Spinal Degeneration and Lumbar Multifidus: What You Need to Know | Podcast Ep. 354

Hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langmaid. On today's episode we're talking spinal degeneration and lumbar multifidus muscle action. These two things play together. What is the association? Is it causation? Is it correlation? We're going to take a look at the latest research highlighting at the bare minimum the the association and also why this is so important specifically for patients with low back or leg pain. There's a lot to dive into on this topic. Lot of great clinical pearls coming out of the research. Before we get started, I want to say a few words about the smart Chiropractor and the Payday Practice. If you're looking to build monthly recurring revenue in your practice, pick up the Payday Practice. This is the book. It is our new book and it showcases step by step how to think about, implement and begin generating recurring revenue in your practice with a specific focus. You can do this through knowledge services, inpatient care or my favorite E Commerce, getting a E Commerce store up and rolling so you can create monthly recurring revenue. The Payday Practice is out right now on Amazon. You can pick yourself up a hard copy or if you visit the Smart chiropractor you can pick up a digital copy and we'll drop that link down in the show notes as well. But as I said at the top on today's episode, we're talking research. A paper that came out in Scientific Reports. It is titled Spinal Degeneration is Associated with Lumbar Multifidus Morphology in Secondary Care Patients with Low Back or Leg Pain. This came out in 2022. It is a brand new study and it has some great information. Now if you have been following along with me, you have probably seen that I teach an MRI course and I read probably 30 MRIs, maybe 20 a day, five days a week for a couple years as part of an orthopedic group back in the day. So I got really acquainted with what was going on in the cervical and lumbar spine specifically related to lumbar changes and even more specifically related to multifidus changes. And when there becomes fatty infiltration in the multifidus. Multifitus is one of the primary stabilizing muscles in the lumbar spine. And when that muscle deteriorates or becomes has a lot of fatty infiltration, it's not optimally working. When that starts to occur, there is definitely, in my opinion a cascade that happens. And did the atrophy come first in the muscle? Did the degenerative changes Come first. Those are good questions and really, really, really difficult to answer. But the bottom line is there's an association between those two things. And if you are looking or your patients are bringing in MRI reports, the other thing I'll tell you to keep in mind, unless a chiropractic, a dakbar is reading it, a chiropractic radiologist, quite often multifitus changes are not documented and overlooked. I would say 90% of the time when I looked at a film and I saw stark multifidus changes, unless a dacbar was reading it, it was not on the report. So taking a look and feeling comfortable on how to read lumbar images, specifically in this case is really, really important. If you need help with that, we sell a course that's MRI essentials for the practicing chiropractor. You can pick it up at the evidence basedchiropractor.com or just take any course. But learning that and being able to read MRI images comfortably, not just the sagittals or the laterals, but the axials, that's where you're going to really see what's going on with the multifidus muscle. Really, really, really important. So related to this study, low back pain, top three causes of years lived with disability in every global region. I know we hear that all the time and it's a top cause of disability, but this is literally worldwide. It's in every single global region. I'd never really seen that put that way before, so I thought it was important to point out. Now, in the past, biopsy evidence has suggested that ongoing neurocompressive effects from disc herniations on the nerve root could result in alterations to the lumbar multifidus fibers supplied by that nerve. And also imaging, as we discussed just a moment ago, suggests that herniations in patients with chronic radiculopathy can be associated with increased fatty replacement of the multifidus muscle. So there's something going on here. There's no question about that. And it makes sense as well when we think about the multifidus and its innervation. Often when there's a nerve root block or something to that effect, we can actually see multifidus degeneration because the nerve that's feeding it could be disrupted by or ablated in a procedure that's meant to take care of pain, but also can affect function. And if somebody has had certainly a laminectomy or any type of lumbar spinal fusion, specifically a posterior approach fusion, this can be a really, really big deal. You're Cutting through everything to just get in there. You're cutting out material, you're taking it out, you're inserting hardware in the case of a fusion, you're taking out the lamina in the case of a laminectomy. And anytime you're doing that, you're disrupting a lot of this tissue. And as you disrupt the tissue, you disrupt the nerves and the nerve innervation. And the nerve's ability to help the muscle function optimally or facilitate that function is a big deal. And if it gets cut, that is going to create challenges long term. So they looked at a couple different things related to MRI pathology. When they were saying, how do we associate these two things? They were looking at degenerative changes. So disc degeneration. They were looking at whether there was a disc bulge or herniation, whether there was a high intensity zone. I often think of that in terms of a annular tear, whether there was modic marrow changes, whether modic end plate changes. Were there endplate defects, were there any vertebral osteophytes or any bone spurs hanging out, or was there any facet arthrosis? So those were the primary things they were looking for on the MRI to determine if there's any associated characteristics. Now, axial measures were taken from a single slice located at the level of the disc at the lower end of the foramen, the lower third. And all the measurements were acquired at L4,5 and L5s1 bilaterally. So that's how they went about things. They had over 500 cases in this study, and they found that after adjusting for age, sex, bmi, only the presence of, of four or more of those pathologies we just listed were associated with significantly lower average and worse multifidus. Cross sectional area is kind of how they define that, the meat of the multifidus muscle. So if there were four or more of the pathologies we just listed, that was in effect telling you with pretty good certainty that there were going to be significant multifidus changes. Now, with that being said, I want to tie back to those findings one more time because often we see these all together. So it sounds like, wow, four or more. That's kind of a lot. Yeah, it is a lot. But as I review this list one more time, you're going to notice that quite often these are just rattled off practically in a report. So it's not uncommon that somebody would have four or more of these disc degeneration. Probably if they're older than 40 years old, that's going to be the case Disc bulge just about the same. If they're older than 40, they might have that disc herniation, high intensity zone modic changes, endplate defects, osteophytes, or facet arthrosis. You're probably gonna end up with the majority of those, if not all of them, if you live long enough. But these are common findings on an mri. Now, when you bulk four of these together, that told us more often than not that there were going to be multifidus changes. So if you're taking a look at that list, if you wrote down that list, if you're thinking of that list, see what you see. Take a look at the mri, the next lumbar MRI you look at and see if you find that that is also the case. Now, when specifically considering how these conditions directly have a neuromechanical relationship with the muscle, in other words, there's herniations that can have neural compression, facet arthrosis, osteophytes. There were mixed results. So with osteophytes showing no significant association by themselves, disc herniations demonstrating a mixed outcome, and facet arthrosis consistently showing significance with when two or more levels were affected. So just another interesting side note to this study. So lumbar multifidus, Let me say that one more time. If there were osteophytes, it didn't really play a role. Makes sense to me. A bone spurt. Often I see osteophytes happening off of the anterior portion of the vertebra. There's not really any nerves feeding the multifidus muscle up there. So that makes sense to me. It doesn't really have any specific correlation unless it's one of those four or more disc herniations were mixed, which also makes sense. I would be interested to know whether the disc herniation, if it was more lateral, if it was more central, whether or not that had an effect, I'm not sure based upon this study, but interesting to know and also makes sense to me because I think to that and I say, well, if the disc herniation were happening in a certain place that was causing neuroforaminal compression, that could affect the innervation of the multifidus muscle. That would make sense. Additionally, facet arthrosis showing significance when two or more levels was affected. That's interesting because when you see facet arthrosis at two or more levels, I don't want to overstate it and say it's that severe degenerative change at that point in time. But that tells us that there's multi level issues. There's probably more going on than just that. And you're probably hitting those thresholds that get into the realm of multifidus function, which over time can decrease the, the cross sectional area of utility, increasing fatty infiltration and really destabilizing the lumbar spine. And this is an important component. There's a couple other findings here, but I wanna touch on this in relativity to rehab. And this is a really, really important piece of this. Especially with your post surgical patients and potentially I'm gonna say just as significantly with your hopefully non surgical patients. But if somebody's going through and evaluating whether a surgery should happen or not, if somebody has abject fatty muscle infiltration and multifidus, you have to set expectations appropriately. They're not going to be somebody quite often that is going to go through a couple visits and be 100% well. If they have, if they're practically on the verge of instability based upon a lack of muscle function in the deep stabilizing muscles of the spine, two sessions, not going to overcome that. So setting the expectation, and this is important because if somebody expects that they don't get the result. And now quote, unquote chiropractic didn't work, then they go get the surgery. After the surgery, their rehab is abysmal and atrocious because they have nothing supporting what was just performed. They had stuff taken out, they have more muscle decay. I'll say whether that is due to the muscle being cut and stitched together, whether it's due to fluid, whether it's due to hardware being put in, they are down a really, really slippery slope. So it's important for people to. Nobody knows this or thinks of this. So it's important to be able to look at an image first. Which is why it's important to look at the images, not just the report. Look at the images and say, hey, here's what's going on. You have a lot of fatty infiltration in the muscle right here. That tells us that muscle is not functioning as well as it could be. And that's really important for your back. Now that could be causing pain or it could not be causing pain. But even if it's not the cause of the pain, this is gonna be something we're gonna work on. And it's going to take some time. That fat doesn't get pushed out. When you do two sit ups or two cat cows, this is going to take some time. Additionally, if you're thinking about having injections or surgery, it's going to further impact that, and not necessarily in a positive way, you're going to have to take an active role in this one way or the other. And describing that to people is really, really important to help them ultimately make good clinical decisions because they have no clue otherwise. And I can guarantee you 99% of the time their surgeon's not telling them that kind of stuff. So there were a significant association with smaller cross sectional area of the multifid and no clear mechanical neuromechanical mechanism. And that's interesting as well, where this study had a mixed bag, which is why it was saying it really showcased when there were four or more findings. Now, over time, degenerative processes such as degenerative disc and modic changes may potentially contribute to recurring episodes or long periods of back pain, which could inhibit muscle activity and eventually impact the multifidus muscle quality. So which came first? Chicken and egg? Difficult to say. This study does not provide the answer. We might not get that answer for decades to come, but there clearly is an association. The ultimate findings here were several pathologies were associated with smaller proportions of muscle, particularly multilevel degenerative discs, multilevel facet arthrosis and moderate to severe modic type 2 marrow changes. These associations remained as the number of different pathologies reached four or greater, supporting a potential dose response relationship between spinal pathology and lumbar multifidus morphology. So that is really the takeaway message. If you're reading reports, hopefully you're looking at those images. Keep a keen eye on what's going on with the multifidus. Not only is it a big player in spinal stability, is it a contributor to pain patterns? Probably if the pain came first and then you're getting muscle atrophy and degradation as a result of non use. That's one way. If did the muscle injury come first and now you're end up in pain, that would be another way. But clearly during the rehabilitation process, whether in your practice or any other practice, people need to understand that muscles don't change overnight. As Gary Vaynerchuk would say, you don't get big muscles by watching other people do pushups. So this is a matter of them taking a really active role in their recovery. That is how they're gonna get best results, with some patience, with some hard work and with some active care. And muscles, as we know, they do not atrophy typically overnight. So this really gets down to inspiring lifestyle changes with many of these patients and subsequently on those post surgical patients. I want to tie back to that really quickly on Those post surgical patients where their lumbar spine is torn up and that multifidus, I've seen it where I couldn't visualize the multifidus and somebody has ongoing pain quite often more surgery is not the answer and that's a hard thing when people hear that. But it also needs to be clearly stated so they understand they have issues. And those issues aren't gonna be solved overnight. And it's not necessarily a structural issue where something needs to be cut out. This is a rehabilitative issue where you need to do the most you can with what you have. That is where you and I, I think as chiropractors come in to offer those strategies where even if they don't have great multifid dysfunction, we what else can they do? What other muscles synergistically can they strengthen to get them the best results possible. 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