Chiropractic Outcome Studies on Treatment of Fragmented/Sequestered and Extruded Herniated Discs and Radicular Pain
By: Mark Studin DC, FASBE(C), DAAPM, DAAMLP
William J. Owens DC, DAAMLP
Citation: Studin M., Owens W. (2016) Chiropractic Outcomes on Fragmented/Sequestered and Extruded Discs and Radicular Pain, American Chiropractor, 34 (11) 26, 28, 30, 32-33
Research Review:
Disc herniations are a common diagnostic entity in chiropractic practices with varied etiologies ranging from auto accidents to sports injuries to slips and falls and any other type of trauma that can cause the disc to tear. Treatment has varied from doing nothing to conservative care to opiates and the surgery and in the recent past, opiates and surgery have been the treatment of choice leaving a population of too many addicts and too often failed surgeries. This is not to suggest that all surgeries or opiates are unnecessary, but if drugs and/or surgery can be avoided it is an obvious choice.
When considering disc issues, Fardone et. Al (2014) defined the nomenclature that has been widely accepted both in academia and clinically and should be adhered to, to ensure that reporting and visualizing pathology is consistent with the morphology visualized. In the past, this has been a significant issue as many have called a bulge a protrusion, a prolapse or herniation. In today’s literature Fardone’s document has resolved much of those problems.
Herniated Disc: “Herniated disc is the best general term to denote displacement of disc material. The term is appropriate to denote the general diagnostic category when referring to a specific disc and to be inclusive of various types of displacements when speaking of groups of discs. The term includes discs that may properly be characterized by more specific terms, such as ‘‘protruded disc’’ or ‘‘extruded disc.’’ The term ‘‘herniated disc,’’ as defined in this work, refers to localized displacement of nucleus, cartilage, fragmented apophyseal bone, or fragmented annular tissue beyond the intervertebral disc space. ‘‘Localized’’ is defined as less than 25% of the disc circumference. The disc space is defined, craniad and caudad, by the vertebral body end plates and, peripherally, by the edges of the vertebral ring apophyses, exclusive of the osteophyte formation. This definition was deemed more practical, especially for the interpretation of imaging studies, than a pathologic definition requiring identification of disc material forced out of normal position through an annular defect.” (page E1454)
Protruded Disc: “Disc protrusions are focal or localized abnormalities of the disc margin that involve less than 25% of the disc circumference. A disc is ‘‘protruded’’ if the greatest dimension between the edges of the disc material presenting beyond the disc space is less than the distance between the edges of the base of that disc material that extends outside the disc space. The base is defined as the width of the disc material at the outer margin of the disc space of origin, where disc material displaced beyond the disc space is continuous with the disc material within the disc space. The term ‘‘protrusion’’ is only appropriate in describing herniated disc material, as discussed previously.” (page E1455)
Extruded Disc: “The term ‘‘extruded’’ is consistent with the lay language meaning of material forced from one domain to another through an aperture and with reference to a disc, the test of extrusion is the judgment that, in at least one plane, any one distance between the edges of the disc material beyond the disc space is greater than the distance between the edges of the base measured in the same plane or when no continuity exists between the disc material beyond the disc space and that within the disc space.” (page E1455)
Extruded Sequestered, Fragmented Disc or Migrated Disc: “Extruded disc material that has no continuity with the disc of origin may be characterized as ‘‘sequestrated.” A sequestrated disc is a subtype of ‘‘extruded disc’’ but, by definition, can never be a ‘‘protruded disc.’’ Extruded disc material that is displaced away from the site of extrusion, regardless of continuity with the disc, may be called ‘‘migrated,’’ a term that is useful for the interpretation of imaging studies because it is often impossible from images to know if continuity exists. (page E1455)
Bulging Disc: “The terms ‘‘bulge’’ or ‘‘bulging’’ refer to a generalized extension of disc tissue beyond the edges of the apophyses. Such bulging involves greater than 25% of the circumference of the disc and typically extends a relatively short distance, usually less than 3 mm, beyond the edges of the apophyses. ‘‘Bulge’’ or ‘‘bulging’’ describes a morphologic characteristic of various possible causes. Bulging is sometimes a normal variant (usually at L5–S1), can result from an advanced disc degeneration or from a vertebral body remodeling (as consequent to osteoporosis, trauma, or adjacent structure deformity), can occur with ligamentous laxity in response to loading or angular motion, can be an illusion caused by posterior central subligamentous disc protrusion, or can be an illusion from volume averaging (particularly with CT axial images).” (page E1455)
It was reported by McMorland, Suter, Casha, du Plessis, and Hurlbertin (2010) that over 250,000 patients a year undergo elective lumbar discectomy (spinal surgery) for the treatment of low back disc issues in the United States. The researchers did a comparative randomized clinical study comparing spinal microdiscectomy (surgery) performed by neurosurgeons to non-operative manipulative treatments (chiropractic adjustments) performed by chiropractors. They compared quality of life and disabilities of the patients in the study.
The study was limited to patients with distinct one-sided lumbar disc herniations as diagnosed via MRI and had associated radicular (nerve root) symptoms. Based upon the authors’ review of available MRI studies, the patients participating in the study were all initially considered surgical candidates. Both the surgical and chiropractic groups reported no new neurological problems and had only minor post-treatment soreness. 60% of the patients who underwent chiropractic care reported a successful outcome while 40% required surgery and of those 40%, all reported successful outcomes. This study concluded that 60% of the potential surgical candidates had positive outcomes utilizing chiropractic as the alternative to surgery.
Although the previous report concluded that a chiropractic spinal adjustment is an effective treatment modality for herniated disc a more recent study (Lehman ET. Al. (2014), further clarifies the improvement with chiropractic care. This study considered both herniated discs and radiculopathy or pain radiating down into the leg as a baseline for analysis. The study also considered acute and chronic lumbar herniated disc pain patients.
In this study the acute onset patient (the pain just started) reported 80% improvement at 2 weeks, 85% improvement at 1 month, and a 95% improvement at 3 months. The study went on to conclude that the patient stabilized at both the six month and one-year mark after the onset of the original complaint. Although one might argue that the patient would have gotten better with no treatment it was reported that after two weeks of no treatment only 36% of the patients felt better and at 12 weeks up to 73% felt better. This study clearly indicates that chiropractic is a far superior solution to doing nothing and at the same time helps the patient return to their normal life without pain, drugs or surgery.
Chiropractic Care and Herniated Discs with Leg Pain
|
2 Week Improvement |
1 Month Improvement |
3 Month Improvement |
|
80.6% |
84.6% |
94.5% |
In a prospective outcome study, Ehrler et. Al. (2016) studied outcomes of chiropractic care on both extruded and sequestered disc patients. They reported “The purpose of this study was to evaluate whether specific MRI features, specifically axial location and type (bulge, protrusion, extrusion, sequestration) of a herniated disc, are associated with the short and long term outcomes of patients treated with high-velocity, low-amplitude SMT specifically to the level of the symptomatic, MRI confirmed, herniation. This is the first study to address this question. Studies searching for predictors of improvement after treatment in previous low back pain patients did not target type and axial location of the herniated discs.Additionally, patients with disc sequestration were not excluded from this study.” (Page 196)
Ehrler et. Al. continued “Over 77% of patients with disc sequestration reported clinically relevant “improvement” compared to 66.7% of patients with extrusion. Although not statistically significant, 100% of patients with sequestration reported clinically relevant improvement at the 3-month data collection time point and at all data collection time points a higher proportion of patients with sequestration reported clinically relevant improvement. There were no significant differences for disc herniation location either by spinal level or in the axial plane for any of the data collection time points. This now calls into question the traditional thinking that disc sequestrations are more dangerous than herniations that remain attached to the parent disc and are more likely to require surgery. However, the studies reporting this did not consider chiropractic spinal manipulative therapy as a treatment option.” (page 197)
I would like to leave you with a last and seemingly unrelated statement. I felt it was important to add this at the end since many of our critics negatively portray the safety of chiropractic care. This statement shall put that to rest leaving only personal biases left standing. Whedon, Mackenzie, Phillips, and Lurie (2015) based their study on 6,669,603 subjects and after the unqualified subjects had been removed from the study, the total patient number accounted for 24,068,808 office visits. They concluded, “No mechanism by which SM [spinal manipulation] induces injury into normal healthy tissues has been identified” (Whedon et al., 2015, p. 5). This study supersedes all the rhetoric about chiropractic and stroke and renders an outcome assessment to help guide the triage pattern of mechanical spine patients.
References:
Case Report
Abatement of right leg radicular clinical signs and symptom in a 58-year-old male with advanced degenerative disc disease, disc bulging and grade II spondylolisthesis using a comprehensive approach to care including multiple modalities, non-surgical spinal decompression and chiropractic care.
BY: Christopher Quigley DC, CCST
Abstract: Objective: To examine the diagnosis and care of a patient suffering from chronic low back pain with associated right leg pain and numbness. Diagnostic studies include standing plain film radiographs, lumbar MRI without contrast, chiropractic analysis, range of motion, orthopedic and neurological examination. Treatments include both manual and instrument assisted chiropractic adjustments, ice, heat, cold laser, Pettibon wobble chair and repetitive neck traction exercises and non-surgical spinal decompression. The patient's’ outcome was very good with significant reduction in pain frequency, pain intensity and abatement of numbness in foot.
Keywords: degenerative disc disease, spondylolisthesis, chiropractic adjustment, Pettibon wobble chair, cold laser, non-surgical spinal decompression, nerve root compression, lumbar radiculopathy.
Introduction: A 58 year old, 6’0”, 270 pound male was seen for a chief complaint of lower back pain with radiation into the right leg with right foot numbness. The pain had started 9 months prior with an insidious onset. The patient had first injured his back in high school lifting weights with several episodes of pain over the ensuing years. The patient had been treating with Advil and had tried physical therapy, acupuncture, chiropractic and ice with no relief of pain and numbness. Walking and standing tend to worsen the problem and lying down did provide some relief. A number of activities of daily living were affected at a severe level including standing, walking, bending over, climbing stairs, looking over shoulder, caring for family, grocery shopping, household chores, lifting objects staying asleep and exercising. The patient remarked that he “Feels like 100 years old.” Social history includes three to four beers per week, three diet cokes per day.
The patient’s health history included high blood pressure, several significant shoulder injuries, knee injuries, apnea, hearing loss, weight gain, anxiety and low libido. Family history includes Alzheimer’s disease, heart disease, colon cancer and obesity.
Clinical findings: Posture analysis revealed a high left shoulder and hip with 2 inches of anterior head projection. Bilateral weight scales revealed a +24 pound differential on the left. Weight bearing dysfunction and imbalance suggest that neurological compromise, ligamentous instability and or spinal distortion may be present. Range of motion in the lumbar spine revealed a 10 degree decrease in both flexion and extension. There was a 5 degree decrease in both right and left lateral bending with sharp pain with right lateral bending.
Cervical range of motion revealed a 30 degree decrease in extension, a 42 and 40 degree decrease in right and left rotation respectively and a 25 degree decrease in both right and left lateral flexion. Stability analysis to assess and identify the presence of dynamic instability of the cervical and lumbar spine showed positive in the cervical and lumbar spine and negative for sacroiliac dysfunction. Palpatory findings include spinal restrictions at occiput, C5, T5, T10, L4,5 and the sacrum. Muscle palpation findings include +2 spasm in the psoas, traps, and all gluteus muscles.
Cervical radiographs reveal significant degenerative changes throughout the cervical spine. This represents phase II of spinal degeneration according the Kirkaldy-Wills degeneration classification. Cervical curve is 8 degrees which represents an 83% loss from normal. Flexion and extension stress x-rays reveal decreased flexion at occiput through C4 and decreased extension at C2, C4-C7.
Lumbar radiographs reveal significant degenerative changes throughout representing phase II of spinal degeneration according to the Kirkaldy-Willis spinal degeneration classification. There is a 9 degree lumbar lordosis which represents a 74% loss from normal. There is a 2 mm short right leg and a grade II spondylolisthesis at the L5-S1 level.
Lumbar MRI without contrast was ordered immediately with a 4 mm slice thickness and 1 mm gap in between slices on a Hitachi Oasis 1.2 Telsa machine for optimal visualization of pathology due to the clinical presentation of right L5 nerve root compression.
Lumbar MRI revealed
T2 sagittal Lumbar Spine MRI: Note the Modic Type II changes and the L2-3 Schmorls node.
T1 Sagittal Annular fissures at multiple levels and spondylolisthesis at L5S1
T2 Axial L4-5: Focal Disc Protrusion Type Herniation
Definition –Bulging Disc: A disc in which the contour of the outer annulus extends, or appears to extend, in the horizontal (axial) plane beyond the edges of the disc space, over greater than 50% (180 degrees) of the circumference of the disc and usually less than 3mm beyond the edges of the vertebral body apophyses.3
Definition: Herniation is defined as a localized or focal displacement of disc material beyond the limits of the intervertebral disc space.3
Protrusion Type Herniation: is present if the greatest distance between the edges of the disc material presenting outside the disc space is less than the distance between the edges of the base of that disc material extending outside the disc space.3
Definition: Extrusion Type Herniation: is present when, in at least one plane, any one distance between the edges of the disc material beyond the disc space is greater than the distance between the edges of the base of the disc material beyond the disc space or when no continuity exists between the disc material beyond the disc space and that within the disc space. 3
Definition: Annular Fissures: separations between the annular fibers of separations of the annual fibers from their attachments to the vertebral bone. 4
Definition – Radiculopathy: Sometimes referred to as a pinched nerve, it refers to compression of the nerve root - the part of a nerve between vertebrae. This compression causes pain to be perceived in areas to which the nerve leads.
The patient underwent multimodal treatment regime consisting of 4 months of active chiropractic adjustments, non-surgical spinal decompression with pretreatment spinal warm-up exercises on the Pettibon wobble chair and neck traction and heat. Post spinal decompression with ice and cold laser. The patient reported long periods of symptom free activities of daily living with occasional short flare-ups of pain. Exacerbations are usually of short duration and much lower frequency. The only activity of daily living noted as affected severely at the end of care is exercising.
Post care lumbar radiographs revealed a 26 degree lumbar curve a 15 degree (38%) increase
Post care cervical x-rays revealed a 10 mm decrease in anterior head projection and a 2 degree improvement in the cervical lordosis.
|
Range of Motion |
pre |
post |
increase |
|
Lumbar |
|||
|
flexion |
60 |
60 |
0 |
|
extension |
40 |
40 |
0 |
|
r. lateral flexion |
20 |
25 |
5 |
|
l. lateral flexion |
20 |
25 |
5 |
|
cervical |
pre |
Post |
increase |
|
flexion |
50 |
50 |
0 |
|
extension |
30 |
40 |
10 |
|
r. lateral flexion |
20 |
35 |
15 |
|
l. lateral flexion |
20 |
20 |
0 |
|
r. rotation |
38 |
70 |
42 |
|
l. rotation |
40 |
80 |
40 |
Discussion: It is appropriate to immediately order MRI imaging with radicular pain and numbness. Previous health providers who did not order advanced imaging with these long term radicular symptoms are at risk of missing important clinical findings that could adversely affect the patient’s health. The increasing managed care induced trend to forego taking plain film radiographs is also a risk factor for patients with these problems.
This case is a typical presentation of long standing spinal injuries that over many years have gone through periods of high and low symptoms but continue to get worse functionally and eventually result in a breakdown of spinal tissues leading to neurological compromise and injury.
Chiropractic treatment resulted in a very favorable outcome aided by an accurate diagnosis. This is also the case where the different treatment modalities all contributed to the success of the protocol. The different modalities all focus on different areas of pathology contributing to the patients’ disabled condition.
|
Modality |
Therapeutic Goals |
|
Chiropractic adjustment |
Manual and instrument assisted forces introduced to the osseous structures that focuses on improving motor segment mobility |
|
Cold laser |
Increases speed of tissue repair and decreases inflammation.4 |
|
Pettibon wobble chair |
Loading and unloading cycles applied to injured soft tissues and |
|
Pettibon neck traction |
speeds up & improves remodeling of injured tissue as well as rehydrates dehydrated vertebral discs.5 |
|
Non-surgical spinal decompression |
Computer assisted, slow and controlled stretching of spine, creating vacuum effect on spinal disc, bringing it back into its proper place in the spine.6,7 |
|
Ice |
Decrease inflammation through vasoconstriction |
|
Heat |
Warm up tissues for mechanical therapy through increasing blood flow. |
|
Posture Correction Hat |
Weighted hat that activates righting reflex resetting head posture.8 |
A major factor in the success of the care plan in this case was an integrative approach to the spine. John Bland, M.D. in the text Disorders of the Cervical Spine writes
“We tend to divide the examination of the spine into regions: cervical, thoracic and the lumbar spine clinical studies. This is a mistake. The three units are closely interrelated structurally and functionally- a whole person with a whole spine. The cervical spine may be symptomatic because of a thoracic or lumbar spine abnormality, and vice versa! Sometimes treating a lumbar spine will relieve a cervical spine syndrome, or proper management of cervical spine will relieve low backache.”9
When addressing the spine as an integrative system, and not regionally it has a very strong benefit to the total care results. The focus on the restoration of the cervical spine function as well as lumbar spine function is a hallmark of a holistic spine approach that has been a tradition in the chiropractic profession.
References:
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