332- What To Do About Adjacent Segment Pathology

Welcome to the Evidence Based Chiropractor where each week we deliver the latest chiropractic research and marketing strategies all in the time it takes to get to your office. Now here's your host, Dr. Jeff Langmaid.

Hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langmaid. On today's episode, we're talking all about adjacent segment pathology. This is a real thing that probably is happening more often than you really take note of based upon the surgical numbers that we've seen over the last five, ten plus years. And there is a great study that just came out. We're talking February of 2022. It is a case report, but it showcases adjacent pathology in a real way, stimulates some questions and has a bunch of clinical pearls. That's what we're gonna go through on today's episode. Before we get started, I wanted to say a few words about the smart chiropractor. The smart chiropractor powers your patient journey to provide you with more qualified leads, more new patients, better retention and more consistent reactivations without spending any money on advertising. You could check it all out. We believe in a teach and invite consistently philosophy based upon great content. Communicating your message to your people and to new people each and every day through those primary channels. We're talking Google business, Facebook, Instagram, email, huge ROI driver and much, much more. Check that all out@the smartchiropractor.com but as I said at the top of today's episode, we're talking about a study that came out in February 2020. It is in the Journal of Family Medicine and Primary Care. We'll drop that link in the show notes as we do each and every week. And it's titled Adjacent Segment Pathology of the Cervical Spine A case report. This was put out by Dr. Eric Chu. I have actually known Eric for quite a few years. Great guy. Has built an incredible, incredible multidisciplinary, multi unit practice in Hong Kong. And, and this is a really cool study because here is where I'll set the stage. Adjacent segment pathology. We know that these challenges occur adjacent to a previous fusion site. Couple things to keep in mind based upon my experience working in surgical groups for many, many years. One, just because somebody has a disc replacement, emotion preserving, quote unquote device rather than a true disc fusion doesn't mean adjacent segment pathology won't take place. Critical to keep in mind, nothing beats what we are born with, so to speak. So biomechanics are changed. Adjacent segment pathology still occurs even if they have A disc replacement as opposed to a true fusion. Second key. Most of the time, this shows itself worse at the level above than the level below. Most of the time there are exceptions to that rule. But if you see a fusion site, be sure to take a look at the level above. Also take a look at the level below, but take a look at the level above. Additionally, when I described this to patients in practice, I'd sit down and see 20, 30 patients a day reviewing MRIs, et cetera. I'd see a lot of people coming back who previously had fusions. Guess what? Because of adjacent segment pathology, because of weight of gravity, they went back to the same things that got them into that position in the first place, at the first level. All of those things and much, much more. And what I would describe to them quite simply in patient language, I would say, hey, you got five bones in that low back, right? Five bones in your lumbar spine if you fuse two of them. Now we have four quote unquote units doing the work of five. So everybody's working overtime. You can only work overtime so long before you have to pay the piper. So you can describe this in patient language, but let's dive into some of the doctor language so we can really dive into this study on today's episode. So adjacent segment pathology, technically it refers to degenerative changes observed at the functional spinal units adjacent to the site of previous fusion procedures. Now, all spine surgeries, as I said, I don't care whether it's a disc replacement, whether it is the newest fangled disc. Well, this one allows more motion than the ones in the past. Yeah, I've heard it all before. I've seen it all before. It still takes away the normal anatomy, it takes away the normal biomechanics, and nothing that's been built to date exactly mimics what occurs. It's ridiculously complex, the motion patterns that occur in our spine as we go through our day to day. So all spinal surgeries alter motion across a joint. They can contribute to additional stress and mechanical loads on the segments above and below. And this can be complicated by a variety of factors. Things to keep in mind, age related changes, anatomical disruption. Anytime you do surgery, it is trauma. You are taking stuff out of the body. And you are, in theory, if it's a laminectomy, a laminotomy, maybe you're not. Or foraminotomy, you're not putting stuff back in, but you're taking stuff out. The body does not like empty space, so it's gonna fill that in. With fluid or scar tissue. If you're putting stuff in, AKA a disc, replacement, screws, fusion apparatus, you are going to end up with challenges. And that's just the way it is. Way too many people out there believe that the surgery is fixing the problem and it is just not true. The surgery might provide temporary relief and should be used in extreme cases, but it is not this. Well, I just like started over the clock. It's just not the way it works. Especially when surgery is being performed in areas that have a lot of existing challenge. Meaning if you have a ton of osteophytes, multilevel, you have disc desiccation, multilevel, you have multilevel disc herniations, these are compromised multilevel issues. Now, a single level surgery might provide a significant amount of temporary relief, but it's still adding to and it's gonna accelerate even more the changes that are happened or happened at the other level. So these are just really, really important things to keep in mind. So anatomical disruption can complicate adjacent segment pathology. Surgical technique Bottom line is you look at a continuum, there's a bell shaped curve of surgeons and probably not too many of you want to think about this. It's scary to think about, but you know, very few are really good, very few are really bad. And if you are 50%, you are the median line. So you, there's, there's a lot of surgeons that just aren't very good out there and that ties into their technique malalignment of the spine. So this is existing biomechanics. A lot of times I would see the surgeons looking really intently at what's going on on the imaging to understand, for instance in the lumbar spine, sacral base angle, et cetera, so that they understand how to create a fusion or a disc replacement in a way that is going to provide the best result possible. But if you're coming in there super compromised, it's difficult, you can only do so much and then pre existing comorbidities can be issues and challenges as well. So if you have previous osteoporosis, diabetes, you're a smoker, degenerative spondylysis, all those things can play a role. So in this study there's a 61 year old individual who presented with severe neck pain into the right extremity. It had been going on for a few months and they described having the same, this happens all the time. They described having the same symptomatology 30 years years ago when they had a C5,6 and C6, C7ACDF, that's anterior cervical disectomy infusion. So they had about 20 years of good relief. That's a, that's a pretty damn good run. So, you know, 20 years of symptomatic improvement. But over the last decade they started to see things, you know, kind of pick up again. They noticed some of the same symptoms and over the last few months it became pretty bad. So during examination they found neck motion was limited to 10 degrees in extension, should be about 60, 40 degrees. Degrees of bilateral rotation, should be about 80. And they noticed some right bicep and wrist extensor motor strength decreases 4 out of 5 and numbness along the C5 dermatome. So these are important things. Now, let's say now they went one step further. They took the imaging and they saw in the study, it shows a few pictures of the imaging. Looks pretty nasty, certainly not even close to the nastiest thing that I've seen. But you can tell that there's been some work done and you could tell it's greatly affected the areas below. So on the imaging, they of course noted there was hypolordosis of the spine changes. Biomechanics, there were fusion of C5 through C7, so multilevel fusion, in this case disc degenerative changes throughout cervical spine disc height changes at 3, 4, 4, 5, narrowing of the canal at 4571. And at right 4, 5, they had some foraminal narrowing on the right side. So the thought was, was that there is some right side C5 nerve root compression. So that's when the treatment began. So that's really what was going on. And I think we're talking about a specific individual here because this is a case report, but this can be extrapolated out to a ton of patients you are seeing. And here's where this matters so, so much. We know that over a million elective spinal procedures are being performed. Not all fusions, but a million elective spinal procedures plus are being performed each and every year. So if you pull that back, I know it's increased pretty dramatically over the last 25 years, each year. But let's ballpark it. I'm going a little high with these numbers, but a million a year times 25 years. Most people that had stuff done 25 years ago are still alive, right? They might have had it done at 45, 50 years old. Now they're 65, 70 years old. So 25 years, a million a year, 25 million people. There's 300 plus million people in The United States right now. It's like that's, I mean, it's like 5 to 10% of the population has probably had some work done on their spine, which is ridiculous and extreme, but it's the, it's what's out there. So when you're noticing that somebody has had a previous fusion. When you're noticing somebody has had previous work done on their spine and please, I've saw this every single day. Somebody had a surgery done 20 years ago. They don't know what the surgery is. They're not even sure if it was a surgery. And we see this, right? So this is where imaging can play a huge role, especially if somebody's having ridicular complaints. Somebody's having complaints that they're like, this is like what was going on many years ago. And I went to see a doctor, they did something, and it wasn't a chiropractor, it was a medical doctor. They did something and I was good for a long time. Chances are that something was not a steroid injection because it would have wore off very, very quickly. So, so if they're saying these key phrases, these key clues, please investigate further because understanding what's going on is a big deal. And here's the scoop is, you know, I talk about this week in and week out, but if they are coming to see you, the alternative, this is a privileged place to be in. So us as chiropractors, you listening right now? Do the best you can with these people. Don't let them walk out the door and go somewhere else. Cause you know what's gonna happen, they're gonna keep getting added on. They go back to a pain management doctor, they go back to their primary care doctor, they go back to the medical doctor. Chances are more likely than not that they are gonna end up with, well, let's work on that next level. Well, let's work on the. I saw this every day and you see people, I saw people that had 75, 80% of their spine fused. And it wasn't all done at one time. I'm not talking about Harrington rods, I'm talking about stair stacking these things over the course of decades. It's sad. And these people get to that point where there's literally nothing else they can do except live in abject pain. And it's, it stinks. So we need to take that very seriously. As conservative care providers, as chiropractors, as probably the people can, can make the biggest difference in their lives. How? By utilizing a movement based techniques that we do, by focusing on the balance of strength and flexibility by decompressing, whether it's, you know, I'm not talking about surgical decompression, but by hand, you know, putting axial traction into some of these segments, using flexion, distraction, providing at home techniques and care that they can utilize in addition to the care and practice so, so important and can make a difference in these people's lives like you have not seen. Even if they don't find full resolution of symptoms, which quite often, if they've had previous work done, the dam's already been broken, Pandora's box had already been open. There's only so much you can do. So you don't have to expect to find full resolution of symptoms. But if you can just keep them from getting more and more surgery, that is a huge win and something we all need to take seriously. So in this case, at the completion of the treatment, her symptoms were resolved and her neck extension was regained to about 50 degrees from 10 degrees and to about rotation, about 65 degrees, which is a huge, huge improvement. And then from a business perspective, but it also is good patient care. The patient entered a spinal rehab program once a month for continuing care, for basically maintenance. Critically important, important to offer and emphasize as well. Don't be shy about this stuff. Especially with these individuals that are going about their day. They're not changing their jobs, they're not changing their habits and they have issues. These issues are not going to go away. But with management, they can certainly be minimized. So the progression of adjacent segment pathology results from compressive loading on those adjacent segments and also nutrient diffusion. So when there's a fusion that takes place, the nutrient diffusion dramatically changes right there. And also, one thing to keep in mind, it is never the case that the entire disc is removed. The surgery would take like a gazillion hours. So when somebody goes in and removes the discs and places in, excuse me, a apparatus, whether it's a motion preserving device or whether it is a straight cage, portions of the disc remain. Now, those portions are not going to re herniate because most of the disc gets wiped away. But I've had this happen before and it's like there's still some disc there. Yes, there's always still some disc there. If you were trying to clean out the entire disc, it doesn't slide out, it doesn't come out like a lego brick, you know, it takes little bits. You're taking little, little tiny bits with these very, very finite tools. So you want to get a majority of the disc out, but most of the disc or a good portion of the disc may remain. So radiographic changes to adjacent segments include osteophyte formation, disc degeneration, foraminal narrowing, spinal stenosis, instability, scoliosis. All of these things can take place at adjacent levels. So bottom line is, keep these people at top of mind, make sure that you're educating them on what happened in the past, what can happen in the future, and that you don't really wanna go down that cascade unless you have to of continued surgery. Key messages in this one Adjacent segment pathology refers to degenerative changes at segments immediately contiguous to previous spinal fusions. Symptomatic ASP is a disappointing long term outcome for patients after spinal fusion. Nobody wants it, but it's gonna happen as gravity does. Patients with ASP will have ongoing share, general practitioners and tertiary units and non surgical measures should be utilized. So hopefully this was a good eye opener or a refresh to adjacent segment pathology. I thought it was a great way to just approach this in a real way with real numbers, with a real patient and draw out some of those key messages for you to be able to communicate with your patients. So that is a wrap on today's episode. Before we conclude, I should say, if you are interested in orthotics, my father has had a ridiculously good experience with Power Step orthotics and they are offering listeners of the Evidence Based Chiropractor show a free sample pair. Yes, a free sample pair. I cannot stand behind this product enough because I see my dad using it day in and day out. This is somebody who's had radiculopathy, he's had neuropathy issues, he's had low back issues. And to see the relief that he's gained, he just, you can't walk around without having shoes on, all those things. And these insoles have helped him tremendously. You can check it out and grab a pair for yourself. Pro.powerstep.com sample pro.powerstep.com sample I will drop that link in the show notes. Pick yourself up a pair of insoles from Power Step. Have an awesome week in practice and I will talk to you soon.

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