The Multifidus and Degenerative Disease Patterns | Podcast Ep. 362

Foreign hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langme. This week we are back with research. We're talking about the multifidus muscle. Again. We highlighted a study a few weeks ago about this and this continues that conversation. A lot of great clinical pearls you can take away and some surprises as well. So definitely a episode you want to tune in and pay attention to. Before we get started, I want to say if few words about the smart chiropractor. The smart chiropractor can help power your patient journey by helping you acquire more new patients have better retention and more consistent reactivations, all on autopilot. No paid advertising necessary. You can learn about how we do that@thesmartchiropractor.com again that is the smartchiropractor.com we work with over 300 practices around the world to do this and we'd love to work with you. So if you would like to set yourself up and dial in for success in 2023, head over to thesmartchiropractor.com but as I said at the top, today we're talking research. This study just came out. It is hot off the press European Spine Journal and it is titled Different Degeneration Patterns of Paraspinal Muscles in Degenerative lumbar diseases. A MRI analysis of 154 patients. If you want to check out the study, we'll drop a link down in the show notes for you to check it out. But as you probably know, I am big on the multifidus muscle. I think it is critically important and it's often cut with surgical intervention. And if your patients have MRIs, if you're not looking at it, it's one of those things that's just missed. Unlike every MRI ever. Like it took me years of reviewing MRIs before I saw it. Not because it's hard to see, I just wasn't trained to do so. And as a byproduct of that, I never saw it on any reports. So with that being said, this is a critical piece of the puzzle because if your patient has fatty infiltration of multifidus, if they're multifidus, it's totally shot. In other words, it's going to be really difficult to get progress. Now that doesn't mean that they can't excel with conservative care. They can, but their expectations should be tempered. And this is where patient dropout comes into play. When you're not meeting their expectations, you're unable to accurately communicate really how long it's going to take. And by the way, injections and surgery are not the answer if the multifidus is fatty hemo infiltration or if it's cut. So this is about having intelligent conversations with your patients so that they can make the best decisions for their care so they don't drop out of your practice because they're, quote, unquote, not getting anywhere when it's just gonna take longer. And setting that expectation is absolutely critical. So we all know degenerative change of the paraspinal muscles is associated with a host of lumbar disorders and diseases. It's a big deal. Paraspinal muscle is composed of a few different key components. Iliopsoas, quadratus, lumbar, lumborum, erector, spinae, and multifidus. We're going to focus on the erectors and the multifidus with this study specifically. And the lumbar paraspinal muscles play a really, really important role in the stability of the spine in the maintenance of coronal and sagittal alignment. Now, I'm not the biggest hawk over, you know, static alignment. I think it's really about dynamics. Now, static images can give us insight into that. But we see time and time again when there's. Everything's on a scale, right? Life is about moderation. So is there a perfect coronal and sagittal alignment? Well, yeah, that's perfect, but normal is a range, and it's okay to be within that range. You don't have to be perfect to be functioning at a really, really great level. But when we get outside of that range, that's when it creates challenges. So I'd encourage you, if you like, you know, scoff, you know, at sort of static images and alignment and those sort of things. Don't throw the baby out with the bathwater. There's really impact here, but it can be nuanced and it can be ranges, and that is a. Okay. Now we also know that the degree of muscle degeneration is associated with spine degeneration and sagittal balance. So that's where it's all coming together here. All of these things play a role. And if somebody has big time, you know, their multifidus and erector muscles just aren't working. There's fatty infiltration. They're not functioning appropriately. They're atrophied. Well, they're going. This is the cascade, right? Now you start to see advanced degeneration. Now you start to see changes to sagittal balance, to alignment. And guess what? Now you start to see altered Biomechanics and movement patterns that result in pain over time. So reversing this, these things all play together. It's not one thing, it's everything. And by the way, we're under the constant strain and stress of gravity, and we're continuing to age. Two factors that none of us can escape, at least to date. So these are why understanding this is why understanding this research is so important and why applying it, in my opinion, to your conversations. What you learned today might not change the way you treat patients, but it should change the way you communicate with patients. So let's dive into the multifidus. Multifidus fibers are oriented obliquely relative to the spine, while erector muscles are bundled parallel to the long body axis. So that is something to keep in mind. It's like, I love hearing stuff like that because it helps me really visualize what's going on in spinal anatomy was not. I did not get an A plus in it. So really being able to just understand, okay, I can get that. Erectors travel north and south. They travel along the spine. Multifidus travel obliquely. I can, I can get down with that. And remember that. And additionally, the cross sectional area of the psoas and multifidus in asymptomatic population increases caudally gradually, while the cross section area of erector gradually decreases. So one's becoming bigger, one's becoming smaller as it travels down the spine. Important to keep in mind. So in this study, how did they take a look at this? Well, they examined 154 patients with degenerative lumbar disease. What were the cutoffs? Well, the average duration of pain was 11 months. It ranged from one month to 36 months. 11 months was the average. So what does that tell us? Well, the average person was in chronic pain because chronic pain is defined by three months or more, 90 days or more generally. So if the average here was 11 months, all these people had chronic pain? Well, not everyone, because there was some people with one to two months. But the average person in the study had chronic pain. And with 11 months, the average person was into chronic pain 3x over the threshold. So they'd been sitting there for a While. Patients under 18 years old and over 90 years of age were excluded from the study. So if you're super old, over 90, or if you were not yet an adult and you were under 18, then you were excluded from this study. Now, what did they find? A couple very, very important things. They found that the paraspinal muscles have been recognized as the lumbar Stabilizers, and they're a protective factor in degenerative lumbar disease and atrophy. And fatty infiltration, as we talked about at the top, are two major features of muscle degeneration. So when we're looking at muscle degeneration, there's two things that we're primarily looking at. Atrophy. How are these muscles? Are they plump, are they big, are they strong, or have they atrophied? Are they withering away? And then the second component to that is how much fatty infiltration. Now, this is gonna show up on a T. MRI image as white. So when you see those muscles and it's a lot of white as opposed to a lot of dark, that tells us that there is a lot of fatty infiltration going on. So if you want to take a look, that is a good way to look at it. Make sure you're looking at the T2s. If you're looking for that whiteness to show you that there's fatty infiltration. Now, researchers in the past two decades have shown that the degeneration and function of paraspinal muscles are closely related to the process of lumbar degeneration. And they can affect. Here's where the rubber meets the road. They can affect long term clinical outcomes related to lumbar spine degenerative diseases. So is it important to build these muscles? Yes. Is it important to maintain these muscles? Yes. Is it important to never let them get to the point of atrophy and fatty infiltration? Of course. But also the other side of this, and I want to touch on this very, very clearly. If you've had patients that have had foraminotomies, laminotomies, laminectomies, certainly any spinal fusions, look at the multifidi. You pretty much have to chop through all of the paraspinal muscles, and they are never the same. Let me repeat that. They're never the same. The doc might try to stitch some of them up on the way out, but by and large, many of these muscles are. Some of the muscle I should say is going to be, quote, unquote, untethered. It's not going to be stitched back together. Others, you're going to have an abundance of scar tissue. It doesn't work the same. So surgery has permanent changes. Whether it's a minimally invasive surgery, whether it's a maximally invasive surgery, it doesn't matter. When you use a scalpel and you cut through, and I know some people say, well, we use an endoscope, we kind of just go through and separate the muscle instead of cutting. Muscle gets disturbed in all cases, all the time in every surgery that is spinal related. So this is important to keep in mind, especially of course, if there's a posterior approach. Right. So this is really important to keep in mind with your post surgical patients. All of them are gonna have MRIs. Take a look at the MRI, pull up the axials, look at the T2s and see what those muscles look like. See if they're even there to begin with and see if they're dark or white. The more white they are, the more fatty infiltrated they are. But take a look at the atrophy. This is really important as well. People that have gone through surgery rightfully so, if they're coming in to see you and they still have pain, they're probably pretty frustrated. They don't know what to do. And many believe, well, I guess I'll go. This is just the truth. I guess I'll go see the chiropractor. But really, I know I'm probably gonna have to have surgery again in the future. It's like, hold your horses. Surgery did a lot of the damage. It causes damage. So understanding that rehab's gonna take time, Things will never be the same, but they can be better. And that movement based care, Chances are, unless they have these red flags or crazy anomalies, 95, 99% of the time, they don't need more surgery. What they need is patience. They need some inspiration. They need rehab and exercise, and they need, as best as they can, great segmental, regional and whole body movement. If they do that, they're gonna be in a great spot or a lot better than if they keep going back for more surgery. Because I have RA if ever seen that be the solution? Rarely, if ever. And I've seen thousands of surgical patients in multiple orthopedic groups that I worked in. I sat with these people each and every day, all day for over half a decade. And surgery rarely, you know, creates a wondrous sort of result, especially if it's second and third surgeries. So previous studies have indicated that both degenerative lumbar spondylolisthesis and degenerative lumbar kyphosis patients with multifidus and arrector muscles are significantly degenerated compared to asymptomatic subjects. So let's dive into some of the specifics on this study. Don't mean to get off on a tangent there on the surgery, but I think it's really, really important for us to keep that in mind. This study showed that multifidus atrophy was more significant in those spondylolisthesis patients compared with the kyphosis patients. And spondylolisthesis patients showed heavier fatty infiltration in the lower lumbar spine compared with the kyphotic patients. And those are degenerative kyphosis and degenerative spondylolisthesis. Also, degenerative kyphosis patients showed more significant atrophy of the erector spinae muscles at L2 L3, 2 L5 S1 segments. And heavier fatty infiltration at L1 L2 to L2, L3 when compared to the spondylolisthesis patients. So important to keep that in mind. While Tifidus is the largest and most medially of the deep paraspinal muscles, it originates on the sacrum, remember, in the ilium, and inserts around the spinous processes and lamina in a fanning pattern. Now, here is something in this study that I thought was awesome that I never heard put this plainly before. Multifidus is innervated by the medial branch of the dorsal rami unisegmentally. So each band of that multifidus gets innervation from one dorsal ramus only. And these independent features make the multifidus develop segmental degeneration in spondylolisthesis patients genetic. Due to the disc and facet joint degeneration, segmental stability becomes compromised. And as a stabilizer, multifidus bears greater load on the segment where slippage occurs, which starts that cascade of advanced multifidus degeneration. So that's really how this all comes together. And if you think about a dorsal rami being, you know, whether somebody has. And I know it depends upon the ablation. But sometimes people go in and they're getting all these ablations and they're getting, you know, nerve roots essentially cut is what it is. Don't forget that this really affects the multifidus. And, you know, again, just because you can't feel. It's the old fire alarm chiropractic example, right? It's like, oh, the fire alarm's going off. Do you change the. You know, do you take the batteries out of the fire alarm, or do you address the fire when somebody has abject pain Again, the different strokes for different folks. There's different things that go on. But by and large, these things are way overdone. What are these things that I'm talking about? Ablations. And they. I mean, people going in and cutting nerve roots because there's pain in a segment. Well, guess what? That person is going to have advanced intervention like 99% of the time because now you've just de innervated a segment. Yeah, you got rid of the pain. But what was the actual problem that was causing that pain? Chances are once you take, once you do that, well, Tiffany's gonna fall apart, the segment's gonna fall apart over time. I don't feel pain. Yeah. For the next three months until the segment falls apart. And now you're looking at more advanced interventions as time goes on. So these researchers also found that the erector spinae muscles in kyphotic patients exhibited multisegmental degeneration, which was different than the unilateral segmental degeneration of the multifidus. So multifidus degeneration of the present study was more significant compared to the healthy controls in previous reports. A couple other findings they had was multifidus showed greater levels of fatty infiltration in the lower lumbar spine. Definitely look towards that L4 L5, L5 S1 level. In my opinion, if you're checking out the images compared to the arrector spinae. Additionally, segmental degeneration is more significant in patients with spondylolisthesis compared to those with kyphosis. And in contrast, erector spinae degeneration was more significant in kyphosis patients. So here are the conclusions. If we wrap it up, put a bow on it. Here are a few sentences that I will quote from the study. Quote. Paraspinal muscles have different degeneration patterns in degenerative lumbar diseases. Multifidus degeneration is segmental in both spondylolisthesis and kyphotic patients, while arrector spinae degeneration diffusely in kyphotic patients and correlated with the severity of kyphosis. Multifidus degeneration is more significant in the spondylolisthesis group, while erector spinae degeneration is more significant in the kyphotic group. So all important things to keep in mind. In my opinion, this study was really good because the findings are interesting. But some of what we highlighted in terms of unilateral innervation, in terms of how those muscles sit, the multifidus obliquely, the erectors up and down, they're just things I hadn't thought about in a long time. So I'm a big fan of checking out the images as probably you can gather by now, whether it's post surgical patient, non surgical patient. If you have an mri, throw up those axials on your DICOM viewer, turn on the T2 images and take a look at the multifidus that is going to allow you to have more productive, better, clearer conversations with with your patients. And before we wrap, I want to say a few words about PowerStep. PowerStep supports this podcast. I'm going to ask you to support them. And what does supporting them mean? They're going to hook you up with a free pair of orthotics. So why wouldn't you take advantage of that? Use the code EBC evidence based chiropractor at pro.powerstep.com sample pro.powerstep.com sample these are orthotics I use myself. My dad uses. 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