CASE REPORT: Chiropractic High Velocity-Low Amplitude Adjustments in the Presence of a Herniated Disc without Compromise of the Cauda Equina

Case Report

By: Steve Lininger, DC, CICE

TITLE: Chiropractic High Velocity-Low Amplitude Adjustments in the Presence of Herniated disc without Compromise of the Cauda Equina

Abstract: The objective was to demonstrate where an MRI was initially utilized to diagnose a lumbar herniated disc with no evidence of compromise of the cauda equina, and the patient was then subsequently safely and effectively treated with chiropractic high velocity-low amplitude adjustments.

Background: (1) High-Velocity Low Amplitude (HVLA) thrust techniques are among the most commonly used manipulative treatment techniques. (2) Most patients do not experience significant adverse effects following the use of these techniques. (3, 4) There is currently no strong evidence to suggest that HVLA thrust techniques should not continue to be used, where applicable, by appropriately trained and competent practitioners. (5) In a major study, Eighty Percent (80%) of the patients studied had a good clinical outcome with post-care visual analog scores accompanied with resolution of abnormal clinical examination findings (following chiropractic care). Anatomically, after repeat MRI scans, Sixty-Three percent (63%) of the patients studied revealed a reduced size or completely resorbed disc herniation (following chiropractic care) (5).

Key Words: Chiropractic, Spinal Adjustment, MRI, Herniation

Introduction: A 39-year-old male patient presented to our clinic on 05/30/17 with; lower back pain, weakness, burning in his left leg, and pains that radiate from his lower back into his left leg. The patient reported that he had lower back and left leg symptoms for approximately the past two months. The patient reported that he had previously been treated by two practitioners before arriving at our clinic with little to no changes in pain levels or function. The patient stated that he had also been having symptoms of irregular balance and painful and limited sexual relations due to pain.

The patient initially reported 5 out of 10 lower back pain on the verbal analog scale, as well as radiating left leg pains.

History: The patient states that he did not have any back or left leg pains prior to the initial episode of two months. There were no reported injuries or traumas.

Objective Findings: An examination was performed and revealed the following:

Vitals: 157/112 Blood Pressure. Pulse is 76 beats per minute. Temperature is 99.5F.

Range of Motion:

Lumbar Motion Studies:

Flexion: Normal = 90                           Exam- No pain present.

Extension: Normal = 25                       Exam- No pain present.

Left Lateral Bending: Normal = 25     Exam- Pain present at above 10 degrees and spasms.

Right Lateral Bending: Normal = 25   Exam- Pain present at above 10 degrees and spasms.

Orthopedic Testing:

The Orthopedic testing revealed the following positive orthopedic tests in the lumbar spine: Lasegue’s Straight Leg Raise Test with pain located at the L5/S1 level, Straight Leg Raise Test with pain located at the L5/S1 level, Valsalva’s Test indicating the presence of a space-occupying lesion at the Lower lumbar region.

Neurological Testing:

The Neurological examination revealed normal 5/5 = Full range of Motion / Maximum Strength in the; Quadriceps, Hamstrings, Calfs, and Extensor Hallicus Longus muscle regions. Hammer reflex testing revealed 2+ = Normal reflex findings in the; Patella and Achilles reflexes. Pinwheel dermatome testing revealed abnormal Left-Sided Hypoesthesia in the following levels; L1, L2, L3, L4, L5, and S1. The patient was unable to perform the Heel Walk over a three-foot range.

MRI Results:

Because of the patient’s symptoms of; radiating and burning left leg pains, which clinically correlated with the patient’s objective findings of; Left-sided Hypoesthesia upon at L1, L2, L3, L4, L5, and S1 demonstrated upon pinwheel dermatome testing, a Lumbar MRI was ordered on 05/30/17 to diagnose lumbar disc pathology.

The MRI images were personally reviewed. The lumbar MRI revealed a lateral protrusion-type herniation at the level of L5/S1 with impingement on the left S1 nerve root. Additionally, there is a left lateral disc protrusion-type herniation with a torn annulus at L4/5 with no nerve root impingement. There is disc bulging at the; L3/4, L4/5, and L5/S1 levels.

Lumbar MRI Studies

Treatment Plan:

After reviewing the history, examination, and MRI’s, it was determined that chiropractic adjustments were clinically indicated with modalities including; intersegmental traction, electric muscle stimulation, wobble chair exercises, and standing on a vibration platform. Diversified technique adjustments combined with “Pettibon” Rehab equipment and protocols were used to adjust the subluxation diagnosed levels of; C4, C5, T4, and T5, L4, L5. Although there were herniated and bulging discs present in the lumbar spine there was no compromise of the cauda equina. Therefore; there was no contradiction to performing a spinal adjustment because there is no stenosing of the cauda equina present on the MRI or root involvement in the central canal. As long as there is enough space between the cauda equina and the herniation or bulge then performing chiropractic adjustments are a reasonable treatment protocol.

Lumbar Motion Post-Treatment Physical Examination:

Flexion:                         Normal=90       Exam- 90 with no pain

Extension:                     Normal=50       Exam- 25 with no pain

Left Lateral Bending:   Normal=25       Exam- 25 with no pain

Right Lateral Bending: Normal=25     Exam- 25 with no pain

The patient responded favorably to the spinal adjustments and therapies over the course of three months of care.   During the treatment plan, the patient was seen three times weekly, and a reevaluation was performed approximately every thirty days.   At the end of the third month, the patient demonstrated subjective and objective improvement. The patient demonstrated; decreased spasms and tender points, decreased pain scores, an increase in the ability to perform ADL’s with a normal sleeping schedule. The patient states that he no longer had the same difficulties with sexual performance and daily work and home activities. His Oswestry Disability Questionnaire score which was initially a 68%, reduced to 0%. His verbal analog scale which was initially a 5 out of 10, reduced to a zero out of ten. His pinwheel test dermatomal findings demonstrated normal findings at the end of his care plan. The patient is now able to Heel Walk over a three-foot range.

Conclusion:

The patient presented two months post the onset of symptoms. The symptoms were constant and idiopathic. The pain was located in the lower back and the left leg. The history and examination indicated the presence of a space-occupying lesion in the lumbar region. Lumbar MRI was ordered, and two lumbar protrusions were detected at the L4/5 and L5/S1 levels as well as disc bulges at; L3/4, L4/5, and L5/S1 levels. Because the herniations and bulges were not compromising the cauda equina, it was safe to adjust the lumbar spine (6). The patient after chiropractic care went from a 5 out of 10 on the verbal analog scale to a 0 out of 10 and regained full ranges of motion in the lumbar spine with no residual pain upon movement.

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

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

References

1. 1.Gibbons, Tehan, HVLA Thrust Techniques: What are the risks?, International Journal of Osteopathic Medicine (2006) 4-12.
2. 2.Johnson S, Kurtz M. Osteopathic Manipulative treatment techniques preferred by contemporary osteopathic physicians, J AM Osteopath Assoc 2003; 103:219-24.
3. 3.Royal College of General Practitioners. Clinical Guidelines on acute and recurrent low back pain. London: RCGP; 1996. Chapter 2.
4. 4.Waddell G. The back pain revolution. Edinburgh: Churchill Livingstone; 1998. Chapter 16.
5. 5.Magnetic Resonance Imaging and clinical follow-up: study of 27 patients receiving chiropractic care for cervical and lumbar disc hernitations. J MANIPULATIVE PHYSIOL THER, 1996 Nov-Dec; 19(9): 597-606.
6. 6.Treatment Options for a Herniated Disc; Spine-Health, Article written by:John P. Revord, MD