is flexed greater than 30 degrees and in the arc of motion between 30 and 70 degrees. There’s also an additional examination or test that can be done, which is called a contralateral straight leg raise, which means when you raise the leg on the contralateral side, of the opposite side, you are [sounds like: “surging” 10:50] on the side that is having pain already. So those are common tests that we can do, additionally you can do a hip extension test, and this allows us to examine for possible herniated discs above the L4-L5 level, which are higher herniated discs, and this can also prompt us toward the diagnosis of a herniated disc. So once the physical examination is done and the part of the history-taking is performed, the next step is for the doctor to prove to himself, and also to the patient, that indeed there is something going on, and the next step would be to get imaging. X-ray sometimes can help us in the diagnosis of finding pathology in the back, and should always be the first step in terms of treating a patient, and the next step would be to get an MRI without contrast of the lumbar spine to evaluate for the soft tissue structures that are about the spine and about the back, to see if there’s any clear diagnosis or clear pattern that shows us this pathology.
Dr. John Alchemy: Great. So I have a question. There’s a lot of ambiguity around the term “herniated disc” and “bulging disc,” and I think sometimes I see them used interchangeably. The only reason I’m bringing this up is because the AMA guide 5th edition specifically talks about “herniated discs,” and the sections where this diagnosis-related estimate rating takes place, a common rating method in the AMA guide doesn’t say “bulging disc” there, it just says “herniated disc.” So what’s the difference there, or is there a difference? Do you look at the two as the same?
Dr. Athanassious: So for me, I listen to what the patient’s history is, I look at their physical examination and I say to myself, is there a clear pattern of distribution? For instance, is this patient’s story or his history or her history following what makes sense as where a nerve would normally distribute the sensation? And if it is pinched, or has narrowing upon it would show pain and would give a patient the sense of pain in that distribution. Then I go to look, so that’s always the first thing, because I never look at imaging without having a good idea of what I think the diagnosis is before I look at the imaging. The next step is to look at the imaging and see, is there a place that correlates with the patient’s story, the reticular pattern, which is that pattern of pain surging down the leg, that makes sense? And then I say ‘Well, is it pushing on the nerve? Is it deflecting the nerve, and does it look like, for instance, the patient has right-sided leg pain? Is that herniation or that bulge even on the right side at all? Because sometimes, it’s not. A person may come in complaining of right-sided leg pain, and then when the MRI is looked at, there’s actually no compression seen on the right side and if there’s anything, there’s a minor bulge on the contralateral side or the opposite side. In which case, that person does not have a herniated disc, simply has a bulging disc, which may be slightly dehydrated and may be bulging slightly into the spinal canal, which usually has a copious amount of space to allow for small bulging discs without any symptoms. When I really think of a herniated disc, I think of a disc that has caused fissuring within the annulus fibrosus or the outside ring of the disc, and a small fragment of the middle part, or the nucleus pulposus, being pushed out into the spinal canal. I don’t think of a bulging disc in general as a herniated disc.
Dr. John Alchemy: Got it.
Dr. Athanassious: Unless the bulge is so severe that it is pushing on the nerves, and the patient’s history of physical examination findings point directly to that pathology, that MRI finding, as being the cause for the patient’s pain. In which case, if it’s so, such a large bulge, and all of the ducks are in a row, and everything lines up, then that is a herniated disc. The bulging disc has become such a large bulge that it, there’s no longer room for both the nerve and the herniation to exist in the same space, and the nerve is stealing the narrowing or stenosis of that side.
Dr. John Alchemy: Great. So just to summarize: Patient’s history, physical exam, and then some verification with some imaging.
Dr. Athanassious: Exactly.
Dr. John Alchemy: Got it. Okay, great.
Dr. Athanassious: And I will further go on to say that if all of these factors do not line up, and something does not seem to make sense, then I would very much caution doctors to think that this is the reason for the patient’s pain.
Dr. John Alchemy: Right, got it.
Arun: In your experience, do you think it’s easy for doctors to attribute pain to a herniated disc when it’s not, in fact, the case?
Dr. Athanassious: I think that, as, I can’t say that, you know, as a broad example, but I think that as a doctor, each and every one of us want to find an answer for our patients and allow them to have help with their pain symptoms. And I think that if we find some type of radiographic finding, let’s say there’s an abnormality in the radiographic findings, I think that some doctors may attribute this to a discogenic pain, which means that pain coming from the disc bulge, when in fact there may be another issue going on.
Dr. John Alchemy: Sure.
Arun: There’s this term, “annular tear,” can you tell us how that relates to herniated discs? Annular tears?
Dr. Athanassious: Well that attributes some of the back pain that occurs during the tear, or the herniated disc. So the outside ring of the disc is made of what we call type 1 collagen, which is a very stiff collagen. The whole outside is also innervated by nerve endings, so when there’s a tear at that level, or there’s a herniated disc, or the inside bulges through the outside layer, there’s a tear there, and that will cause back pain, and that is part of the pain that is felt, for instance, when a patient explains a pop and is found to eventually have a herniated disc.
Dr. John Alchemy: Great, so I’ve got another question. So let’s say I’m a patient with a herniated disc, or I’m an insurance adjuster helping manage a work comp case of an employee with a herniated disc. When that diagnosis is made, what types of restrictions should I expect, as far as like working and bending, and then in your experience, how many people go on to heal and just let the herniated disc settle down? And how many might have to have surgery, and even with that, some people have pain?
Dr. Athanassious: Sure, sure. So, when I look at our patients, once again, part of it is a physical examination finding, right? Does the patient have any weakness? Is the weakness getting worse? Do they have numbness, and is the numbness getting worse? If those things are worse, I generally have a tendency to be very conservative, to place the patient in a brace, and to ask them to not twist, bend at the back, and not to lift any objects greater than 10 to 15 pounds. And I’m very, very conservative with what I allow them to do for the next 1 to 2 weeks to see if we can stop the worsening of these symptoms. Additionally, if the patient just comes in with pain, is found to have a herniated disc, and there’s none of these symptoms, just pain, I usually will have very similar restrictions, but I’m not as concerned with the findings as somebody that has weakness or numbness or tingling. Generally, if a person does not have weakness, does not have numbness, and just has pain, the patient, with these kinds of restrictions and physical therapy and maybe some traction, and maybe an epidural steroid injection, most of these patients eventually will improve over the next two to six months, and will not require any surgery. In fact, I would dare say that out of herniated discs that occur, and pain and people that are taken out of work for herniated discs, 80 percent of these patients can be treated in a conservative manner. And I would encourage that in most cases, they are treated in a conservative manner, unless the patient has weakness that is worsening or has [sounds like: “dilabala incontinence” 20:05], which is a completely separate disease that can occur and it’s called cauda equina, which is a surgical emergency. So in review, the general patient that I see coming in with back pain, pain going to the buttock, radiating down to the legs, I will have a tendency to place them in a brace, ask them to not lift any objects greater than 10 to 15 pounds, I’ll ask them to not twist, bend at the back, only use their legs, and generally I would ask that they go to physical therapy to go through safe back practice so that they can learn about what is safe for them to do with their back so that they put the least amount of stress on the back as possible. I’ll also further encourage them not to sit for long periods of time, as sitting is the highest injured disc pressure that can be done by the body. Afterwards they’re standing and they’re lying down.
Dr. John Alchemy: Interesting, good to know.
Dr. Athanassious.: Yep.
Arun: Yeah, so I’m hearing about these work restrictions and I put myself in the position of an employer who’s hearing these work restrictions, these things that their employee cannot or should not do, I’m also imagining what it’s like to do, to be a claims adjuster who’s reviewing a doctor’s note, like a PR-2 report, that wherein the herniated disc is being described by the doctor. And I’m wondering, how can a non-medical professional, but somebody who has a stake in the worker’s comp claim, how can they ensure that the doctor is diagnosing the herniated disc correctly, and not using the term too liberally? Like, how can I make sure that- [crosstalk]
Dr. Athanassious: That’s exactly what I was talking about, is trying to make sure that the ducks are in a row, okay? You need to have the history, physical examination, radiographic findings, all should line up. For instance, a patient comes in complaining of back pain, pain going to the literal thigh, and pain going to the top of the foot, radiating down to the top of the foot. And then we have the MRI, which is showing that the patient has an L4-L5 herniated nucleus pulposus, as read by the radiologist, that is the patient that all the ducks are in a row. They have a herniated disc that is bothering the L5 nerve, for instance it’s on the right side, the patient has back pain and leg pain going in the L5 distribution or nerve pattern, that is something that really there’s no question. That is showing us that that pain can be attributed to the pathologic findings found on the MRI and x-ray. [crosstalk] On the converse, if you have somebody that has a bulging disc, and it clearly shows in the MRI report that there is no, the nerve is not being touched, there’s no compression on the nerve, and the patient states that he or she has buttock pain radiating down the leg to the heel, which is the S1 nerve distribution, and there’s no herniation or no compression seen, then one of two things is happening. One, the patient, when they are sitting upright, they are just touching the nerve, or two, that is not the reason that is attributing, the patient’s not getting the pain from that side.
Dr. John Alchemy: Great. So in conclusion, just to summarize, if you are an insurance adjuster, if your patient, trying to understand this, then you gotta have the history, the physical exam telling you what side, what distribution, and then that imaging that would support that term used, “herniated disc.” Is that right?
Dr. Athanassious: Sure. I think that in general, we can’t speak in absolutes, but I can say that in general, the more things that line up from what you just said, the higher likelihood that a surgical treatment or an epidural steroid injection will be beneficial for that patient at that level, on that side.
Dr. John Alchemy: Great, great. So, Dr. Athanassious, what would be the best way for our listeners if they wanted to get in touch with you, and maybe find out more about their back pain, be they work comp patients, et cetera, what’s a good way to get a hold of you?
Dr. Athanassious.: So they can just find all my information, it’s on Santa Rosa Orthopaedics website, I believe the website is www.sro.com, and I think that that would be probably the best way. I could give you the phone number, you could read a little bit about me and about the practice and what we have to offer. And it allows you to really get a good idea about what’s going on. And actually, let me just correct myself. The website is actually www.srortho.com.
Arun: Got it. And I’m sure you could find it just by searching Santa Rosa Orthopaedics in Google.
Dr. Athanassious: Yep, or even with my name, or Google, or any of those things, it will pop up just fine.
Arun: That’s right. So look up Dr. Christian Athanassious, Santa Rosa Orthopaedics. Dr. Athanassious, any closing thoughts on herniated discs? Bulging discs?
Dr. Athanassious: No, I think that in general, a patient should understand that this may not necessarily mean that they need surgery, and most people will get better with non-surgical treatment. And if somebody does have symptoms such as progressive weakness, bowel or bladder incontinence, they should seek medical treatment as soon as they can to be led down the right treatment, because some of these things can be permanent damage. So it needs to be looked at seriously, but on the converse, understand that not all of these are treated surgically, and that there are other options for treatment.
Arun: Great. Alright, well thank you so much for coming on the show with us today.
Dr. Athanassious.: Alright, thank you for having me.
Arun: Alright, once again, this is the California Work Comp Report, Monday, May 11th, 2015, and we were just talking about herniated discs. Tune in next time, and we’ll talk to you then.
Narrator: Thank you for joining us for this episode of the California Work Comp Report. We look forward to next week, and continuing our discussion of work comp claims in California. Questions or comments? Got a great worker’s compensation story to share? Find us on Twitter at @ratefast or at rate-fast.com.