Academy of Chiropractic Personal Injury & Primary Spine Care Program
Quickie Consult 1149
Clinical Information 275 CI
Preamble: Many of the issues I bring to you are very small, yet each issue is just that, an issue. If you take care of the small issues, then you will be able to build and more importantly, focus on the bigger issues...a larger practice and more family time. -Mark Studin 2006
"Thecal Sac Innervation and CSF Leakage"
Dr Studin: Now you'll have a question about anatomy that disc and sac anatomy?
Guest Doctor: Yes. My question is the Durham matter also innervated like the rack noise matters innovated with nerves and blood vessels?
Dr Studin: No, only the Arachnoid is and the ARACHNOID has a, B and c, no susceptive. And that innovation is very important because it has pain sensation. And remember the A, B and c fibers are the speed of the gnosis after slow, medium, and fast. So there all kinds of pain cycles that happen immediately and then those that linger, if anything, even contacts the secal sac at the spinal level, up in the brain it's called the Dura. Even though there was an arachnoid layer that quote the Dura layer, but covering the spinal cord in their roots, it's called the secal sac with those two layers.
Guest Doctor: Do I need to know these function, I'm pretty sure I need to know the function of the ABC fibers like the AD fibers that has more of an intense pain after an injury.
Dr Studin: not really. The significant part is that if there is fecal sac involvement, you're going to know there is localized pain initially. But it can linger for server c fibers which are slow and there's going to be no radiating pain with that. Not unless there's quarter root issues or, some type of chemical radiculopathy. Do you want me to explain chemical ridiculous and fully you got that down?
Guest Doctor: Go ahead and explain it please.
Dr Studin: When you have the nucleus pulposus in the annulus fibrosis when a piece of the nucleus, the inner material, which is a gelatinous substance made of 98% water and proteoglycans, that's the mixture that it's suspended in, and that's a type two collagen. When you have just even a drop of it leak from the inside out. Say you have an annual Fischer, it's no longer called an annular tear. Say you have an annual Fischer, but it breaches the outer layer. If that dropped touches a nerve. It's like a flame thrower. It's neurotoxic. That's chemical radiculopathy. That's why a fragments or sequestered disc is so painful, because there's a huge amount of the a nucleus proposes contacting the nerves and even a drop of it, I work with researchers at Yale a few years ago and we looked at this, quite in depth and your patients suffer from that terribly if they have a chemical orbiculates and it could come and go because the drop can squeeze out a drop can squeeze out the drop in, squeeze out. Usually that wound repairs the end of the annual, would repair with a little bit of Collagen, but that's chemical radiculopathy and that can cause radicular type pain, which would be also at the monster blonde EMG because it affects the roots as a rule. So next question.
Guest Doctor: I wouldn't work on cerebral spinal fluid. I have some whiplash patients in my passive treating patients where I think the triple spinal fluid is leaking somewhere. My question is where is it leaking and do you do a blood patch? Where do you do the blood patch?
Dr Studin: No, you really need to do a nuclear study to see if the CSF leak. That's the only way to do it. it's often the less than issue of CSF leaking that, remember when you have flection and extension, when you have flection, the CSF space compresses. When you out of extension, the CSF space, it extends or elongates. So you've to be careful when you are flection because there's less space in the same amount of fluid. Fluid acts as a solid and can really damage the nerves, but if you think that CSS is leaking, you need to work with a neurologist and they're going to do a nuclear study. It's the only way to do it.
Guest Doctor: So a pet scan or a SPEC scan won't do it.
Dr Studin: Not really, Pet scam is really a metabolic scan, usually not. And I've not had experience with that. When I deal with the neurosurgeon his answer is you need a nuclear study, that's why when people look at they say there's tonsil or herniations and as a result of the top herniating you get a CSF leak, they laugh, they say you only can tell that was a nuclear study. Now we can a pet scan do it. Possibly. I don't know the definitive answer to that, but I'll find out.
Guest Doctor: Well the main thing is I got patients with intense daily headaches to just pounding headaches. And I think that it doesn't fall into a certain vertical gene just what it does in my opinion. There is a cerebral spinal fluid alteration somewhere in that brain cavities or wherever, I don't know.
Dr Studin: So what is saying is a CT Cyst Sterner Graham, I've never heard of that before, so there are things too to be able to look at, though invasive, they help to accurately diagnose CSF leak, especially in the presence of multiple body defects, MRIs, the tech CSF and associated complications such as in Cephalon seals and an meningioma seals, and looking at a 3D T2 drive MRI's, systemnography to localize the CSF leak. So the answer is really, if you're looking at the brain and looking at CSF leaks and you're looking at issues, you're to want to look at shifts in the brain. Perhaps, there's a myriad of things to look at and to do. If you think that your patient has the CSF leak, get them a good neurologist, or even a neurosurgeon, preferably and not neurologist, the neurologist, more so diagnosed and they're a surgeon more so fixes you need a really topflight a neurologist. Now I work with a vascular neurologist, she'll be more than happy to take your phone call to discuss this with you. She'll be back in New York this October 18th, 19th and 20th. You must come in here to speak. She's great, tell her you work with doctors do and they were out in Montana. You think your patient might have a CSF leak? What should I do?