Academy of Chiropractic’s

Lawyers PI Program 265

From the Desk of :
Mark Studin DC, FASBE (C), DAAPM, DAAMLP

"Reporting Disc Bulges as a Risk Factor and the Complications as Sequella"

Disclaimer:This consultation is not designed to tell you how to diagnose your patient, nor  suggest how you prognose your patients. It is to give you general insight in how to apply research findings in the clinical setting. 
 
 
Educational Flyer #98 discusses innervation of degenerative intervertebral discs. A concept you should own by now and have taken the MRI courses. To be redundant, a degenerative disc and bulging disc is synonymous. 
 
However, how that is reported can be tricky because often the courts gets confused, as well as the doctors and lawyers in how this phenomena impacts our patients; their clients. 
 
For me...and I can only share with you my clinical experience; explaining why a patient with a bulging disc has an exacerbation of pain with no further clinical issues WAS always a dilemma until recently. Now I can explain it, although I have little solutions to help the patient, other than a referral to a pain management doctor. This is a diagnosis of exclusion of all other possibilities and leaves the competent producing cause of the patients pain, an inflammation of the nerve endings in the bulging disc. 
 
Educational Flyer #98 says:
 

CRITICAL UPDATE – Innervation of Degenerative Intervertebral Discs

Can a degenerative intervertebral disc be injured?  YES
Can that injury cause significant, permanent and persistent functional losses?  YES
Is it true that a degenerative disc has MORE nerve endings than a healthy intervertebral disc?  YES
Is there any scientific evidence regarding innervation of the degenerative disc and how that happens? YES
 
In a very recent research paper published in the Journal of Orthopedic Research (2011), the authors continued the work on the innervation of degenerative intervertebral discs. They stated, “Normal lumbar IVD [intervertebral discs] is avascular and aneural except for the outer 1/3 of the annulus fibrosis (AF).   However, previous studies have described the ingrowth of nerves into the AF and nucleus pulposus (NP) of degenerated IVD...” (Lee et al., 2011, p.265). 

When an intervertebral disc is degenerative, there is a complex series of chemicals that increase the growth of tiny blood vessels and nerves that transmit pain.  These nerve fibers are involved with creating discogenic pain.  That is pain created in and by the intervertebral disc in the absence of any nerve root compression.  These pain syndromes are very real and are often confusing because they present without a dermatomal pattern of neurologic symptoms and negative electrodiagnostic testing. 

This paper published in 2011 not only once again confirms the innervation of a healthy intervertebral disc, but also reiterates the increase in pain innervation in degenerative discs.  When clients with degenerative (pre-existing) disc disease are evaluated, working with a clinician that understands the intricacies of the anatomy of the intervertebral disc is critical to correlating causation, bodily injury and persistent functional losses.
 
Reference:
Lee, J. M., Song, J. Y., Baek, M., Jung, H. Y., Kang, H., Han, I. B., Kwon, Y. D., & Shin, D. E. (2011).Interleukin-1β induces angiogenesis and innervation in human intervertebral disc degeneration. Journal of Orthopedic Research, 29(2), 265-269.
 
For me. this was a "game changer" in how I approached many of my trauma cases. In my narratives, I now add the following language:
 
MRI Discussion:

As reported by José García-Cosamalón et. al in 2010 who concluded that "Upon degeneration, the intervertebral disc becomes densely innervated even in regions that in normal conditions lack innervation. This increased innervation has been associated with pain of intervertebral disc origin. The mechanisms responsible for nerve growth and hyperinnervation of pathological intervertebral discs (degenerative discs/bulging discs) have not been fully elucidated... In addition has been reported that neutrophins that regulate the density and distribution of nerve fibers...also play a role in inflammatory responses and pain transmission (C-Fibers) by increasing the expression of pain-related peptides and modulating synapses of nociceptive neurons at the spinal cord."

Simply explained, Ms. Patient 's degenerative/bulging discs in the cervical and lumbar spine  has nerve fibers that have grown into the annulus fibrosis and nucleus pulposis of the disc, and upon trauma, an inflammatory response was created causing pain in her previous asymptomatic degenerative disc. Without the accident date 4/02/2011, this process would never have been initialed and explains the persistent pain cycle that will never reverse based upon the risk factor of a pre-existing degenerated/bulging disc.

And yes...I do add the citation as a reference at the end of the report.