Annular Tears

Frequently asked questions about annular tears:

1. What is the disk?

- The intervertebral disk is a structure that provides mobility  between the bones of your spine.
- It is best to think of the disk as a gasket or ball-bearing that aids in motion.

2. What are the parts of the intervertebral disk?
- Outer fibrous layer, called the annulus fibrosis (annulus)
- Inner gel layer, called the nucleus pulposus (nucleus)

3. How does a normal healthy disk work?
- The disk is a pressurized system which allows motion. 
- The nucleus contains gel that allows for motion
- The annular fibers provide structural support for the nucleus

4. What is a herniated disk?
- A herniated disk (sometimes called disk protrusion or disk extrusion) is when the gel in the nucleus pushes outward, stretching or breaking through the annular fibers
- A herniated disk can be painful if it pushes on a nerve root. This may cause pain that shoots down your limb (often called radiculopathy or "sciatica")

5. What is an annular tear?
- An annular tear is a tear in the annular fibers
- It can be identified on an MRI as a "high intensity zone." This is a bright area that is seen in the otherwise dark disk as shown in the picture below.  (The annular tear is in the white dot in the back aspect of the second disk from the bottom as indicated by the black arrow)

The MRI image above is called a sagittal slice, which is a slice through the middle of your body (separating the left and right side of the body).  The left side of the screen represents the front of the body, and the right side represents the back of the body.

The image below is from what is called an axial slice, which is a cut through the body separating the top and bottom of the body.  This image is specifically through the L4-L5 disk.   In the center of the screen is an oval structure with a whitish center and black outer rim- that is the disk.  The whitish center is the nucleus, and the black outer rim is the annulus.  Within the annulus, there is a thin white line toward the lower part of the annulus- that is the annular tear (indicated by the white arrow).

6. Are a herniated disk and an annular tear the same thing?

- No
- They can co-exist, but they can also occur separately
- A simple (and mostly true) way to think about it is that annular tears cause low back pain, herniated disks cause pain that shoots down the limb when it pushes on a nerve root

7. What are the symptoms of an annular tear?
- Stiffness in the low back when waking in the morning
- Vague pain that is difficult to localize
- Pain putting on shoes and socks in the morning
- Pain with prolonged sitting
- Shifting positions while sitting
- Tendency to axially off-load while sitting (e.g., using straight arms with a fist to push yourself off the table)
- Improvement in symptoms when walking following prolonged sitting (e.g., when first stepping out of the car after a long car ride, once you have straightened out)
- Pain with Valsalva maneuvers (e.g., coughing, laughing, sneezing, sexual intercourse, and bowel movements)

8. What about muscle spasms?
- Muscle spasms are sometimes experienced along with annular tears and herniated disks. However, they can be seen in the absence of a herniated disk or annular tear.
- Muscle spasms are often not the primary source of pain.

9. What is the treatment for an annular tear?
- Physical therapy
- Injections, such as epidural steroid injections can be a useful complement for physical therapy.  One particular approach, called a transforaminal approach, may be more effective than other alternative approaches that are more commonly used.
- Medications, such as oral steroids can be used early on in treatment course.  We find that transforaminal epidural steroid injections below the level of the disk injury, however, tend to work better than oral medications.

Musculoskeletal Ultrasound

One of the underrated tools that Drs. Chimes and Hyman have at their disposal when diagnosing and treating patients is the use of musculoskeletal ultrasound.

Most people are probably familiar with ultrasound to some extent, physical therapists will often apply therapeutic ultrasound to injured tissues and ultrasound is typically used to visualize unborn babies. Musculoskeletal ultrasound  is closer to the ultrasound utilized during pregnancy, the idea being that the probe emits super high frequency ultrasonic waves which go through a gel medium before being transmitted through the skin and different body tissues (such as muscles and tendons) before bouncing back and being received by the probe.

The frequency of these ultrasonic waves produces an image that is incredibly high resolution (3 times higher than MRI). The ability to view these images in real time is unique compared to other imaging modalities, allowing the doctors to observe the dynamic movement of body structures. An additional benefit of this is the ability for the patient to give feedback in real time, this is important because it is clinically significant whether or not the patient is experiencing any pain at the location of the probe where inconsistencies are observed. This can help the doctors discern whether the irregularities are concordant with their symptoms or simply incidental.

Patients will often come into our office and state that they have had a previous cortisone injection performed by another physician. While they probably did have a corticosteroid injected, that isn't really the relevant detail. More important is where the medication was placed, and how it got there. Historically, and the way that most physicians today do these injections is on a landmark basis. What that means is the doctor will insert the needle and once a landmark is reached (often when the needle hits a bone), then the placement of the needle will be adjusted relative to that landmark before the medication is injected. While injections done with this method can give patients relief, this technique doesn't completely take into account the variety in each person's anatomy or allow for the precision required to reliably hit the intended target. Even if the target is missed, it is likely that the medication was somewhat absorbed by being injected in the general area, giving the patient variable levels of relief.

Having the ability to use musculoskeletal ultrasound to guide these injections has been shown to dramatically increase the efficacy of these injections (check out these two articles). The ultrasound machine allows the target structure and the needle to be visualized in real time, which has multiple benefits. First, by seeing the needle in real time, landmarks do not need to be used, making the procedure more comfortable for the patient by allowing the physician to avoid having the needle touch down on bone, which can often be quite painful. Another advantage of using ultrasound is that the needle can be more precisely directed towards the target, allowing the doctor to know exactly where the medication is being injected. This can be helpful in a situation where the injection doesn't offer the patient any relief, allowing the doctor to definitively rule out that particular structure as the pain generator.

Let's use shoulder pain as a common example.  The supraspinatus is a structure that can contribute to shoulder pain in many patients. One example of an injection where the benefit of ultrasound is obvious is a subacromial bursa injection where medication is injected into the subacromial bursa directly above the supraspinatus, bathing the tendon in medication. The placement of the medication is especially important because if the medication were to be injected directly into the tendon and there was even a small tear present, it could lead to even further degradation. The subacromial bursa itself is maybe a millimeter or two thick, smaller than the width of the average needle used to inject it, as you can see in the images below. You can see how even the best sports medicine physicians in the world would have trouble reliably hitting this target when using a landmark based technique.

This is an width of the average needle used to inject medication. You can see how small it is.

As you can see in this ultrasound image, the bursa (indicated by the arrow) is a very thin fluid filled sac smaller than the tip of the needle

Scapular rehab exercise series

This link contains a great series of scapular rehab exercises we recommend for patients with shoulder pain.

The article that describes the thought process behind these exercises can be found at this link, which I wrote with one of my former residents and one of my former Sports Medicine fellows.

Japanese housing, Doctors, and what happens when you dispose of something valuable

There was a very interesting Freakonomics podcast I listened to today, discussing the Japanese housing market.

In Japan, it is fairly routine for houses to have a half-life of 30 years, and when a house is purchased, the owner often demolishes the old home and builds a new one.  There are some historical reasons for this (e.g., many homes needed to be rebuilt after bombings in World War 2, high frequency of earthquakes), but regardless of the reason, Japan is unique in that homes are treated as a disposable property.  Therefore, unlike the United States or other wealthy nations, Japanese homes depreciate in value after they are built.

This leads to a huge drag on the economy, and has contributed to economic stagnation in Japan over the past 20 years.  The economics of this are pretty simple- when you take something that has a high intrinsic value, but treat it like it is disposable, you are wasting money.  The money that is being spent rebuilding perfectly fine homes is NOT being used elsewhere.  There is an opportunity-cost loss.

This is not true in the United States, and it is something we do better than Japan.  When people buy a home in the United States, they maintain it.  They go to Home Depot and improve it.  The home gains in value.  They realize it would be frankly insane to bulldoze something worth a million dollars or more.

Japan was able to do fine when companies like Toyota were thriving, but they were doing so in SPITE of their cavalier attitude to disposing of homes, and once the rest of economy was stagnating, those losses were hard to recover.

Bottom line: it is not in a society's best interest to treat something of real intrinsic value as disposable.

This reminds me of a consulting problem one of my MBA friends was telling me about, working for the United States Army.  He was consulted to figure to calculate "how much is one infantry man overseas worth?"  This was important for overseas missions, because the support costs for a soldier are very expensive- building bases, you need things like cooks, child care for families, gas to ship everyone and their equipment overseas, etc.  I think it worked out to about $1 million per infantryman, which was a sufficient justification for the Army.  If something is worth $1 million, it's worth spending money to build an appropriate support structure.

So .... listening to this podcast, and thinking about the question about infantryman, it made me think "how much is a physician worth?"

It's very clear to me that the societal trend is "not very much."  That's a mistake we are currently making in the United States, treating physicians like disposable resources, similar to the way Japan treats homes, and it's a very expensive mistake.  Some examples to that come to mind:

1. Valuing MBAs more than MDs.  If you look at the leadership of most hospital organizations, they have MBAs in the leadership positions, and they give the main decision-making capacity to the MBAs.  I love MBAs, and they have their role, but when non-physicians make health care decisions, they tend to neglect important patient care issues.  I'd be ok with, and support, perhaps a 60%:40% split in MD-to-MBA leadership in health care.  I don't know what the actual numbers are, but I'd guess that the current split if probably closer to 95% MBAs or other administrators, and a very small amount of MD influence.

Same things are true for most national health care panels.  For things like the Affordable Care Act, physician input in minimal.  There may be a token physician on a panel of 15 people, but most of the decision-making capacity goes to people representing pharma, the hospital administrators, electronic health records, or policy makers.

2. Treating MDs as employee worker bees, rather than as valued talent.  A colleague of mine relayed a story where the head physician of a large physician group was mediating a conflict between one his best physicians and their practice administrator, and the head physician commented that the practice administrator was the "person who did the most for the practice."  The physician predictably left the practice, and the head physician did not realize how offensive it was to de-value the work being done by the physicians in the group.  He viewed the administrator as the person who "got stuff done", and the physicians were merely the worker bees churning out widgets.  As a patient, do you want to be cared for by an organization who views you as a widget?  Unfortunately, these stories are common.

Similarly, one of my physician colleagues belongs to a Rotary organization, and has noted how it's a wonderful opportunity for thought leaders to gather, which gives them an opportunity to think about big picture issues, develop a vision, and implement tactics as their businesses evolve.  He noted that there are thought leaders from most industries other than medicine, but not that many physicians, and in particular very few employed physicians.   The physicians who belong are private-practice owners, so they are coming in the capacity as business owners, rather than as physicians per se.

Do you see what is happening?

In industries other than medicine, it is recognized that the people with the most education and the most experience also bring value to their organizations when they are given the freedom to think about the big picture, mingle with like-minded colleagues, and develop as human beings.

Current forces in place, however, are treating physicians like interchangeable parts, whose role is mainly to push buttons.  I don't mean that metaphorically- physicians are literally being paid to push buttons.  There are requirements from CMS (the Centers for Medicare and Medicaid Services, which is the Voldemort behind all negative changes in healthcare) that physicians need to push buttons that verify they are using their Electronic Health Record in a "meaningful way."  These are called "Meaningful Use" requirements.

It's time consuming, exhausting, and soul sucking.

My colleague Brian White has put it well- "Medicine, in its purest form, is a closed door with a patient and doctor talking to one another."  Anything that gets in the way ..... well, it gets in the way.

So, how much is a doctor worth?

I don't know.  I'd like to think that we have value, in many ways, comparable to that of an infantryman, which is $1 million.  It may actually be much higher ....

As a thought experiment- take someone you knew growing up who was in the top 5% of your high school class.  Have them go to a good college, and have them spend 4 years in a hard major, with challenging elective classes, working hard enough to get a GPA of 3.6 or higher, and using their discretionary time volunteering, doing research, and studying for the MCAT.

Then have them spend ANOTHER four years taking harder classes, in a pool of similarly competitive people, with their entire lives dedicated to medical school.  Add in the cost of not earning any money (.... and keep in mind these were very good students, so they'd typically get good jobs out of college), not saving for retirement, and all the opportunity cost associated with them not entering the work force.  Add in the cost to their social life- delaying marriage, having kids.  THEN add in about $200,000 of debt, assuming they don't already have debt from college.

Then add in ANOTHER 3-6 years of residency training.  Factor in another 3-6 years of opportunity cost loss in delay in entering the work force, the societal cost in having a very smart and talented subset of people delaying family/kids/planting roots, and the interest on the $200,000 of debt they are not yet able to pay off.  Take into account the opportunity cost loss that, had they gone into a field other than medicine, this is when they would have been rising through the ranks, getting promoted, and developing professionally.

Then add in ANOTHER year of fellowship training for the most talented and ambitious subset of these physicians.

At this point- how much value does that person have?  One way to think about it- a schoolteacher, nurse, and physical therapist all have lots of value, right?  At this point, you have a training time that is equal to all three of those professions combined, except that you are starting with a group that had a more stringent set of baseline requirements as an entry point.

All of that .... and that's before they even start their career.

So, it wise to treat that as a disposable commodity?  What is the cost to society when, for example, a physician decides to retire early because they are frustrated with compliance with CMS?  What is the cost to an organization when a physician walks way from their practice because they feel undervalued?  What is the cost to you as a patient when someone chooses a career in finance instead of medicine?

The United States simply can't afford the cost of treating physicians the way the Japanese treat homes.  Physicians have value, and systems built on undervaluing things with true intrinsic value cannot sustain the opportunity-cost loss in the long term.  It's like taking a beautiful 12-year-old home and bulldozing it because you want a new layout.  It's better to focus on upkeep, improvements, and appreciating what you have.

In search of a better way:

We here at Lake Washington Sports & Spine think that there is a better way.  All of the societal forces that are in place that devalue the importance of a physician- that's simply not the way we do business.

Everything we do here is built from our vision- "helping our patients be the best possible version of themselves every day, using the musculoskeletal system as a guide."

Why do we keep our billing and coding person Natalie in house?  Because it provides a better experience for the patient.

Why do provide information about exercise on our blog?  Because it provides a better experience for the patient.

We value our physicians, not just because we are the owners, but because we believe that if we value EVERYONE on the team, it allows us to provide a better experience for the patient.

Meet the Team: Natalie Straub

 

Q. What is your title at Lake Washington Sports & Spine?

A.  Billing and Coding Coordinator

Q. What is that exactly?

A.  I review each claim coded by the physicians to ensure they are coded correctly and also edit them when it is necessary.  I submit the claims to the insurance companies and follow up when a claim is denied.  I also am responsible for patient billing including answering any questions, setting up payment plans and working to ensure all accounts are paid by insurance and patients to meet a zero balance due.

Q. Many patients ask questions about co-insurance versus a copayment. What is the difference?

A.  A Copay is a payment made by a patient at the time of service that covers most general office visit consultations (ie: NO procedures done in office).  Coinsurance is your share of the costs of a health care service NOT covered under a Copay (ie: an Ultrasound, an injection, basically anything that is NOT a general visit consultation).  Also remember, some insurance plans do not have copays at all therefore all types of visits (consultations, procedures) fall under coinsurance only.

For example:  Patient “Bob” has Premera.  He does not have a copay listed on his insurance card so we do not collect any copay.  His Premera policy has a $500 deductible that the patient is responsible to meet before they pay 80% of the claim charges (so basically, Bob has to pay the first $500 of his medical expenses himself before his insurance pays anything).  Let’s say Bob already met that deductible and since Premera will only pay 80%, that leaves 20% coinsurance Bob’s responsibility.   

Q. What are examples of things that patients need to address before their visit to make sure that their claims are paid appropriately?

A.  If going through a health insurance (Regence, Premera, Aetna, ect) please make sure you check your benefits in advance and understand if you will owe a copay that day or coinsurance once your claim processes.  If going through an accident/injury claim, make sure you provide us with all claim information including the name of the company we are billing, claim number, claim manager or adjuster name/phone number and the date of injury.  Also, you need to have all chart notes from other treating providers faxed to us before scheduling your appointment.

Q. Do you have tips for patients so that they can better understand their coverage and benefits?

A. Contact the customer service phone number located on your insurance card and provide them with the name of the physician you’re seeing here.  If they are unable to locate that physician in their network, give the practice name and/or our billing name Emerald City Sports and Spine Medicine with our NPI (National Provider Identifier) which you can contact the office for.  Ask your insurance rep if we are in-network or contracted and to see what your benefits are for your appointment.

Q. From a patient perspective, how does it improve the quality of the patient experience that you are actually in office, as opposed to off-site?

A. I can immediately access all needed documents not scanned into patient charts and also can communicate directly with the medical assistants and physicians to resolve any billing issues rather than waiting for an email or call back.  Also, if a patient needs to drop off information needed to process their claim they can do so in office with me versus again an email or phone call.

Q. What are the characteristics of the ideal patients for Lake Washington Sports & Spine?

A.  Some characteristics include:

•Ready to make a positive change to become the best version of themselves

•Take responsibility for their care and do so by showing up on time to their appointments and paying their bills on time

•Trust in the staff here to do what’s in the patients best interest; following the physicians advice in clinical care and knowing we will do everything we can to get their claims processed through their insurance.

Q. In addition your role as a Billing and Coding specialists, you often serve as an unofficial "Ambassador of Good Cheer," accompanying patients on their visits and provide feedback on patient communication. What are things that you have learned from those experiences, and how does that translate to better care?

A. I have learned that some patients look for “counseling” rather than a clinic evaluation which I feel hinders the patients care.  I’ve learned it’s important to be empathetic to patients but to also steer them towards specific questions and actions that really focus on getting the patient better.  The physicians have many people to see in one day and if all they get with a patient is 15 minutes, it’s very important to utilize those 15 minutes by staying focused on “what can we do as team to get you better faster!”

Q. Do you feel like your perspectives are valued by Dr. Chimes and Dr. Hyman? How does that translate to a better patient experience?

A. Yes.  When the physicians value my thoughts and knowledge it allows me to do what I do BEST.  It allows me to bypass long conversations of why we should or shouldn’t do something and instead get claims processed and paid and work with patient’s to get their accounts to a zero balance.

Q. Are there common questions or topics that patients should bring to your attention sooner?

A. Whenever there’s a change in insurance, let me know ASAP!  It’s very helpful to know when a member id has changed, when an insurance has switched, when a new accident/injury claim has been opened...basically anything that changes how your bills will be processed I need to know BEFORE your appointment to give you my best service available.

A very nice review a patient shared with us, on yelp

2/17/2014

I want to thank Dr. Chimes and LWSS for the very positive experience that I had recently.

I have been dealing with chronic abdominal pain since 2001. In 2001, I had a series of tests that included X-rays, Ultrasound scan, CT scan, MRI, and Bone scan. While it was comforting that none of these diagnostic tests revealed anything really bad like a tumor or cancer, there was also nothing revealed to explain the pain I was having. In the intervening years, some of these tests were repeated in an ongoing attempt to diagnose the problem.

I saw Dr. Chimes for the first time in December, 2013 based on the recommendation of a physical therapist who I have great confidence in. In the initial consultation that included an extensive review of the history of my case, Dr. Chimes recommended another Ultrasound scan which he personally would perform at LWSS. In this test, he discovered what appeared to be a tear in the abdominal wall in the area of my pain. During the procedure, he also consulted with his partner, Dr. Hyman, to review the test and seek his opinion. Based on this diagnosis, a CT scan with contrast was ordered. This test confirmed the abdominal tear and provided further detail and clarity on the condition.

After many years of frustration, I now believe the source of the pain has been revealed and I am consulting with a surgeon to understand possible options to deal with the condition.

Feel free to share the experience that I had with anyone who might find it of value.

Howard Fitz

Blog post about the dangers of following guidelines

This is an interesting link to the downsides of following "evidence-based" guidelines

a few thoughts:
- guidelines are based on consensus, not evidence
- as this case shows, people who are on these guideline panels often have financial conflict of interest
- always be wary, as a consumer, when you hear the word "quality".  Often the word quality is used when they really mean cost containment
- to that end, guidelines often use research, as the cliche goes, the same way a blind man uses a light pole- for support of a previous supposition (usually not paying for something), rather than for enlightenment