by Dorothy C. Sims, Esq.

Trauma, no matter how mild, has the potential of aggravating or worsening any pre-existing degenerative disease of the spine. Often the defense medical expert will claim all symptoms of a back injury are due to a prior degenerative disc disease.  This may be  claimed in spite of the fact that either the patient was completely asymptomatic before the trauma or the symptoms worsened significantly immediately after a trauma.

References.

“It has been reported that pre-existing degenerative changes, “no matter how slight,” adversely affect the prognosis.”    SOURCE:  Norris SH, Watt I. The prognosis of neck injuries resulting from rear-end vehicle collisions. J Bone Joint Surg. 1983; 65B: 608-611
“Chronic neurological sequelae develop after a single acute or multiple chronic traumatic episodes to the cervical spine and spinal cord.” SOURCE: Richard C. Schneider and Robert Knighton . Chronic Neurological Sequelae of Acute Trauma to the Spine and Spinal Cord: Part III The Syndrome of Chronic Injury to the Cervical Spinal Cord in the Region of the Central Canal. J. Bone Joint Surg. 1959; 41:905-919

“The high incidence of cervical osteoarthritis and spondylosis observed in those presenting years after acceleration/deceleration injuries suggests a very strong causal relationship, especially when the disease is localized to one or two levels”. SOURCE: Foreman Stephen M., Croft Arthur C. Whiplash Injuries : The Cervical Acceleration/Deceleration Syndrome. 2nd edn. Philadelphia, Lippincott Williams and Wilkins, 1995 p-340

Although we suggest that mechanical loading precipitates degeneration, the most important cause of degeneration could be the various processes that weaken a disc before disruption, or that impair its healing response. The combined effects of an unfavorable inheritance, middle age, inadequate metabolite transport, and loading history appear to weaken some discs to such an extent that physical disruption follows some minor incident.

A common example is that of disc herniation following a cough or sneeze. It could be argued that such a weakened disc should be considered degenerated, even if it remains structurally sound. However, a disc is unlikely to become painful until it becomes disrupted, so there is little to be gained by anticipating future events and applying the term “degeneration” before this crucial nonreversible event actually occurs. As suggested previously, accelerated biochemical or cellular events in a structurally sound disc could be designated “early degenerative changes” to distinguish them from changes that are entirely typical  of the disc’s age. The multifactorial nature of disc weakening suggests that, from a medicolegal standpoint, all discs are “vulnerable” to a greater or lesser extent, and the vulnerability can only be gauged from the violence, or otherwise, required to disrupt the disc and initiate degeneration.
The underlying cause of disc degeneration is tissue weakening occurring primarily from genetic inheritance, aging, nutritional compromise, and loading history. The precipitating cause is structural disruption occurring from injury or fatigue failure.

Adams MA, Roughley PJ. What is intervertebral disc degeneration, and what causes it?

Spine. 2006 Aug 15;31(18):2151-61. Review.
“When symptoms are more severe or progressive despite the use of a collar and when they occur in younger patients, operative treatment may be necessary”.  SOURCE: Way Lawrence W, Doherty Gerard M. Current Surgical Diagnosis and Treatment. McGraw Hill 11th edn 2003, New York, p- 1209 }

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According to The Journal of Neuroscience, researchers from  the University of Iowa have discovered a new horizon for the treatment of depression.  Where?  In the acid-sensing ion channel-1a (ASIC1a), of course.  Traditional antidepressants work as Selective Serotonin Reuptake Inhibitors (SSRI’s), and most antidepressants are really variations on this idea; which for some either do not work, or have intolerable side-effects.

In a series of bizarre sounding tests with mice (such as the “forced swim test”), the researchers (Coryell et al.) analyzed an entirely different approach.  Recent studies have suggested a relationship between depression and processes within the amygdala, so the researchers studied the effect of inhibiting activity in a portion of the amygdala, the ASIC1a.  In short they found a hyperactive ASIC1a leads to anxiety related behavior in the mice, while a decrease of ASIC1a activity decreased “conditioned and unconditioned fear”.  In a relatively new field for depression studies, the researchers isolated compounds which would inhibit ASIC1a activity (notably using a compound called PcTx1 - extracted from tarantula venom), and put them to work in the mice’s brains.

What they found was that the inhibitors had a marked decrease in depression and anxiety associated symptoms.  Moreover, the inhibitors did not interfere with Serotonin levels, leading the researchers to two potentially great conclusions about the ASIC1a inhibitors - They do not act in the same manner as SSRI’s, which is good news for those whom SSRI’s haven’t helped much, or those who can’t tolerate such medicine; and, the inhibitors would not interfere with SSRI’s, and could be used with SSRI’s for a greater benefit.  In the scientists’ own words, the inhibitor “reduces the emotional burden of stressors…thus reducing heplessness and other stress-evoked depression-related behaviors” - and, they “might produce added benefit when combined with these currently available therapies”.

This research is of course in the initial stages.  Some may be skeptical to see the results translated to humans, though the researchers do claim that “the strong predictive validity” of prior research “suggests that ASIC1a antagonists may have similar antidepressant effects in humans”.  Though you might have to wait a while to see commercials pitching tarantula venom alongside Zoloft, for the time being it doesn’t seem like so bad an idea.

Sources:

http://www.upi.com/Science_News/2009/04/30/UPI-NewsTrack-Health-and-Science-News/UPI-67791241127840/

1000. W. Coryell, A. M. Wunsch, J. M. Haenfler, J. E. Allen, M. Schnizler, A. E. Ziemann, M. N. Cook, J. P. Dunning, M. P. Price, J. D. Rainier, et al.
      Acid-Sensing Ion Channel-1a in the Amygdala, a Novel Therapeutic Target in Depression-Related Behavior
      J. Neurosci., April 29, 2009; 29(17): 5381 - 5388.

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Gregoire Alix reports for Le Monde from
the Dutch city of Apeldoorn: “‘In 2020, all energy consumed in Apeldoorn
will have to be renewable, without fossil fuels, without nuclear power,
and produced in our own city.’ With graphs for support, Michael Boddeke,
the official in charge of sustainable development for this city that
looks like a blossoming village at the center of the Netherlands, is
optimistic: solar, wind, and biogas from organic waste and wastewater
should suffice to warm and light this town of 156,000 residents.”

Read the full story here.

Robert Barnes and Michael D. Shear, The Washington Post: “The White House scrambled yesterday to assuage worries from liberal groups about Judge Sonia Sotomayor’s scant record on abortion rights, delivering strong but vague assurances that the Supreme Court nominee agrees with President Obama’s belief in constitutional protections for a woman’s right to the procedure.”

Read the full article here.

The Los Angeles Times recently published an article with some good news for those whose anti-depressants aren’t working.  The Times took another look at the landmark STAR*D study, noting it shows that for those whom a single treatment of antidepressants fails, treatment for depression is more likely to be successful when a patient is treated with cognitive therapy as well as (or even in place of) an antidepressant. Cognitive therapy, the study found, can help bolster or replace antidepressants, by correcting negative thought patterns.  However, while it seems to be efficient, cognitive therapy is not necessarily accessible; the Times goes on to note that:

compared with dispensing medications, talk therapy is time consuming, costly and, according to a 2008 study in the Archives of General Psychiatry, increasingly difficult for patients to find. Because of changes in the field, as well as insurers’ growing unwillingness to reimburse for talk therapy, the practice of psychotherapy, and the number of psychiatrists who practice it — has declined dramatically.

The Times proceeds to cite various statistics on the decline of psychotherapy; for example how from 1996 to 2005 visits to the psychiatrist which involved psychotherapy as opposed to medicinal therapy dropped from 44.4% to 28.9%.  In all likelihood it is actually worse, since it’s not efficiency but economics which have determined the decline, and the healthcare and economic climate has changed much from 2005 to present.

The Psychiatric Times has provided a more in depth look at the decline, through an analysis of the same study.  They found a disincentive for psychotherapy:

was highlighted by a Practice Research Network study that documented that third-party reimbursement for a single 45- to 50-minute outpatient psychotherapy session is 40.9% less than reimbursement for three 15-minute medication management visits. Visits provided under managed care tended not to include psychotherapy.

Providers then, might be partly to blame for the lack of availability of such treatment; The Psychiatric Times also notes that, in spite of the evidence for psychotherapy’s efficiency, “patients who pay out-of-pocket are more likely to get psychotherapy from psychiatrists than those who have private insurance”.  A patient’s access to psychotherapy is very often determined in advance, and the study showed that blacks and Hispanics, as well as those who have public insurance (such as Medicaid) were less likely to get psychotherapy from psychiatrists; moreover patients in the Northeast are slightly more than twice as likely to get it than those in the South.

In short, if a single treatment of antidepressants has not worked for you, psychotherapy is a promising alternative or booster.  However, keep in mind the difficulty of obtaining it.  Moreover, a battle rages over the efficacy of what provided psychotherapy can be obtained (it is generally part of a managed care plan, in which patients are treated for medication and therapy separately); which is another topic in itself.

Sources:

http://www.latimes.com/features/health/la-he-nondrugs13-2009apr13,0,3549435.story

http://www.psychiatrictimes.com/psychotherapy/article/10168/1353217?pageNumber=1

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