Thursday, 14 January 2016 14:55

CASE REPORT: The Utilization of Long Term Care for Herniated Lumbar Discs with Chiropractic for the Management of Mechanical Spine Pain

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by Anthony P. Calantoni, DC, CCEP, DAAMLP


Title: The Utilization of Long Term Care for Herniated Lumbar Discs with Chiropractic for the Management of Mechanical Spine Pain


Abstract: To explore the utilization of chiropractic treatment consisting of spinal adjusting, axial traction, electrical muscle stimulation, and core stabilization exercise for the management of mechanical spine pain. Diagnostic studies included physical examination, orthopedic and neurological examinations, and lumbar spine MRI.  The patient reports long-term success in reducing pain levels and increasing functionality by having the ability to perform activities of daily living (ADL’s) without frequent flare-ups which he reported of prior to undergoing chiropractic treatment.

Key Words: low back pain, sciatica, chiropractic adjustment, disc bulge, disc herniation, axial  traction, spinal manipulative therapy.

Introduction
On 2/6/2015, a 49 year old male certified nursing assistant, presented for consultation and examination due to a work injury which occurred on 11/12/2001.  The patient stated he sustained a lifting injury that resulted in severe low back pain.  He stated that he was under the care of a pain management interventionist receiving epidural injections in his lumbar spine on an ongoing basis since the injury occurred.  He added that the injections helped him to cope with the elevated pain levels he experienced on a frequent basis. The patient had previously received chiropractic and physical therapy for his injury and reported that the therapies did help him when he was actively treating.  He informed it had been over 3 years since he last treated with chiropractic or physical therapy.

The patient presented to my office on 2/6/2015 with a chief complaint of lumbar pain.  He rated the discomfort as a 7 on a visual analog scale of 10 with 10 being the worst and the pain was noted as being constant (76-100% of the time).  The onset of pain was a result of the work injury described above.  He reported that the pain would aggravate by activities which required excessive or repetitive bending, lifting, and pulling. He stated he experienced flare-up episodes 4-6 times a month depending on the type of activities he was involved with.  The quality of the discomfort was described as aching, gnawing, sharp, shooting, and painful and was noted as being the worst at the end of the day. He stated that when his pain levels were elevated, it would limit his ability of getting a good night sleep.  The patient further noted he was experiencing numbness and tingling in both legs and his right foot.

Prior History:

The patient denied any prior or subsequent low back injuries and/or traumas.

Clinical Findings:

The patient was 5 feet 10 inches and weighed 230 pounds. His sitting blood pressure was 132/86 and his radial pulse was 74 BPM.  The patient’s Review of Systems and Family History were unremarkable.

An evaluation and management exam was performed.  The exam consisted of visual assessment of range of motion, manual muscle tests, deep tendon reflexes, digital and motion palpation, and other neurological and orthopedic tests.  Palpation revealed areas of spasm, hypertonicity, asymmetry, and end point tenderness indicative of subluxation at T12, L2, and L4.  Palpation of the lumbar muscles revealed moderate to severe muscle spasms in the left piriformis, right piriformis, right sacrospinalis, right gluteus maximus, right erector spinae, right quadratus lumborum and right iliacus. He presented with postural deviations that were found using a plumb line assessment showing short right leg (pelvic deficiency), head tilted to the left, high left shoulder and high right hip.  Point tenderness was notably present along the midline of the spine at the L4 and L5 level.

Manual, subjectively rated strength tests were performed on some of the major muscle groups of the lower extremities, based on the AMA Guides to the Evaluation of Permanent Impairment, 4th Ed., 1993/5th ed., 2001. A rating scale of five to zero was used, with five representing normal muscle strength.  A muscle strength loss of the lower extremities indicates a neurological facilitation resulting from dysfunction in the lumbar spine.  Grade 4 muscle weakness was noted on the right extensor hallicus longus.

Dermatomal sensation was decreased at L4 on the right and decreased at L5 on the right.

Reflex testing was completed and was diminished: 0/+2 on the right patella and +1/+2 on the left patella. The following lumbar orthopedic examinations were performed and found to be positive: Ely's on the right, Hibb's on the right, Iliac compression test and Bragard's on the right.

Lumbar Range of Motion tested with Dual Inclinometers:

Range of Motion            Normal         Examination                       % Deficit

Flexion

90

40

 

56

Extension

25

10

 

60

Left Lateral Flexion

40

20

 

50

Right Lateral Flexion

40

15

 

62

Left Rotation

35

25

 

29

Right Rotation

35

20

 

43

Flexion and left lateral bending were painful at end range. The patient’s limitation to bend is corroborated by the persistent spasticity of lack of motion eliciting pain upon exertion in the lumbar spine.

MRI Results:

The MRI images were personally reviewed.  The lumbar MRI performed on 9/29/2014 revealed anterior positioning of the L4 vertebral body with respect to L5 with a right L4-L5 protrusion compromising the right neural foramen. There is a central herniation at the L5-S1 disc.

Fig. 1,  (A), (B), (C) shows in T2 MRI images (A) is Sagittal and (B) is Axial at L4-L5 and (C) is Axial at L5-S1

Fig. 1 (A)  Sagital

 

Fig. 1 (B) T2 Axial at L4-L5

Fig. 1 (C) T2 Axial at L5-S1




After reviewing the history, physical and neurological examination, and MRI’s it was determined that chiropractic treatment was medically indicated and warranted.  Frequency of treatment was determined 1 time a week.

The patient was placed on a treatment plan consisting of high velocity low amplitude chiropractic adjustments, axial traction, electrical muscle stimulation, and core stabilization exercise. The patient responded in favorable fashion to the chiropractic treatment over a 6 month period.  The patient demonstrated subjective and objective improvement and his care plan was reduced to one time every two weeks to manage and modulate pain levels associated with his permanent condition.

On follow-up re-evaluation approximately 9 months after starting supportive treatment the patient showed improvement in range of motion testing. 

Lumbar Range of Motion was tested with Dual Inclinometers:

Range of Motion            Normal         Examination                       % Deficit

Flexion

90

70

 

13

Extension

25

20

 

20

Left Lateral Flexion

40

35

 

12

Right Lateral Flexion

40

30

 

25

Left Rotation

35

30

 

15

Right Rotation

35

25

 

29

The patient also reported a reduction in pain levels rating the low back discomfort as a4 on a scale of 10 with 10 being the worst and the pain was noted as beingintermittent 25 to 50% of the time. Decreased muscle spasm in the lumbar paraspinal muscles was noted as well as better symmetry and tonicity.  The patient reported the ability of getting a better night sleep and waking up in the morning with less rigidity and achiness.  He stated he was able to perform his work duties and activities of daily living with less flare-ups and exacerbations occurring only 1-2 times a month.  The core training exercises we worked on have helped stabilize the patient’s spine and protected it from reinjuring the already injured tissues. 

Conclusion:

Chiropractic care has been shown to be both safe and effective in treating patients with disc herniation and accompanying radicular symptoms1-4. Spinal chiropractic adjustive therapy has been proven to modulate pain6. This patient presented with chronic low back pain sequela to an injury that occurred over 13 years ago.  The patient had prior success in reduction of pain when he was treating with chiropractic in the past then discontinued treatment.  The patient has been treating with pain management intervention since the injury occurred and it has helped him reduce his pain but has done minimal for him from a functional and mechanical standpoint. The history and exam indicated the presence of 2 herniated discs in the lumbar spine. Lumbar MRI’s were ordered prior to being evaluated and the images were viewed to establish an accurate diagnosis, prognosis, and treatment plan. Long term chiropractic treatment has been utilized successfully in this case study to reduce pain levels and restore the patient’s functional capacity of performing activities of daily living and work duties with less flare ups and exacerbations of low back pain.     

Competing Interests:  There are no competing interests in the writing of this case report.

De-Identification: All of the patient’s data has been removed from this case.

  1. Leeman S., Peterson C., Schmid C., Anklin B., Humphryes B., (2014) Outcomes of Acute and Chronic Patients with Magnetic Resonance Imaging-Confirmed Symptomatic Lumbar Disc Herniation Receiving High-Velocity, Low Amplitude, Spinal Manipulative Therapy: A Prospective Observational Cohort Study With One-Year Follow Up, Journal of Manipulative and Physiological Therapeutics, 37 (3) 155-163
  2. Hahne AJ, Ford JJ, McMeeken JM, "Conservative management of lumbar disc herniation with associated radiculopathy: a systematic review,"Spine35 (11): E488–504 (2010).
  3. Rubinstein SM, van Middelkoop M, et. al, "Spinal manipulative therapy for chronic low-back pain,"Cochrane Database Syst Rev(2): CD008112. doi:10.1002/14651858.CD008112.pub2. PMID 21328304.
  4. Hoiriis, K. T., Pfleger, B., McDuffie, F. C., Cotsonis, G., Elsangak, O., Hinson, R. & Verzosa, G. T. (2004). A randomized clinical trial comparing chiropractic adjustments to muscle relaxants for subacute low back pain. Journal of Manipulative and Physiological Therapeutics, 27(6), 388-398.
  5. Coronado, R. A., Gay, C. W., Bialosky, J. E., Carnaby, G. D., Bishop, M. D., & George, S. Z. (2012). Changes in pain sensitivity following spinal manipulation: A systematic review and meta-analysis.  Manuscript in preparation. 
  6. Whedon, J. M., Mackenzie, T.A., Phillips, R.B., & Lurie, J.D. (2014). Risk of traumatic injury associated with chiropractic spinal manipulation in Medicare Part B beneficiaries aged 66-69. Spine,  (Epub ahead of print) 1-33.

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