By: David Lincoln DC

Abstract:
Objective: The purpose of this case report is to describe a patient who presented to our office, as a surgical candidate for a large lumbar disc extrusion, to determine if his scheduled low back surgery could be avoided with Chiropractic care.

Clinical features: A 33-year-old male presented with complaints of constant low back pain and constant left leg radiating pain that started 2 years prior. The patient’s Lumbar MRI demonstrated a large L4-5 disc extrusion displacing multiple nerve roots causing moderate spinal stenosis and severe constant low back and radiating left leg pain. The patient had attempted pharmacological approaches, physical therapy, and chiropractic providers without improvement. Spinal surgical consultation resulted in the scheduling of a lumbar discectomy.

Key Words: extrusion, chiropractic adjustment, non-surgical spinal decompression, spinal stenosis, foraminal narrowing, lumbar discectomy

Case Presentation:
Patient was a 33-year-old, 6’2”, 235 lb. male who presented with a chief complaint of low back pain and left leg radiating pain, numbness, and tingling. Low back pain started approximately 2 years prior to presenting to our office and had become constant moderate-severe pain less than a year prior to our initial evaluation. Radiating left leg pain, numbness, and tingling had become constant moderate-severe in severity more than 6 months prior to our initial evaluation. The patient was unable to correlate his symptoms to any one specific injury. Associated symptoms included decreased ranges of motion, weakness of the left leg and low back, and sharp pains with certain movements. The patient reported marked reduction in the ability to: lift, sit for prolonged periods of time, stand for prolonged periods of time; walking for prolonged periods of time; sleep through the night, work, and picking up either of his two 6-month-old twin daughters.

Prior to presenting to our office, the patient had pursued the following conservative approaches unsuccessfully: OTC (over-the-counter) anti-inflammatories, Medical Doctor, Prescription Medications including Gabapentin, Physical Therapy, and various Chiropractors. He was referred to a Spinal Surgeon who determined the patient was a surgical candidate, and surgery was then scheduled. Prior to the surgery date, the patient was convinced by a business affiliate to seek our opinion before undergoing the surgical procedure. Evaluation of the patient was performed in our office.

Exam:
Patient Details:
Height: 6ft, 2in
Weight: 235 lbs.
Blood Pressure: Left: 136/91 Right: 125/91
Dominant Hand: Right
Demeanor: Alert, Oriented x 3, Cooperative

Review of Systems:
The patient denied any fever or chills, and was negative for any change in skin, head and neck, immune, cardiac, respiratory, digestive, urinary, hepatic, renal or psychiatric issues, except: history of anxiety and sleep apnea.

Past Medical, Social, and Family History:
Unremarkable.

Clinical Findings:
Decreased lumbar ranges of motion, most significantly with lumbar left lateral bending and lumbar extension.

Sensory testing:
Moderately decreased vibratory sensation of the left big toe and left 5th toe; decreased pinwheel sensation and light touch sensation to the left L5 and left S1 dermatomes; all other upper and lower extremity dermatomes were considered normal with pinwheel and light touch sensation.

Motor testing:
There was no evidence of visible muscle atrophy or muscle fasciculations. The patient denied experiencing any “muscle twitching” in the legs.
Muscle testing in the upper extremity was within normal limits bilaterally and all myotomes were graded +5/5 bilaterally. Muscle testing in the lower extremity was within normal limits bilaterally and all myotomes were graded +5/5 bilaterally, except: 4/5 muscle strength of the left Extensor Hallicis, left foot dorsiflexors, and left foot everters.
(Muscle Strength Rating System: x/5=Muscle Strength 0=Paralysis 1=No Movement/Minor Contraction 2=Movement w/no Gravity 3=Full ROM/Perceptible Weakness 4=Full ROM/Moderate Resistance 5=Full ROM/Maximum Strength)

Reflexes:
Reflex testing revealed: Biceps, Triceps, Brachioradialis, Patella, Hamstring, and Achilles. Deep Tendon Reflexes were present and equal bilaterally being rated at 2/4, except: Left Achilles 1/4 with Jendrassik Maneuver; and Left Hamstring 2 sluggish/4 with Jendrassik Maneuver. There was no evidence of clonus.
(Deep Tendon Reflexes: 0=Absent; 1=Trace/Hyporeflexia; 2=Normal; 3=Hyperreflexia; 4=Hyperreflexia with Clonus)

Orthopedic Testing:
Positive Minor’s sign; Negative Dejerine’s Triad; positive Left Straight Leg Raise (SLR) at approximately 60 degrees of hip flexion causing increased radiating pain down to the left foot; positive Bowstring Sign on the left leg for increased radiating pain down to the left foot; positive Kemp’s test on the left side for increased low back pain and radiating left leg pain down to the foot.

Palpation:
Lumbar Spine: Palpatory Tenderness graded 1-2/4 and Palpatory muscle spasm graded 1-3/4. Motion palpation of the Low Back revealed vertebral biomechanical dysfunctions.
Thoracic Spine: Palpatory Tenderness graded 1-2/4 and Palpatory muscle spasm graded 1-2/4. Motion palpation of the Thoracic region revealed vertebral biomechanical dysfunctions.
Cervical Spine: Palpatory Tenderness graded 1-2/4 and Palpatory muscle spasm graded 1-2/4 in the Neck. Motion palpation of the Neck revealed vertebral biomechanical dysfunctions.

(Tenderness Scale: 1=Tenderness on deep touch; 2=Tenderness on deep touch w/ withdrawal response; 3=Tenderness on light touch; 4=Tenderness on light touch with withdrawal response
Muscle Spasm Grading Scale: 1=Slight increase in tone; 2= Marked increase in tone; 3=Considerable increase in tone and passive movement is difficult; 4= Affected part is rigid)

Imaging Results:
A lumbar MRI without contrast was performed 6 months before presenting to our office. The MRI images were personally reviewed, and below are the images and findings:

Images 1 & 2

Images 3 & 4

Images 5 & 6 

Utilizing the recommended nomenclature of the combined task forces of the North American Spine Society, American Society of Spine Radiology, and American Society of Neuroradiology (1), the following was reported:

     Alignment: Normal

     Conus Medullaris: Normal

     Soft Tissues: Normal

     Vertebrae: Normal

     L1-2 Disc: Normal

     L2-3 Disc: Disc desiccation without disc space narrowing or disc bulge. (Images 1 &3)

     L3-4 Disc: Normal

     L4-5: Disc desiccation with mild disc space narrowing. Left subarticular disc extrusion measuring 1.7 cm transverse by 1.1 cm AP by 1.2 cm craniocaudal extending posteriorly from the L4-5 disc margin. Displacement of the left-sided nerve roots posteriorly. Moderate spinal canal narrowing. (Images 1, 2, 3, and 4)

     L5-S1: Mild disc space narrowing and disc desiccation. Subarticular 0.5 cm AP disc protrusion indenting the epidural fat. Without significant spinal canal narrowing. Mild left facet arthrosis. Mild bilateral neural foraminal narrowing. (Image 6)

Treatment:

     The patient underwent a multimodal treatment regime consisting of manual chiropractic adjustments, non-surgical spinal decompression, and photobiomodulation (cold laser) therapy for 12 weeks at a frequency of 2 times per week. Spinal stabilization exercises were also prescribed after the 4^th week of treatment when the patient’s pain was markedly reduced.

Results:

     Subjective:

     After 4 weeks of treatment, the patient’s constant 6-8/10 low back pain and constant 6-8/10 left leg radiating pain was reduced to: occasional 0-4/10 low back pain and frequent 0-2/10 left leg radiating pain.

     After 8 weeks of treatment, the patient’s symptoms were: occasional 0-5/10 low back pain and no left leg radiating pain.

     After 12 weeks of treatment, the patient’s symptoms were: occasional 0-3/10 low back pain and no left leg radiating pain.

     Other measurements of improvement at the end of the 12 weeks are as follows:

1. Lumbar ranges of motion: Normal ranges of motion with no pain except for minimal pain upon left and right lateral bending.
2. Vibration sense: Improved from moderate to minimal decreased vibration of the left big toe.
3. Pinwheel sensation: Improved to normal in the L5 and S1 dermatomes, except a patch of decreased pinwheel sensation on the lateral aspect of the left foot.
4. Muscle strength: Normalized. No weakness (5/5 muscle strength) of left foot dorsiflexors, everters, and Extensor Hallicis Longus.
5. Reflexes: Lower extremity reflexes are all considered normal (2/4), except left Achilles reflex was graded 1/4 with Jendrassik Manuever.
6. Left Straight Leg Raise: Normalized. No low back pain and no radiating leg pain.
7. Bowstring Sign: Normalized.
8. Kemp’s test: negative for radiating pain and positive for minimal low back pain.
9. Functionally: patient can lift heavy and workout at the gym; can sit, stand, walk, sleep through the night, and pick up his twin daughters with little to no pain in the back and without any radiating left leg pain.

     After the 12 weeks of care, non-surgical spinal decompression treatments and Photobiomodulation treatments ceased, and the patient was treated with chiropractic adjustments 1 time per week for 8 weeks and then reduced to every other week. The patient was instructed to perform a 5-10 minute low back strengthening exercise routine 5 days a week indefinitely to help maintain spinal stability. The goal to manage his low back condition is for the patient to maintain a stable and asymptomatic low back with the prescribed strengthening exercise routine and one chiropractic office visit every 3 weeks.

     At the time of writing this case study, it had been nearly 6 months since initiating our treatment plan with the patient. The patient experienced one mild flare-up of low back pain, without radiating pain, caused by working under a house for 10 hours the same week he missed his scheduled chiropractic visit. One chiropractic adjustment to treat the biomechanical dysfunction of the lumbar spine completely resolved his symptoms.

Discussion:

     Significant intervertebral disc pathology may require surgery, but not in all cases. In this particular case, the patient was presented two options for treatment of his large herniated disc (more specifically a large “extruded disc”) with ensuing neurological deficit and moderate spinal stenosis. The patient decided to pursue chiropractic treatment including non-surgical spinal decompression to exhaust all non-invasive approaches before doing surgery, which he knew he could pursue if this option failed to yield his desired results (2). Fortunately, the patient’s outcome with chiropractic care was excellent and he is thankful he chose this path.

     A misconception with some health care providers, albeit less and less common these days, is that a herniated disc should not be treated by a Chiropractor. Research has shown chiropractic care to be safe and effective in treating herniated discs, including herniated discs with associated radiculopathy (2,3,4) It is important to note that a Doctor of Chiropractic that is properly trained in the diagnosis and case management of spinal biomechanical lesions, including herniated discs, is trained to determine safe and effective treatment for each individual patient. Not all disc herniations are appropriate to render a chiropractic adjustment to, and it is the responsibility of the treating Doctor of Chiropractic to determine when this is the case. In some cases, this may require the Chiropractor to consult and collaborate with a Neurosurgeon or Fellow in Spinal Surgery and request “clearance” from the surgeon to perform chiropractic adjustments.

• All identifying information has been removed from this report
• There are no conflicts of interest in producing this report

References:

1. David F. Fardon, MD, Alan L. Williams, MD, Edward J. Dohring, MD, F. Reed Murtagh, MD, Stephen L. Gabriel Rothman, MD, Gordon K. Sze, MD. Lumbar disc nomenclature: Version 2.0. Recommendations of the combined task forces of the North American Spine Society, American Society of Spine Radiology, and American Society of Neuroradiology. The Spine Journal 14 (2014) 2525-2545.
2. Leemann S, Peterson CK, Schmid C, Anklin B, Humphreys BK. Outcomes of acute and chronic patients with magnetic resonance imaging-confirmed symptomatic lumbar disc herniations receiving high-velocity, low-amplitude, spinal manipulative therapy: a prospective observational cohort study with one-year follow-up. Journal of Manipulative and Physiological Therapeutics. 2014 Mar-Apr;37(3):155-63.
3. McMorland G, Suter E, Casha S, du Plessis SJ, Hurlbert RJ. Manipulation or microdiskectomy for sciatica? A prospective randomized clinical study. Journal of Manipulative and Physiological Therapeutics. 2010 Oct;33(8):576-84.
4. BenEliyahu DJ. Magnetic resonance imaging and clinical follow-up: study of 27 patients receiving chiropractic care for cervical and lumbar disc herniations. Journal of Manipulative and Physiological Therapeutics. 1996 Nov-Dec;19(9):597-606.
5. Drew Oliphant. Safety of Spinal Manipulation in the Treatment of Lumbar Disk Herniations: A Systematic Review and Risk Assessment. Journal of Manipulative and Physiological Therapeutics. 2004 Volume 27, Issue 3, pages 197-210.