Clinical Pearls That Will Make You a Better Decompression Doctor

Hey there and welcome back. I'm Dr. Vince Leone, executive producer and co-host of the Practice Builders Podcast. With my partner in crime, Dr. Kyle Pankinen, we deliver proven strategies to help you grow fast, specialize with confidence, and build profitable staff-run practices. Let's go ahead and dive into today's episode now.

Hi, I'm Dr. Kyle Pankinen. Welcome to today's episode of the Practice Builders Podcast. I got to say, as I record this episode today, I'm pretty excited. We're just a few days away from the Decompression Certification Summit, 4th annual. I'm speaking about 5 hours this year at the summit, and I'm going to do all things clinical at the summit. And so what I want to do with today's podcast is just give you a little sampling of A few of the, what I call clinical pearls that will make you a better decompression doctor. So that's the title, Clinical Pearls That Will Make You a Better Decompression Doctor. And I'm the clinical director for specialized practice. And these are the types of things that I'm gonna go over with you. This is a small sampling of what we teach our doctors. We keep them up to date on all the latest and greatest in spine research, Spinal decompression research, laser, Class IV laser, and shockwave. And one of the things that we consistently teach at Specialized Practice is, first off, be an excellent clinician. Master your trade. If you are a decompression doctor, you need to be a master of the spine. You need to understand and know what the latest research findings are. And because— and you need to know world-class examination procedure because you want to select the right patients who are going to benefit most from spinal decompression. So you can be, you know, good at a lot of things, but you gotta be a good doc. You gotta be a good clinician. You gotta be a master of it so that you get the results. And that alone can make you a success. Now you throw in the marketing, the systems, the things like that that we also teach at Specialized Practice, then we round out the whole spectrum. And then we get doctors that, that's when they double their practices and they go from a struggling doc to a million-dollar practice. And so this, this is just going to give you a taste of what we teach. Like I said, these are just a few of the things I'm going to teach at the summit. So you're going to learn a couple new things, I think, from what I'm going to present here, which will make you a better doctor. You're going to help more patients, and then that's going to increase your revenue and your bottom line too. So I always A lot of my episodes go a little more towards the clinical end because part of being successful in a business is being good clinically and generating referrals and word of mouth and those types of things. And so I always tell doctors, concentrate on being the best doc you can be. And so, and if you're a decompression doc, this is very relevant, but this is really for any doctor that's treating the spine, period. And all chiropractors are doing that. So clinical pearl number 1 are Modic changes. What are Modic changes? Well, these are specific MRI-visible degenerative changes in the vertebral endplates and bone marrow, and they're often associated with chronic low back pain or degeneration. And there's 3 different types of Modic changes that can show up on MRI. There's type 1, 2, and 3. Number 1 is inflammatory, number 2 is fatty infiltration, and number 3 is sclerotic or sclerosis. Okay. For the purposes of this very brief discussion here on this topic, let's pay attention to Modic type 1, because when you see that, docs, on an MRI report, Don't brush that off as, oh, it just means there's some degenerative change. MODIC Type 1 is a big, big honking deal. So new and exciting research is showing that MODIC changes are more than just mechanical injury or load. They may be the initial— that, or this may be the initial insult that sets up in an inflammatory response. Interestingly, so this inflammatory response, they can see on end plates, but we're also finding in studies that bacterial pathogens can come in through these inflamed end plates. They can penetrate into the disc through annular fissures, for example, and cause low-grade chronic infection In the disc, the title of one study here is Chronic Low Back Pain: Modic Changes and Low Grade Virulent Infection. And then they talk about efficacy of antibiotic treatment. They've actually done studies where they've used antibiotic treatment. Can you believe this? For treating what they think is maybe a low grade infection in these discs. One study showed it seemed to help a little bit over placebo, a little more. That was a little while back. A more recent study showed though not as much of an effect. In fact, they said probably is not going to do a whole lot for these types of infections. And but the take-home messages from these is when you see MODY type 1 changes, Know there is significant inflammation. There could be a low-grade infection, and Modic Type 1 changes are going to potentially confound your results or make it more challenging. Another study on this, they did a case of 450 recurrent lumbar disc herniation cases. There was a 5-year follow-up, and in the study there were 316 cases of repeat microdiscectomy and 134 cases of instrumented fusion. And these are all cases that had persistent MODIC Type 1 change. And what they found was that they had an earlier recurrence Of their original disc problem they did surgery for. The recurrence rate showed up at a little over half a year, 0.58 year, so a little over half a year was the median time to a revision surgery with persistent Modic Type 1 change. And in the people that didn't have a Modic Type 1 change in the end plates, If they had to do a revision, that time was over a year. Also, revision after repeat—they had 48.8 percent persistent type one had the highest revision rate among all modic patterns after repeat. Discectomy. So sometimes they had to go on to have a 3rd surgery. Okay. They also degenerate at a higher rate. They have a higher segment failure rate. 29.7% progressed to Furman grade 5 versus 5.8% with no modic change. So what's the take-home? You're a decompression doc, you get the MRI report and it talks about Modic change. Okay, you're thinking inflammation, possible low-grade infection. The research is suggesting that. How is that gonna change your treatment approach? One, you're gonna concentrate on inflammation a lot more, right? Definitely gonna do laser on a case like this. We prefer Class IV because we think it gets deeper penetration to get in there better. You're definitely gonna get them on some type of supplementation that's gonna help reduce inflammation. And you are going to also counsel them on an anti-inflammatory diet. In other words, you're gonna pay— Greater attention to inflammation and have things in your protocol that are going to address this inflammation. The other thing I want to share with us is a lot of these infiltrations, this bacteria is coming from the gut. And there's actually a new field of study called the gut-disc axis, and they find that The gut bacteria can translocate into the disc. And I think that's what this— if there's a mode of change, they're inflamed in their spine, they're likely inflamed in their gut then too and have leaky gut. Bacteria leaks from the gut, enters circulation, and works its way into the vertebral endplate. Penetrating into the disc, setting up a low-grade infection. Some of these people, you gotta ask them in their history, do you have gut health issues, digestive problems, gas, bloating, constipation, diarrhea, things of that nature, irritable bowel type syndrome? And if they do, you may need to give them some work in conjunction with a functional medicine doctor. to help them with their gut health. That could be the difference between a successful case and a failure. And you counsel the patient that, hey, this disc case might be a little more challenging because of this MODIC Type 1 change. You're inflamed, Mrs. Jones, and so we really gotta work on that, and that this case might be a little more complex and take longer. That's all about decompression case selection and knowing which cases are gonna be maybe a little easier and knowing that this is gonna be a little more challenging case. Next study I wanna share with you, this is really interesting. We know from studies, I've actually read articles that are just by, I just read one by a doctor, not a professional, it was in Dynamic Chiropractic. And he said that the decompression disc is totally, had no nerve innervation. That is bogus, that is baloney. The outer annular fibers of the disc are richly innervated. That's why when you have an annular fissure, those things can cause raging pain. However, what we are seeing in studies now, that as the disc degenerates, The nerves from the periphery of the disc, they infiltrate into the central part of the disc, making the disc even a more pain-sensitive structure. Nerves and blood vessels in degeneration— in degenerated intervertebral discs are confined to physically disrupted tissues. They're found in the periphery, like I said, and the end plates of healthy adult intervertebral discs. But degenerative changes can allow all— allow these vessels to grow inward and become associated with discogenic pain. That's the person you look on their x-ray and, oh, they got chronic back pain. So you take an x-ray and they got degenerated discs. Maybe even get an MRI of that patient. All it shows is disc desiccation, dehydration, disc degeneration, loss of disc height, but there's no disc extrusion, protrusion, sequestration, no significant bulges, no evidence on the MRI of nerve root compression. So is that a decompression candidate? Well, it likely is. This is just chronic discogenic mediated low back pain. And as those discs are degenerating, the nerves from the periphery are infiltrating deeper and deeper. And they actually find in studies they can penetrate all the way into the nucleus pulposus. And the disc itself just becomes a pain— more and more pain-sensitive structure. Studies show chronic discogenic pain like that is an excellent decompression case, and those are highly likely to respond. And just know that you can have chronic back pain without necessarily from a disc, without it having to actually be pushing on something. Right? So you can have a Modic Type 1 change, the disc is inflamed. You could have a degenerated disc without the Modic Type 1 change, and then they just have chronic discogenic mediated pain from the infiltration of the blood vessels and the nerves into the disc. And so don't get confused on those when you see those on extra MRI that, oh, Is this disc pain or not? I mean, you'll sort some of that out with your world-class exam, but know that those discs are definitely doing or can be a focal pain generator in the absence of bulge or herniation. Okay, next. This one is really neat. This is brand new. It's called. Rim-positive fragments show more sustained reabsorption. What's up? So they're talking about rim-enhancement lesions. These are on contrast MRIs of the low back where they'll have a sequestered free fragment or a large extrusion. They do a contrast MRI, and what they find is that contrast material actually envelops either partially or fully the disc that is herniated, either extruded or a sequestration, a free fragment. And when they find that uptake of that, the dye, the contrast around it, they call that a rim enhancement lesion. Those that have that versus those that don't have that, there's a differentiation. The chances of them having a reabsorption is 73% when they have a rim enhancement positive versus 50% when they have a rim enhancement. RIM-positive patients had smaller fragments at 1 year and 3 years follow-up. So what is this telling us?

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These bigger discs, these bigger discs, the body can reabsorb them. And what's happening there is they're getting an immunological response. I'm going to talk about this a little bit more in a few minutes. That is In essence, the immune system is working on that extrusion or that sequestration. So if you ever have a contrast MRI where it shows this rim enhancement, even though it's a big honking disc or a sequestration, those are likely going to get better with time and with, of course, The decompression treatment that you are going to offer along with laser because that will enhance the results. We will touch base on this in just a few minutes again because I am going to pose an interesting question to you to make you think. Next one, next one is, can a Schmorl's node be a source of back pain? Hmm, what is a Schmorl's node? It is a disc herniation, right? But instead of bulging posteriorly or anteriorly, it's bulging straight up or straight down. Okay? And the research— so you think, well, is that a pain generator or not? The answer is sometimes. If it's your only MRI finding of significance and it seems to be Coincide with the level where you think the pain is coming from, it could very well likely be a pain generator. If it's new or recently formed, it certainly is a pain generator. If there's inflammation or swelling in the surrounding bone, think MODIC Type 1 change, or there's MRI findings showing bone edema, Yeah. It's more likely painful. So if the MRI has shown there's some activity in the bone around that Schmorl's node, or it's accompanied by a Modic change, likely it's a pain generator. And if it occurs alongside other spine problems like degenerated discs and the pain matches the same spinal level, so you could have Chronic low back pain. You get an MRI or an x-ray, and it just— the only thing it shows is a Schmorl's node. Maybe it's at the superior end plate of L4, and you do your world-class exam, and it shows that's kind of where you localize the problem is at— L4-5, L5-S1, right in that area. Then you ask, was there any trauma recently or in the last six months or so? And you see a Schmorl's node on there. That's very likely that that disc herniation could be the pain generator that hollowed out that area, causing the Schmorl's node. So the answer is yes. Schmorl's nodes can sometimes be a pain generator. 2 more things I'm gonna go over. Oh wait, yeah, look, got these few studies I wanna look at here. 3 more things. Huh. Does size matter, docs? Does size matter? Let's get our heads outta the gutter. We're talking about discs here, okay? According to the latest studies, it doesn't seem to. Here's what I mean. This study says the title, does the size of cervical disc herniation affect clinical parameters in cervical radiculopathy? Here's from the abstract or from the study. Disc herniation size on baseline MRI showed no correlation with symptom severity Or 1-year clinical outcomes, suggesting that inflammatory mechanisms, which we've touched on already, rather than mechanical compression alone, play a key role in cervical radiculopathy. What are they saying? Whether the disc herniation is big, medium, or small, it doesn't seem to matter a whole lot on clinical results. In other words, they all can get better. As long as there is no progressive neurological deficits or red flags, what do you do? You treat them conservatively. Most of these will respond to conservative, non-surgical treatment in the absence of, again, red flags or progressive neurological deficit. And we have too many doctors that are intimidated by the size of disc herniations. I have counseled several doctors over the years that basically relied on decompression case selection based solely on the size of the disc herniation that they see on MRI. So they get the report or look at the images, like, and the patient's coming to them because they wanna See if they're a decompression candidate. They look at the MRI, oh, that's a big disc. I think you better go to the neurosurgeon. Docs, that's baloney. Size, the size does not matter. The size does not matter. Now that doesn't mean it won't be a challenging case. That doesn't mean it might not take a little bit longer, a bigger one than a smaller one, maybe. But over a period of time, 1-year clinical outcomes showed no correlation to size. Okay? Again, with these discs, we gotta be addressing the inflammatory component, not just the mechanical component with adjustments and decompression. That's why you gotta have a robust protocol built around your decompression table, which we teach all our doctors. You gotta have a robust protocol so that you are addressing all these other factors that go along with the disc herniation or bulge itself. So here is the question, docs, and I guess I have sort of answered it. What type of disc herniation tends to respond better to conservative treatment? You and I, Our perception, if we do nothing, we would think, well, small ones should respond better, right? It is not as big. It is not putting as much pressure on the nerve. It should be easier than a big disc. Actually, studies show just the opposite, docs. So this study, Mechanisms and Management of Self-Resolving Lumbar Disc Herniation Bridging molecular pathways to non-surgical clinical success. Studies have shown extrusion and sequestration types of lumbar disc herniation have higher rates of spontaneous resorption, while bulging and protrusion types have lower rates.

Yeah.

Well, so this is saying that a big disc that is going further away from the disc, or even that's totally broken free from the disc, a free fragment, the body is much more likely to reabsorb that and reduce the size of it than it is a bulge or a protrusion that usually aren't as big. Okay, so this may be because the nucleus pulposus tissue in extrusion and sequestration types is more likely to come into contact with the bloodstream, triggering immune and inflammatory responses. That promote reabsorption. They found that all— another study found that all sequestered herniations exhibited partial or complete reabsorption. A systematic review confirmed that the reabsorption rate for sequestered herniations is as high as 96%.

Wow.

It wasn't that many years ago, docs. I remember when I first came out of school, and even when I was in school and so forth too, that they basically taught if you had a free fragment, you got to send them to surgery. You can't adjust or manipulate or do anything to change that. Well, the studies show you don't need to. The body will reabsorb it. And as long as you're monitoring them neurologically and they're not significantly deteriorating, you treat 'em. You treat 'em non-surgically with decompression protocol. And it might take 3 or 4 months, but 96% of these, they're gonna reabsorb. They don't need surgery. They just need time and the right conservative treatment, and they need the doctor with the knowledge to know, okay, I do not need to send that to the surgeon. I am going to save this patient from surgery because I know there is nearly a 100% chance this is going to get better without surgery. Unless you are seeing that motor-wise, you know, they are developing foot drop or, you know, they are really going in the wrong direction, that is a little different. But outside of that, you're gonna treat this conservatively, okay? So big herniations can respond just as good, if not even better, than smaller ones. So again, size does not necessarily matter. Finally, Annular fissures. Okay, they used to call them annular tears. Don't call them that, call them fissures, because a tear suggests that they're all traumatic, and some of them are not. They're degenerative, some of them are. Some are traumatic, but use the nomenclature annular fissure. So on MRI, if there were an annular fissure present that they could see, they would call it many times out. A high-intensity zone. Is that a significant finding? The answer is likely yes. See, annular fissures can be concentric and radial or transverse. They are present in nearly all degenerated discs. If the disc is dehydrated on an MRI scan, It is likely there are at least one or more small fissures in the annulus. Fissures basically then occur in all degenerated discs, but are not all visualized as high-intensity zones. So you see a degenerated disc on extra MRI, you can safely assume there is at least an annular fissure in it. It may or may not be a pain producer, If you see it as a high-intensity zone on an MRI, I would say that chances are that likely is a pain producer. If the fissure is big enough where it's a transverse and extending all the way from the nucleus all the way to the periphery of the annulus so that fluid can escape the nucleus, it almost for surely is a pain generator. So if it is a bigger fissure and it is reaching in towards the nucleus, it is going to leak fluid. It is going to come into contact with the nerve in the annular area of the disc. It is going to irritate those, create an inflammatory response. Sometimes it can break through the fluid if there is a big enough tear from the nucleus extending through the annulus. And then that fluid can leak and cause chemical irritation, chemical radiculitis. So you could have an MRI of somebody with back and leg pain and there is no herniation, there is no bulge, significant bulge, there is no evidence on MRI that they have nerve root compression, but yet they have leg pain. And you can reproduce it with straight leg raise or Bechterew's or slumps or Valsalva. That's because they likely have a disc that is leaking nuclear fluid and it's creating chemical, not mechanical, radiculopathy. And so these annular fissures are very important things to see on And recognize on MRI. The annular fissure, the acute ones, this is the patient— I am treating one right now. She cannot hardly wiggle, she is in such pain. This is the person who just bends over to pick up something off the floor, to put on their socks, and they get this explosion of pain shoots through their back. Sometimes they say, I felt something pop, doc. And it literally Drops them to their knees sometimes and they can't straighten back up again and they're in horrific pain, can't hardly move. That's an acute annular fissure. It's not a pulled muscle. It's not a muscle strain. It's an annular tear, an annular fissure. And those are exquisitely painful. And those are not somebody you wanna throw instantly on the decompression table. Let me tell you, docs, that's a bad day at the office, okay? You're gonna treat them with laser and electric stim and anti-inflammatory, proteolytic enzymes, things like that. But they can eventually be decompression patients once you get 'em out of the real acute phase. So what is this all about? These are, these are new research things that we as disc decompression doctors need to know. This is the type of stuff we teach all of our doctors at Specialized Practice. I share with them the latest research every month, stuff like what I'm going over with you right now, to keep you guys on the cutting edge and to be the best decompression doctors On the planet. And, uh, the better doc you are, the more patients you're going to help, the better your business is going to be, the better your bottom line is going to be. And so hopefully this episode of the Practice Builders Podcast resonates with you. Share us, give us a like, tell a colleague about it, and let's keep this growing. And, uh, we'll be back real soon with another episode. Thank you. Have a wonderful day.

Thank you. Hey, it's Dr. Vince again, and hope you enjoyed that episode. And if you're ready to grow your practice fast with high-value decompression patients, then the Decompression Accelerator could be a phenomenal option for you. This is our 90-day sprint to help you scale with proven systems, staff-driven protocols, and full marketing support, and it's all guaranteed. Spots are limited. Head to www.decompressionaccelerator.com to learn more.