Back issues L4/L5 and L5/S1

Hello Everyone I am new here and I was recently notified of my PEB/MEB. I am an E-6, 14 years Air Force. I was notified of my PEB/MEB on 11 June and also on the same day I requested to see a nuerologist. I do not get along with my PCM very well and I have requested a new one but it was denied which I quickly appealed. He is a young PA with very little experience and no bed side manner.

Listed below is the overview of my third MRI.

My most recent MRI showed Degenerative Disk Disease along with Degenerative Facet Disease in the lower lumbar spine. These appear to be superimposed on a congenitally narrowed central canal. The most advanced changes are present at L5/S1 where a combination of disk protrusion, ligamenatum flavum thickening, and facet arthropathy changes result in narrowing of the central canal to 7mm in AP diminsion. There is also mild to moderate narrowing of the neural formina bilaterally.

After seeing the neurologist he refered me to a neurosurgeon since I failed the nerve test on my legs, the right leg mainly even though both go numb after walking 100 yards or so. I saw the neurosurgeon and she wants another MRI because of the weakness of the muscles and slow reflexes on the entire right side of my body. I am waiting on Tricare to approve that now.

One question I have is there a reason that I must keep the PCM I have? When I appealed they said I have to keep the PCM I have until the MEB is done, I told them I couldn't find that in the AFI, of course they told me they would get back to me. My PCM doesn' t seem to hear anything I tell him. In fact when I was seen after the most recent MRI and I asked him how it looked his response was "it looks like the other two they ain't going to do anything for you". Of course since I saw him I failed the nerve test and the neurosurgeon has said that she wants to do surgery to trim my disk at L5/S1.

I don't want to ramble on but I have been reading the threads for a couple of weeks and back problems don't seem to be rated well. They did my range of motion after 1 cortesone injections and 8 RF burns over a two week period, my range of motion was fairly good considering how numb I was. Right now my legs go numb and I have a lot of pain in the hips and testicular pain that is horrible.

To say the least I am worried I will be put out with so little after 14 years of service....how have most people been getting treated? I have read the VASRD but what one doctor says compared to another, and I have seen a lot of doctors, it is hard to say how the board would interperate it.
 
Click to expand...
Chinook,

No sir. I am not an Army doctor, nor do I practice acupuncture. I am a 92G-cook, E-6 in the SC Army National Guard. In the civilian world, I am also a humble Chiropractor. I do not know much about acupuncture. There are a lot of alternative treatments to traditional medicine without drugs and surgery and more people are turning to these alternative health care methods.

I have seen many patients benefit from conservative Chiropractic care that have avoided the endless confusion associated with pain meds and complications from back surgeries. I always say: "Go with the least invasive care and have the patience to follow the Chiropractic plan of care". Many live in a "McDonalds drive thru" mentality, and are looking for the "quick fix". Patients have to realize if their spine has been pounded and their emotions have been stressed to the max, it take a long time to recover - given the patient is able to reduce the stress factors to any degree. Thanks for asking. I hope I wasn't too long winded.
Chiropractically, dcudoc
 
I think I have found the right spot for me here. I'm AD Navy, with eight years. I am five months shy of a two-year stint with lower back pain that now has been diagnosed in the last year of list of things ranging from spinal stenosis, with a grade 1 slippage, maybe more. lumbrosacral spine spain, spondylylosthesis, a pars defect, degenerative disc disease at the L5/S1 level and it is pressing on my thecal sac.

I have had a series of cuadal injections, a nerve black and discogram that hurt like HELL and have continued to get worse.

I was disqualified by ortho for a fusion and had Neurology tell me that I must have the surgery once I lose half of the 36lbs that I have gained since Nov. 2007.

I was given a fit finding on my PEB and the reconsideration but told that I just needed to prepare for an adminsep. On the reconsideration, I was granted a formal hearing, waiting on a date.

Any suggestions?
 
Welcome dklb,

Sorry to hear of your back pain-its such a terrible thing to have to deal with. Nerve blocks, injections...and I cringe every time I think about the nasty discogram...I'm positive L-1 thru S-1. ouch is right.

Well, I think Jason and the other moderators will have excellent info on the legal/military stuff....but I think we're all thinking that you shouldn't let them admin sep you.

As far as your back goes-remember to start with the least invasive procedures. As you read, Robs42 has been to hell and back with the surgeries. I'm doing ok with acupuncture as far as pain relief-but my injuries are still present. So...we'll see.

But, one thing I'd like to add...I've been a military medic for 12years, but I've actually been in medicine for 20years...time flies. But I'm also a personal trainer and I was the aquatic director for the AF Academy before my injury...I'd like to suggest warm water therapy for conditioning. Weight gain is pretty common in orthopedic injuries. I know, even walking is painful for me...but the one thing that we can do is get into a warm water pool and walk. Depending on how deep the water is-you can take all the weight off your spine. Let me know if you have any questions-but drs usually don't offer this as an option-we have to ask. If your Phys therapy section doesn't have a pool they can send you off base. Just a thought. Take care.
 
dklb_2008,

Welcome aboard, shipmate! I was in the Navy, too. Got out and went to Chiropractic school finished up my service in the National Guard. Chinook had commented on your condition, but I would like to put my in "two cents" worth.

Naturally, I recommend conservative Chiropractic care as a first approach. Unfortunately most of us go to a DC (Doctor of Chiropractic) as a last resort.

Happy Thanksgiving, we are truly a blessed country and thanks for serving.

Chiropractically,
dcudoc
 
Hi dklb & dcudoc,

you know, somewhere in my posts I did mention that I had chiro care in the beginning. That was my first thought! And, it was my initial care. I absolutely belief in chiro care along with oriental medicine.

I asked for a DO in the clinic-we had one and he did adjust me. I had some relief for a while, but as I kept working-things just got much worse. Then our DO left.

I went off base to a Chiro and I loved him! Of course I had to pay for it out of pocket. They looked at all my x-rays, MRI's...I even took in my bone scans. When no one else would explain anything-they did (2 docs in the office). Anyway, the day came that they wouldn't adjust me because of the severity of issues. I think the annular tears??? One doc did mention that DRX machine. It was very expensive for the treatments-I didn't do them.

dcudoc, what do you think of the DRX?
 
Chinook,

The original meaning of Chiropractic in greek: "Chiro" is "hand" and "practico" is "to practice". The laying on of hands is very important in the healing process and a skilled Chiropractic practioner can make a much more specific vertebral subluxation (nerve pressure) correction than a "hands-off" modality because the doc can palpate the direction of the misalignment and adapt the line of drive of the correction (i.e. x,y,z axises). Although, I have heard positive results from the DRX. Other than that, I don't know anything about the DRX in detail. Thanks for the opportunity to talk about a subject I love.

Chiropractically,
dcudoc
 
dcudoc,

I love health and fitness and I enjoy the conversation as well.

As far as the DRX goes, it was similiar-but not, like traction. I know it works differently-but traction just about killed me...OMG it was painful. Maybe because every muscle is tight, there are tears on my discs, with other major problems...anyway-anything that looks like traction and I'm running. ( :

But talking about the "hands on"...that's whats missing in western medicine. Thats why I chose my Oriental Doctor. He does it all....hands on. Yes the needles, cupping, and when I'm loose enough he also adjusts me. He says its going to take a while to get me "lined up" again...but we are working on it. Its been amazing for me.

I would like to know more about how legislation approved Chiro care.
My reasoning is that I've been in touch with the Dr. in charge of teaching acupuncture to other army docs. He says the push should be with acupuncture and not necessarily with oriental medicine. Well, my push is that TRICARE covers alternative medicine. I have contacted my local officials to no avail and I am moving forward.

We should all have choices in our medical care. I don't care if I have to have a military primary care doc and then he/ she refers me out-but I should be able to get a referral to a doctor that helps me.

I'll publicly post this: I asked for warm water therapy-its all I could do. Its almost all I still can do...but anyway-tricare approved me to go to a physical therapy place off base that had a pool. I walked in the water on my own 3X week. The physical therapy place was paid $100.00 everytime I showed up and walked. It kept me moving-but didn't heal anything.
I see my Dr of Oriental Medicine 3xwk and I pay him $50.00 a visit. I walk out of there more aligned and feeling great. I pay $5.00 a visit to a local pool for warm water walking. Tricare paid more for the phys therapy than they would for my oriental treatments with proven results.

It should be a choice. I plan on fighting this on every level. I know it has to do with the law and I'm not sure where to go next. Any ideas.

Wow, I got long winded. Maybe I should have started a new thread. Its so important that while we are going through the MEB/PEB that we don't forget there are other modalities of treatment that work for many many ailments and injuries. We can heal. Please forgive spelling and grammatical errors-I'm rushing ( :

Talk to you soon.
 
Chinook,

I am a just a junior web member and I would change threads as per your suggestion/direction, if it would allow this discussion to progress.

Anyway, you asked how Chiropractic got legislation to be authorized to be a part of the DOD and VA health care systems. Since I am not a lawyer, I am not going to research the legal terms and house bill titles. But, to make a long story short, it is still a work in process.

The way Chiropractic got legislation was by organization. All be it, the Chiropractic community does not have anywhere near the resources that many other associations have. I think the American Chiropracitc Association did most of the palm-pressing. But other organizations, like the International Chiropractic Association, and Federation of Straight Chiropractors and Organizations, for example, organized laterally to add to the ranks. Once organized, being professional and consistant. FYI, Chiropractic has been meeting resistance since it was discovered in 1895.

In the 1990's congress authorized a pilot program (ring a bell?). The five year pilot program was an overwhelming success. Now, the plan is to have all the VA medical centers in the U.S. with a Chiropractor, on staff, by 2010. I am not sure about DOD, but I know there seems to be an effort to expand their staff with more Chiropractic providers, as well.

I try to tell my patients that the One who does all the healing is Jesus Christ. Second, if an individuals' ATTITUDE is not one that is willing to allow the healing to occur, then the healing will not happen.

Chiropractically,
dcudoc
 
Today was not a good day for me, and I really don't know how to respond or handle it. It took me an extra two hours to get up and get going this morning from the pain. That really scared me because I thought I would have to go back to the ER for the pain, which leads me next my next comment and question.

I work in media and when you only have one person that can take photos or write a story, what do you do when you're in pain? As I took photos for the new frockies, my hands trimbled and I cried out of one eye.

But there was nobody else available to do it. I also cried all through my acupuncture appointment, driving there, walking there, checking in and then talking to the doctor and getting the needles in my head, ears and hand.

Has anyone felt like this? :(
 
dklb_2008,

I hear ya, shipmate and I think all have felt the way you felt today, to one extent or the other. However, I haven't done acupuncture. How about it Chinook?

dcudoc
 
Hello dklb, dcudoc...

As a matter of fact I just got back from my acupuncture appt.
Sometimes my appts hurt, but in the long run they always help. And yes, when I drive there I'm usually in pain. But I feel much better than I did 3 months ago-when I got back to Colorado I scared everyone. They didn't even recognize me because I looked and felt so bad.

Lots to say about all this. I know what you are saying about the pain and I'm so sorry to hear how things are going. Yes, I've been there-taking the two hours or more to get ready for work (med tech in the field)....knowing I had to be there and wondering how in the hell I was going to help someone else. First, it shouldn't be like that-the job should never be one deep for you...(medics work in pairs-one to do the fixin, one to do the drivin-when one is out the entire mission is called off-for us, that meant 250 Security Forces sitting and more than a few pissed off CO's.) I have felt the pressure. If you keep pushing yourself, you are going to hurt yourself more-I am living proof. Your body is telling you that you need to rest. Alot of drs will tell you that you have to keep moving or you'll tighten up and get worse... This is the worse...you need to rest. Pain is the indicator. Rest...rest...rest...and then start adding a little walk in....The ER can only do so much. You sit and wait, they document and give you pain meds-quarters for maybe the day and tell you to go back to your PCM in the morning. Nothing gets fixed. * The only thing I do say though---is if you do feel a pain that is different or worse, it could be a slipped disk where you do need urgent / ER care. But you probably know the difference in your pains...when you do too much it feels like this, when you bend it feels like this...Don't hesitate to go to the ER if you think its new pain or you can't stand it...but I think everyone knows what I mean about how they send you away with quarters slip and a note to see your PCM...

Are you on a 4 or 6 hr duty day? Its time to ask for it.

Now, I am only a medic, and "in no way is this meant to take the place of physicians care plan" ;)....but,

When this first started happening to me, I found a couple of great techniques that reduced the pain immediately! The doctors didn't do anything for me but give me morphine. I found these "techniques" on a chiropractic website ( I know you're grinnin' dcudoc:))One is that you lay flat on your back, feet flat but knees bent. Then bring your heels of your feet close to your buttocks as you can and do a pelvic lift. You can place your hands under your butt if you need to. Hold that position for maybe 10 -15 sec or less if need be or longer if it feels good...stretch your feet back to a normal position with your knees still bent...do it again a few more times. Then try and just lay flat on your back all the time you can-knees bent where your pelvis can relax on the floor. You should try to relax your hips at least a couple times a day for at least 15 min at a time. You need to get the pressure off your spine-and this is what does it. Try not to stand too long, sit too long and don't take long walking strides. Less irritation, less pain. When I have an immediate attack-I roll over and do the "dead bug"...on my back w knees bent. Everyone is different, every condition is different-"ask your PCM if this is right for you"...
dcudoc-sound right to you?

I do believe you should keep going for acupuncture-I know how painful it is to drive, move or walk. I'd like to know more about your acupuncturist. Is he/she an oriental medical dr or just licensed in acupuncture? Big difference. I get needles everywhere -legs, back, head, arms...and tonight was cupping. Its the whole body approach. How did you feel after your treatment? Any relief?

As far as work goes, was today just a fluke that it was only you-or is it always that way in your shop? There should always be another person-what about when one takes leave, etc.???

I think its time for your PCM to step up to the plate, get you the reduced work hours and time for your supervisors to know that this is the real deal and they need to schedule correctly.

Ok, all that being said-that is completely my opinion. For whatever its worth. I have been there, and now I'm learning how to control the pain and accept what part of this injury I will have forever. I was a go getter-I made E-7 in 8 years and never -never said no. I kept going because I felt like everyone would think I was a "bad person" " a bad NCO"...well thats all crap. My back is injured. I need to rest and heal. Its ok to hurt, but its not ok to be treated like crap from our co-workers and PCM's. I always tell everyone that no matter how badly you hurt-always stay professional and curtious. It will be ok. Take a hot bath and relax. Make sure that if you are sleeping on your side that you have a pillow between your legs to keep the pressure on your spine even.

Hope that helps answer your questions. I don't wish this on anyone...

By the way-where are you stationed?

For now, sleep tight! Happy Thanksgiving.
 
dklb_2008,

Happy Thanksgiving and I thank God for our free country and those who served and are still serving, and their families. Also, I pray for your healing.

I will explain how the intervertebral discs are involved with the spine.

In the morning after resting the body, the intervertebral discs (between the spinal bones-kinda like shock absorbers) rehydrate because fluid refills the tissue. If the spinal bones are misaligned, the discs attached to the misaligned bones, will be stressed and swelling. The swollen disc, exacerbated by more fluid in the tissue, will inpinge more on the surrounding tissue, (i.e. spinal nerve roots) and can increase pain.

(FYI-as the day goes on, gravity presses on the discs causing them loose fluid and decrease in size. That is why the early a.m. increase in pain ).

This is a condition Doctors of Chiropractic (from the original Chiropractic adjusting philosophy-1895) call: "vertebral subluxation". (Simply stated: nerve pressure resulting in inflamed disc caused by misaligned vertebra).

Chiropractically,
dcudoc
 
dcudoc,

Execellent explination. Isn't it amazing that we don't get that from our PCM's. I feel if we are educated about our condition, we can better take care of ourselves. I agree that one needs to have a positive attitude and wants to heal-in order to heal. I certainly didn't mean to get long-winded before. There's just so much to be said.

Hope your Thanksgiving is great!
 
Chinook,

I had a wonderful Thanksgiving and hope you did too. I am glad the patient education was helpful (hope it was helpful dklb_2008). This forum is a fantastic medium for all to collectively share their knowledge and I have learned very much about the MEB/PEB and the many avenues related to it, and your posts-as well. Thank you for your information.

Like you said, there are so many different areas of expertise and interests, that it is easy to give up on seeking care.

dlbk_2008, It easy to get overwhelmed. Please don't hesitate to ask and seek second, third, fouth, fifth...opinions. Remember the only stupid question, is the one you don't ask.

Chiropractically,
dcudoc
 
I'm stationed in San Diego.

We are undermanned at the time, and I have had some issues with my chain of command not understanding why I wanted a reconsideration and so forth.

My overall desire was to go to sea, but I have been told that based on my condition that was not an option and after I have my surgery, PLD would be the only option.

Well, I got a phone call from my detailer and I asked what his thoughts were and he said that if I couldn't go to sea then I would more than likely be asked to separate.

As for my PCM, they just keep giving me referrals.

We will see what happens.

I go back to the doctor next week, and I am going to ask for shorter hours.
 
dklb_2008,
It sounds like PCM is working with you because of the referrals. What referrals are they giving you? What are your thoughts on what PCM and or what the referrals have offered you? As far as the request with the detailer, he is right...if you cannot go to sea, the Navy does not need you. That is just the reality of it, shipmate(empathetic/affectionate terminology). Now, you need to focus on healing yourself.
Chiropractically,
dcudoc
 
Hello everyone and sorry for going so long in between posts. I haven't been able to get on here much with the increase in appointments and change in activity.

The latest is:

  • I received my date for my formal hearing and have talked to my attorney briefly
  • I had another (cuadal?) Dec. 11 (My 4th)
  • started warm water therapy Dec. 16
  • seeing a new accupuncturist and chiro.
I almost have two to three appoinments a day.

Does anyone have any advice on the hearing part of it?

How is everyone?
 
i was recently seperated from the army due to a L5-S1 disk bulge that is contacting the nerve. unfortunatly, i was only given a 10% disability rating which is messed up. i am using a cane, my left leg has given out on occasion, i have even twisted my leg and now have worse pain in my leg. the pain goes from my back, to my hip, down my leg. worse pain in the knee since i twisted my leg when it gave out. my leg goes numb on occasion when driving. i can not walk for long distances, can not sit or stand for prolonged periods of time. i was given a steriod shot in that section which made it worse. right now i am waiting for the new DD Form 294 to be available ( sometime in january). this is a form in which soldiers who recieved a 20% or less disability rating can get it changed. currently waiting on VA and Social Security. am quite tempted to submit a rather interesting e-mail to a few national news agencies. Dr. Phil recently had a story on his show about how the VA is screwing soldiers over also. had a representitive from the VA on the show and he said that the VA have been misdiognosing PTSD, loosing paperwork, making delays in claims from soldiers, the list goes on. it is a shame that the military, VA and who knows who else is leaving soldiers to fend for themselves just so that they can save money.

Crewchief said:
Hello Everyone I am new here and I was recently notified of my PEB/MEB. I am an E-6, 14 years Air Force. I was notified of my PEB/MEB on 11 June and also on the same day I requested to see a nuerologist. I do not get along with my PCM very well and I have requested a new one but it was denied which I quickly appealed. He is a young PA with very little experience and no bed side manner.

Listed below is the overview of my third MRI.

My most recent MRI showed Degenerative Disk Disease along with Degenerative Facet Disease in the lower lumbar spine. These appear to be superimposed on a congenitally narrowed central canal. The most advanced changes are present at L5/S1 where a combination of disk protrusion, ligamenatum flavum thickening, and facet arthropathy changes result in narrowing of the central canal to 7mm in AP diminsion. There is also mild to moderate narrowing of the neural formina bilaterally.

After seeing the neurologist he refered me to a neurosurgeon since I failed the nerve test on my legs, the right leg mainly even though both go numb after walking 100 yards or so. I saw the neurosurgeon and she wants another MRI because of the weakness of the muscles and slow reflexes on the entire right side of my body. I am waiting on Tricare to approve that now.

One question I have is there a reason that I must keep the PCM I have? When I appealed they said I have to keep the PCM I have until the MEB is done, I told them I couldn't find that in the AFI, of course they told me they would get back to me. My PCM doesn' t seem to hear anything I tell him. In fact when I was seen after the most recent MRI and I asked him how it looked his response was "it looks like the other two they ain't going to do anything for you". Of course since I saw him I failed the nerve test and the neurosurgeon has said that she wants to do surgery to trim my disk at L5/S1.

I don't want to ramble on but I have been reading the threads for a couple of weeks and back problems don't seem to be rated well. They did my range of motion after 1 cortesone injections and 8 RF burns over a two week period, my range of motion was fairly good considering how numb I was. Right now my legs go numb and I have a lot of pain in the hips and testicular pain that is horrible.

To say the least I am worried I will be put out with so little after 14 years of service....how have most people been getting treated? I have read the VASRD but what one doctor says compared to another, and I have seen a lot of doctors, it is hard to say how the board would interperate it.
Click to expand...
 
Hello everyone, I'm new to this forum but I am no stranger to the subject. I've been reading up on the posts and I have to ay that it appears that the more things change the more they stay the same when it comes to back injuries.

My glamorous injury occurred as the result of horseplay on the part of a co-worker when he pulled the chair out from under me at work. I ended up falling right on my tail bone. I could have only been so lucky if I had broken my tail bone, instead I've had to deal with a progressively degenerative condition that has resulted in L4/L5 degeneration, spondolyosis, and an arthritic condition. The first indication of real issues came when I leaned into the car to grab something off the passenger seat and experienced what can only be described as a pain you can only describe as a nail going through your foot. I ended up laying across the front seat unable to move for about 5-10 minutes before I was able to limp to the house and have my wife drive me to the ER.

I was initially unable to feel anything in the entire right de of my right leg, had palpitations in the upper right thigh and my foot felt swollen or like ice, sometimes at the same time. I had a dull pain constantly radiating in my lower back and was given steroid injections that reduced the swelling and allowed me to get back to work for 6-8 months at a time. These shots were given with a floroscope and a local, the only way to do it. I highly recommend this as the reduction in swelling allowed my discs to pop back in place as I was lying across the seat of the bus on the way home and they hit a bump in the road that lifted me off the seat, immediate pain relief.

Since then, I have retired, dealt with a dragging right foot, tripping over cracks in the sidewalk, tension of the muscles in the back that have misaligned my spine and caused me to walk like the Hunchback of Notre Dame. I have recently (the past year and a half or so) had indications show up in my left leg as well. Additionally, I have dealt with isolated heightened sense of pain in localized areas of both legs. One side is around the knee that makes it hard to stand up from a prone position, the other is in the shin area where the slightest touch has left me feeling like someone stuck a brading iron on my flesh.

I recently was able to get the VA to order a new evaluation, my exit eval was a joke. Here I endured multiple MRI's, multiple x-rays, CT scan and range of motion tests, way more than the one MRI I had during my exit physical. I also had the priviledge of having a needle stuck into about 40~50 places on both legs and my back and electricity induced to test my nerve reactions, I am certainly glad that these deep tissue probes were unable to register on the pain sensors as the three times I was able to feel the probe it hurt like hell when the doc moved it around to try and find the right nerve.

While it seems like I am rambling here, I say this all to make a point. You are going to live in pain for the rest of your life, like me, you'll have to accept it. The only thing you can do is to keep your chin up and try to wrok through it. Keep a positive attitude and keep talking about it. The more stories that are out there, the more documentation there is to fight for better compensation.

For those of you who are soon to be boarded, keep a certified copy of every documented session with your physicians. X-rays, MRI's CT-and Cat Scans, every test. These are your only proof that you were injured on active duty. Also, go see your VA rep. Ask them questions about what you should ask to have done. Make sure your final submission is run by them. You may not have a chance to go back and make a claim for anything if you don't do it now. Your VA rep is there to help you. I may not have gotten more than 20% now (10% for he back injury and 10% for tinitus) but even a 0% on something you list in your exit physical can result in more compensation later and coverage at a VA hospital in your state.

If you fail to get a copy of your entire medical record prior to departure, make sure the VA requests one so that you can use it as evidence for furture issues. Your ailements now may seem major but those you encounter 5, 10, 15 years down the road may be worse. It's all about Quality of Life. Too many lose out on their potential coverage because they fail to claim that shoulder injury because it seems minor. That injury can come back to haunt you years later if it never heals and you are unable to work because you can't lift your arm.

Yes this is my first post and it is long but I wanted to lay it all out there and put a plug in for the VA reps who are more than happy to help you claim everything you can. If you are able to stay as I was or if your out on your tail as it seems some may be, you want to be able to have those injuries covered through the VA.

Sorry for the long post but if this helps even one person understand the situation with documentation and the VA it is worth it. I promis to keep future posts shorter.:D

Jack
 
One more thing to mention. If you are having issues with any agency, check with your local Disabled America Veterans Association (there is one in every VA hospital) and see what they can do to assist you in pushing through issues. Use all your resources.

Jack
 
You must log in or register to reply here.
Top