touch v. tech

Monday, July 7, 2014

 

There is nothing like a picture to confirm the clinical diagnosis made at the bedside, even if the technology is not required. Patients want something more tangible than their doctor’s opinion. When they see the diagnostics test that pro athletes undergo to assess their injury, it is no wonder that patient satisfaction is not maximized by high touch instead of high tech. If the guy on the field needs an MRI, then so does my family member. For that reason, it’s worthwhile looking at a few of the high profile injuries in the past week at the World Cup.

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Most fans can appreciate the pain of Clint Dempsey’s broken nose, and the deformity of the initial swelling. From a medical perspective, the diagnosis is made clinically, and even if the nose is flattened or pushed aside, there is no need for x-rays to confirm the break. More importantly are the potential complications of the injury. It’s important to remember that the brain resides behind the front of the face and knowing that the brain has not been damaged is perhaps job number 1 for the doctor. Concussion is a real possibility.

Bones that make up the midface can also be broken and they include the bones of the orbit that support the eye. A blowout fracture can trap eye muscle and prevent the eye normal eye movement. Often it is just one orbit that is affected and the patient complains of double vision, because the muscles can move both eyes in sync.

There is a small bone called the cribriform plate that hides between the base of the skull and the nose. If this is broken, CSF (cerebrospinal fluid) that bathes the brain and spinal cord, and provides some of their nutrients, can leak out of the nose as a clear fluid. This is a rare injury but if missed, the outside world now has a direct passage to the CSF and the potential for meningitis, encephalitis and brain abscess exists.

Septal hematomas are blood clots that form underneath the tissue that lines the nasal septum. The diagnosis needs to be recognized because the pressure of the clot on the cartilage of the septum can cause it to die. This leads to irreversible cosmetic damage and the possibility of recurrent infect8ion and bleeding.

For most people, however, the diagnosis is made by history. A blow to the face, a bloody nose, swelling and pain equal a broken nose. If there are no complications on physical exam, the treatment is ice, pain control and a trip to the ENT doctor in about a week. If the nose needs to be set, it can happen in the office at that time.

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Neymar is the latest one named star to wear number 10 for Brazil (Others include Pele and Ronaldinho) but his World Cup came to a crashing end with a knee to the back. Because of the severity of the pain, x-rays were appropriately done to look for fracture and one was found, a non-displaced fracture of the third lumbar spine (L3). Most likely, he suffered a fracture of the pars interarticularis, a portion of the vertebral body that is prone to stress fractures known as spondylolysis. Fortunately, there was no nerve root involvement and the treatment prescribed for Neymar is rest and rehabilitation.

Most people with low back pain, even it is of acute onset do not need plain x-rays unless there has been a traumatic event. The history and physical exam remain the mainstay of diagnosis again looking for spinal cord and nerve root complications associated with the pain. If there is loss of power, change in sensation, decreased reflexes or change in bowel or bladder function, the next, sometimes emergent step is an MRI to look at the spinal cord, the spinal canal where it sits, the nerve roots that leave the canal and the discs that lay between the vertebrae and can press on those roots as they leave the back.

Back pain usually requires symptom control often in the form or physical therapy or chiropractic care. Short term pain medication may be needed but the key to the doctor visit is to prove on exam that no disaster had befallen the spinal cord.

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Case number three belongs to Angel Di Maria’s quadriceps, the muscle located on the front of the thigh and responsible for straightening or extending the knee. An injury in the quarterfinal game left him hobbled and unable to continue. An MRI confirmed that he had a grade 1 quad strain. An MRI? Really?

For most people in the real world, a pulled or strained muscle is a fact of life and most people don’t seek medical care. Ice, some over the counter pain medicine and time heals all. But there are complications to a thigh strain and bad things can happen, but they are not subtle.

Strains (injury to a muscle or tendon) and sprains (a ligament injury) are graded. A grade 1 strain describes muscle fibers that have been stretched but not torn. Grade 2 injuries means that some muscle fibers have been torn and a grade 3 injury is a disaster because the muscle has been completely torn or ruptured. Grade 3 injuries are usually evident on physical exam because the patient cannot move the joint that the muscle controls. In the case of a quadriceps injury, the patient would not be able to straighten their knee.

Quad strains can have other complications including compartment syndrome when bleeding into the injury can increase pressure within the thigh and cause muscle damage, but again, this is not a subtle diagnosis, though it may be hard to initially confirm. Treatment remains ice, elevation and rest…MRI? Not so much.

The doctor patient relationship is based on trust. Clinical judgment and diagnostic skill are still very much a hands on process. But patients push and sometimes it isn’t worth the doctor’s effort to talk somebody out of test that is being demanded. There is no upside for the doctor. If the test is normal, there can be no ‘I told you so”, and if by chance an abnormality is found, the patient is vindicated. The downside of too much testing has to do with cost, radiation exposure and the specter of the false positive, where the patient is normal but the test result causes further testing and treatment that may not be necessary and can be fraught with its own set of complications.

High touch versus high tech. The game is played every day at the patient’s bedside. And the winner is?

 

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can you say spondylolysis?

Monday, March 24, 2014

A vertebra has a simple role. Stack up 22 of them and you end up with a spinal column that holds the torso upright allowing it to move, protects the spinal cord and is the conduit allowing nerves to exit the cord. Each vertebra fits snuggly with the one above and below with a variety of interlocking parts. Architecture in the body is sometimes poorly designed and the lower lumbar vertebrae may not be able to handle the movement and weight placed upon them by the whole of the upper body. In younger athletes, especially those who have to bend and extend repeatedly, stress fractures can occur at the pars interarticularis, causing pain and spasm, potentially bringing budding careers to a screeching halt.

pars

Timing is everything and the lumbar stress fracture suffered by Kansas Jayhawk 7 footer, Joel Embiid, perhaps came at the worst possible time for his team, just before March Madness. Analysts blamed his absence as one of the reasons for the team’s early exit from the tournament. From Mr. Embiid’s perspective, there probably was no good time to be injured…ever.

The technical term for a lumbar stress fracture is spondyloysis (spondylo=vertebra + lysis=break). The pars interarticularis is placed under significant pressure from the weight of the body when it is asked to bend and stretch. Repeated impact may cause the integrity of the bone to start to give way. Microscopic cracks may eventually cause the pars to break completely through. Some patients have genetics to blame because they are born with thinner vertebral bones. Growth spurts can weaken the bone making it more prone to injury, but most often it is the repetitive activity that causes the bone to fail.

As with most injuries, pain is the first indication of a problem. Broken bones hurt, whether they are microscopic stress fractures or complete broken bones (remember that broken, fractures and cracked all mean the same thing). This is soon followed by muscle spasm as the body tries to protect itself. Low back muscle spasm causes the back to stiffen and the hamstrings then may tighten as the body attempts to maintain posture. X-rays may be helpful in making the diagnosis and a pars defect, a polite way of describing a fracture of the bone, may be identified. The fracture may be one sided or bilateral and the 5th lumbar vertebra is the most common level of injury, followed less frequently by the 4th lumbar vertebra. It makes sense because these are the lowest veterbrae of the lumbar spine and are under the most weight and strain.

Making the diagnosis in the early stage of spondylolysis is important because the injury is treated with time and rest allowing bones to heal. Patience is needed because it can take 12 weeks or more and there are complications to be had if the athlte rushes back to activity. If there are bilateral pars defects or fractures, there is a possibility that the vertebral column might slide forward potentially causing irritation and inflammation to the nerves leaving the spinal canal. This slippage is called spondylolisthesis (listhesis=dislocation). Should this occur,, CT or MRI imaging may be required for diagnosis and surgery needed to stabilize the lumbar vertebrae.

Spondylolysis and spondylolisthesis are common injuries that afflict young athletes. Population studies show that 3-4% of the general young adult population will have spondyloysis, but up to 15% of athletes will have damage that can be seen on plain x-ray. Of those athletes with spondylolysis, almost half will have spondylolisthesis. Athletes increase their risk of developing a stress fracture if they have poor technique, poor posture, lack core stability, strength and flexibility and are guilty of overtraining. While it is a medical mantra that most overuse injuries can be prevented, it’s tough understanding the mechanical stresses that are placed on the lumbar spine of a seven foot tall athlete. With time, Joel Embiid will likely heal nicely and by next fall will be playing in the pros instead if college.

There is a lot to learn from his saga. Athletes often look up to those playing at the next level for guidance and inspiration. Mr. Embiid understood the lesson of listening to one’s body and doing the right thing by it. He might have been able to push through his injury and perhaps his Jayhawks might have won a couple of extra games this year…or he could have turned his back into disaster with a lifetime of pain. Aspiring elite athletes and weekend warriors need to appreciate that playing through pain is not necessarily a winning strategy.

image source: chathamorthopaedics

 

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