Monthly Archives: September 2017

Spine-Related Musculoskeletal Conditions – Part 5 – Disc Bulge, Disc Herniation, and Disc Protrusion

Our posts in this series have been reviewing spine-related musculoskeletal conditions that are frequently seen in dentists and surgeons.  In this post, we will be looking at disc bulge, disc herniation, and disc protrusion.

Disc Bulge, Disc Herniation, and Disc Protrusion


  • Disc Bulge: Protrusion of a spinal disc outside the vertebral body that has not fully ruptured through the disc membrane, known as the annulus.
  • Disc Herniation: Protrusion of a spinal disc outside the vertebral body that has ruptured through the annulus, exposing a portion of the nucleus – the gel-like center of the disc.
  • Disc Protrusion: A general term to describe any type of disc bulge or herniation, in which a portion of the disc protrudes beyond the vertebral body.

Overview: A number of terms are used to describe spinal disc pathology and the associated symptoms.  To complicate matters further, there is not a clear consensus among medical professionals about the precise meaning of each term.

There are thirty-three vertebrae in the vertebral column of the human spine, twenty-four of which articulate and move.  Between each of the vertebrae in the three articulating sections of the spine – the cervical, thoracic, and lumbar spine – there is an intervertebral disc.  Each disc, composed of soft jelly-like center (nucleus) surrounded by a capsule of connective tissue (annulus), provides shock absorption and flexibility within the spine. When the protrusion puts pressure on the spinal cord or a nerve root, it can lead to a wide range of symptoms.

Symptoms: Symptoms will vary based on the location of the disc:

  • Lumbar: Pain radiating down the leg (sciatica) is the most common symptom associated with a lumbar disc herniation. Weakness in the foot and difficulty when raising the big toe (foot drop) and numbness/pain on the top of the foot are also prevalent.
  • Cervical: Pain, weakness, numbness, and tingling in the shoulder, arm, or hand depending on the location of the herniated disc.

Causes: Disc bulges are often the result of the normal process of aging, and by themselves may not cause any recognizable symptoms. Bad posture associated with frequent sitting or standing and occupational hazards such as repetitive bending or standing can accelerate the formation of disc bulges.

Disc herniation is often a progression in severity from a disc bulge.  As discs wear down over time, they may degenerate and lose some of their water content.  This condition, known as Degenerative Disc Disease, is discussed in greater detail below.  As discs degenerate and degrade, they become more flexible and the annulus may be more susceptible to tearing or rupturing.  Disc herniation can also be caused by traumatic, acute injuries such as a hard fall or blow to the back.

Diagnosis:  Diagnosis of a herniated or bulging disc typically begins with a physical exam that tests the patient’s reflexes, muscle strength, walking ability, and sensory perception (light touches, pin pricks, etc.).  If a protrusion is indicated by the physical test, imaging may be ordered in the form of X-rays, MRIs, CT scans, and/or Myelograms.

Treatment:  Non-invasive treatment may include heat therapy, exercise, physical therapy, chiropractic treatment, therapeutic ultrasound, and medication.  Epidural steroid injections may be considered as an intermediate treatment.  For more severe cases, a microdiscectomy may be performed, typically in an outpatient setting.  In this procedure, a small portion of bone and/or disc material is removed to relieve pressure on the affected nerve root.

Our next post will discuss degenerative disc disease.

These posts are for informative purposes only and should not be used as a substitute for consultation with and diagnosis by a medical professional.  If you are experiencing any of the symptoms described below and have yet to consult with a doctor, do not use this resource to self-diagnose.  Please contact your doctor immediately and schedule an appointment to be evaluated for your symptoms.


1. Spine-health,
2. Mayo Clinic,
3. The Neurological Institute of New York,
4. John Hopkins Medicine,
5. WebMD,

Spine-Related Musculoskeletal Conditions – Part 4 – Spondylolisthesis

In this series of blog posts, we have been reviewing spine-related musculoskeletal conditions.  The next condition we will be looking at is spondylolisthesis.


Definition: Occurs when a vertebra (typically in the lumbar spine) slides forward over the vertebra beneath it.

Overview:  The vertebrae in the spinal column are linked together by small joints (facets) that permit the spine to bend forward (flexion) and backward (extension) while limiting rotational movement.  Spondylolisthesis occurs when a joint defect in the vertebrae (resulting from either a stress fracture or degeneration) permits one vertebra to slip forward on the one beneath it.

Spondylolisthesis is most common in the lower back, though in rare cases it can occur in the cervical spine.  It most frequently occurs at the L4-L5 and L3-L4 levels of the lumbar spine.

There are two types of spondylolisthesis: isthmic spondylolisthesis (IS) and degenerative spondylolisthesis (DS). IS occurs when a stress fracture of a small bone called the pars interarticularis permits a vertebra to slip forward over the vertebra below it.  IS is rare, and is most common in young children who participate in sports that put repeated stress on the lower back.

DS is far more common and most regularly occurs among people over the age of 50.  DS is a result of the gradual breakdown of the intervertebral discs and the facet joints in the spine.  As the discs lose volume, more stress and pressure is placed on the facet joints.  As the facet joints begin to degrade under the increased wear and pressure, they may allow too much flexion and cause a vertebra to slip forward over the vertebral body below it.

The slippage can place direct pressure on the spinal cord (spinal stenosis) and on the nerve roots exiting the spinal column (foraminal stenosis).

Symptoms: Lower back pain, leg pain (especially “running down” the leg), and sciatic pain are common.  Numbness or weakness often occurs in one or both legs.  Leg/back pain that is worse when bending over or twisting is common, as is pain that is worse standing than sitting.

Causes: Degenerative disc disease is a common cause of spondylolisthesis.  As we discussed above, when the intervertebral discs lose volume the spinal column becomes more compressed.  Without the shock absorption of the discs, more pressure is exerted on the facet joints.  This pressure and wear accelerates the degradation of the facets and allows for the increased flexion in the spine that can lead to vertebral slippage.  As clinical dentistry has moved from a standing profession to a seated one, dentists are at a higher risk for lower back conditions like spondylolisthesis.  Axial loading (the weight of the body compressing the spine vertically) on the lumbar spine is significantly higher in a seated position than it is standing.

Diagnosis: X-rays are used to determine whether or not a vertebra is out of place.  If the displaced vertebra is putting pressure on the spinal cord or nerve roots, a CT scan may be ordered to identify the severity of the problem.

Treatment: As with many other conditions discussed in this series, conservative treatment may include some combination of physical therapy, exercise, strength training, manual manipulation, and medication.  Epidural steroid injections are sometimes prescribed for those in severe pain.  Spinal fusion surgery is sometimes used for severe pain that has not been successfully treated with less invasive treatment.  Typically, a posterior fusion with a pedicle screw implementation is used, but a surgeon may also recommend a spinal fusion done from the font of the spine simultaneously.

Our next post in the series will examine disc bulge, disc herniation, and disc protrusion.

These posts are for informative purposes only and should not be used as a substitute for consultation with and diagnosis by a medical professional.  If you are experiencing any of the symptoms described below and have yet to consult with a doctor, do not use this resource to self-diagnose.  Please contact your doctor immediately and schedule an appointment to be evaluated for your symptoms.


1. Spine-health,
2. Mayo Clinic,
3. The Neurological Institute of New York,
4. John Hopkins Medicine,
5. WebMD,

What is a Neuropsychological Evaluation? – Part 4

This is the last post in our series of posts about neuropsychological evaluations.  We will conclude this series by discussing (1) why an insurance company would ask for an exam, and (2) how a neuropsychological evaluation can impact your disability claim.

Why Would My Insurer Ask for a Neuropsychological Evaluation?

Unfortunately, it is way too common for an insurer to look for ways to deny a claim, even in the face of strong medical proof of a disability.  This can be especially true for conditions or disabilities that are more subjective than objective, or disabilities that include symptoms that cannot be definitely shown by commonly administered medical tests.  An insurer intent on denying a claim may use Independent Medical Evaluations (IMEs), Functional Capacity Examinations (FCEs), Neuropsychological Evaluations, or a combination of these three exams, in its efforts to undercut a policyholder’s own doctor’s evaluation and medical records (particularly if the policyholder’s treating doctor is supportive of the claim and has clearly indicated that the policyholder should not return to work in their own occupation).

As we discussed previously, the limitations inherent in neuropsychological evaluations may lead to a conclusion that you are less cognitively impaired than you truly are, and/or a recommendation that you are able to return to work.  Further, if the test is administered by a biased evaluator, results can be interpreted and manipulated in order to deny your claim.

What Can I Do?

First, make sure that your insurance company can actually require a neuropsychological examination under the terms of your policy.  Some policies include provisions requiring that claimants undergo “medical exams” or exams “conducted by a physician.”  If your policy contained this sort of provision, you could potentially argue that the insurance company cannot require you to undergo a neuropsychological evaluation, since a neuropsychologist is not a physician, and this sort of exam is not strictly a “medical exam.”

If you must undergo the evaluation, there are several steps you can proactively take to prevent the examination from unfairly complicating or jeopardizing you claim, many of which are similar to steps you should take before an IME.

  • Be sure to provide complete medical records.
  • Carefully fill out any intake paperwork.
  • Advise your medical team of the request for the evaluation.
  • Take notes, including what questions were asked during the interview portion of the evaluation.
  • Report back to your medical team after the test, especially regarding any negative effects, such as increased fatigue after the evaluation.
  • Request a copy of the report.

It is important to note that neuropsychological evaluations are not inherently biased or a poor indicator of disability.  In fact, they can actually be helpful in confirming your disability and demonstrate an impaired level of functioning that makes it impossible to return to work.  In some instances, you may wish to undergo an exam with a truly independent examiner, either proactively or as a follow up to one ordered by your insurer.  As with any new evaluation or course of treatment, you should carefully discuss this option with your current medical team and attorney, and obtain recommendations to a reputable evaluator.


Atif B. Malike, MD; Chief Editor, et al., Neuropsychological Evaluation, Medscape,, updated May 18, 2017.

Neuropsychological Evaluation FAQ, University of North Carolina School of Medicine Department of Neurology,

Kathryn Wilder Schaaf, PhD, et al, Frequently Asked Questions About Neuropsychological Evaluation, Virginia Commonwealth University Department of Physical Medicine and Rehabilitation,