Wednesday, July 9, 2014

Bulges, Herniations, and Extrusions, Oh My! Injured Spinal Discs After A Car Crash (And What It All Means)

  By Brian R Wilson, Esq.

 Car collisions can frequently cause injuries to the lumbar and cervical spine. When the spinal discs or "shock absorbers" of the spine are injured, it can mean pain, immobility, numbness down a limb, and even require therapy and surgery. Anyone who's ever had some sort of spinal disc injury can attest to the pain they can cause.

But what's the difference between a bulging, herniated, extruded, or torn spinal disc? In a recent trial I had in an auto collision case, a local chiropractor did an excellent job of explaining the difference between the various forms of injuries to spinal discs, which you can read below:                                                                

16   Okay.  Thank you.  So have we covered all  

17         the fractures then?                                

18   A.    I believe so.                                      

19   Q.    All right.  Let's move to other injuries or        

20         conditions that you discovered in  ______'s  

21         spine.                                            

22   A.    Okay.  The --                                      

23   Q.    Go ahead.                                          

24   A.    We did a standard orthopaedic neurological        

25         examination when she first entered our office.    

 1         This examination is designed to allow me to provide

 2         a working diagnosis, which is what the problem is,

 3         what's generating the pain, what's the pain        

 4         generator.  And on this examination we saw greatly

 5         decreased range of motion in the lumbar spine and  

 6         in the cervical spine, pain on motion, orthopaedic

 7         tests, which were designed to let me know, again,  

 8         how severe the injury is, is it just a pulled      

 9         muscle, a strain/sprain, a pinched nerve.  Some of

10         them were -- she was in too much pain to perform  

11         them.  There were two orthopaedic tests that led me

12         to believe that she may have a herniated disc in  

13         her lumbar spine.  Specifically Kemp's test and    

14         Valsalva's test.                                  

15                 Along with that, she was experiencing      

16         radiating leg pain.  Because of those findings, I  

17         ordered immediately the MRI, and the MRI did show,

18         along with the pelvis fracture, it showed herniated

19         discs in the lumbar spine level.  The herniated    

20         discs were classified as extruded in nature and    

21         they were at L3/L4, L4/L5 and L5/S1.              

22   Q.    Okay.  Could you show us on the model.            

23   A.    Yes.                                              

24   Q.    And then explain to us what an extruded herniated  

25         disc is.                                          

 1   A.    Okay.  Your discs are the shock absorbers in      

 2         between each vertebrae.  They're designed for low  

 3         transfer and for support.  They're made of mostly  

 4         water.  They're soft tissue.  A herniated disc is  

 5         when enough pressure is on that, that it will want

 6         to come out.  In layman's term, a slipped disc.  A

 7         bulging disc is the beginnings of a herniated disc.

 8         The red on this picture is a herniated disc, on    

 9         this model, if you can see that.                  

10   Q.    Okay.                                              

11   A.    On this model here, this might be a better model,  

12         the red bulging out here is a herniated disc.      

13   Q.    All right.                                        

14   A.    Okay.  The danger is, it will come out really close

15         to this nerve and it will pinch.                  

16   Q.    And it will break off?                            

17   A.    It will break off.  A nerve's like overcooked      

18         spaghetti in real life.  It only takes the weight  

19         of a quarter to cause 60% nerve malfunction.  It  

20         doesn't take much weight.  So an extruded disc is a

21         disc that is bulging even further than most, and --

22         can I use my board now?                            

23   Q.    Absolutely.                                        

24   A.    This would be a good time to explain this.        

25                 MR. WILSON:  Let's go off the video.      

 1              (Off the record discussion was held)          

 2   A.    Okay.  On disc, if we have a normal disc, looking  

 3         at it from top to bottom, and that would be like  

 4         this, (Indicating).  If I'm looking at this        

 5         vertebra like this, there's the disc, this is the  

 6         disc.  A normal disc would have no type of bulge or

 7         deviation around there.  It would be nice and it  

 8         would be smooth and round.  If we have a bulge,    

 9         then we're going to start to see this right --    

10         right there, and a radiologist will measure this to

11         determine if it's a bulge or if it's actually a    

12         true herniation.  So this is a bulging disc.      

13                 Then as we get worse, we have what's called

14         a protruded disc.  Now the bulge has grown more,  

15         and there's a measurement from here to here.      

16         (Indicating).  They measure how long it is here and

17         how deep it is here, and then that measurement    

18         tells them if it's a protruded disc or not.  That's

19         the first stage of a herniated disc, okay.  You    

20         would have a nucleus in the middle, and it's      

21         wanting to come out, it's like a jelly-filled      

22         doughnut, and it's pushing, it's pushing, it's    

23         pushing out.  There's our nucleus.                

24                 Then the next disc you would have would be

25         the extruded disc, and on the extruded disc, the  

 1         nuclear material pushes out, and it actually breaks

 2         the annular fibers that holds that nucleus in      

 3         there.  There's a tear in the fibers, which her MRI

 4         report also said annular tear, so it fits right    

 5         along with an extruded disc.  So this is a        

 6         protruded disc, this is an extruded disc.  Then as

 7         it gets worse, you get a migrating disc.  That    

 8         extrusion will want to float or want to migrate up

 9         and down the spinal column, okay.  And that's      

10         nuclear material.  The nucleus, like that.        

11         (Indicating).  Then the next one, which is the    

12         worst of the worst, is you have a migrating disc  

13         that becomes a fragment.  It broke off in there.  

14         Okay.  This is almost always surgery right here,  

15         okay.                                              

16                 So out of all these discs right in here, we

17         know through studies that this extruded disc is    

18         kind of special because it takes a trauma to cause

19         it.  Studies show that a majority of patients might

20         have a herniated disc and not know it and live    

21         asymptomatically.  That's true for a protruded    

22         disc, but for an extruded disc, when there's a    

23         annular tear, there's almost always over 90%, 95%  

24         chance that there was a trauma that happened that  

25         caused it, meaning a person will know if something

 1         happened for that to occur.  They weren't just    

 2         living with it and then all of a sudden it creeps  

 3         up and comes on when they bend or twist the wrong  

 4         way.  So these are the different types of herniated

 5         discs.  And our patient  had three of these, at

 6         L3/L4, L4/L5 and L5/S1 on the MRI.                

 7   Q.    Thank you.                                        

 8   A.    Thank you.                                        

 9   Q.    Let's return you to your seat so you don't have to

10         stand there.                                      

11              (Off the record discussion was held)          

12   Q.    Generally speaking, what kind of problems can an  

13         extruded disc create in patients?                  

14   A.    Well, it depends on how much pressure's on the    

15         nerve root.  If there's a lot of pressure on the  

16         nerve root, it could be anything from just slight  

17         numbness or tingling down a leg or down an arm, to

18         loss of bowels control, a loss of bladder control,

19         loss of leg function, loss of muscle function.  It

20         all depends on how much pressure is on that nerve.

21         It only takes the weight of a quarter of pressure  

22         to cause 60% nerve malfunction.  So it's important

23         to try to get that disc off as soon and as fast as

24         possible and to start the healing process as fast  

25         as possible to make the strongest repair, strongest

 1         scar formation, so that it won't do that.  That's  

 2         why we ordered the MRI as soon as we did.

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