CASE REPORT: SEVERE DISC HERNIATION WITHOUT RADICULAR SYMPTOMATOLOGY
Richard A. Laviano DC
The patient was a very pleasant 43-year-old male presenting to the clinic with acute onset of low back pain that started 7 days ago after performing some heavy lifting at work. The pain was in the lumbosacral region and right sacral leg joint region and surrounding musculature that radiated into the posterior aspect of the right leg. No numbness or tingling was present. No loss of bowel or bladder control. Any type of movement that involves bending and twisting greatly exacerbates the pain. The pain is constant and especially worse in the mornings. The patient presented with inability to fully weight-bear on the right leg and thus presented with a right limp.
The patient indicated that he had not experienced prior symptoms similar to his current complaints and was symptom-free at the time of the incident above. The patient’s medical, surgical, and family history was unremarkable. He is a healthy Hispanic male.
His superficial appearance did not indicate any apparent distress. Further, observation showed minor’s sign to be present. This sign is present when the patient, in arising from a chair, leans forward, jackknifing the thighs and the dorso-lumbar spine so that the head is over the feet. Using the hands on the thighs or the arms of the chair, the patient pushes the body to an upright position, thus sparing lower limb effort. The presence of this sign is usually indicative of sciatica. There was no apparent spine tilt with him standing upright.
The patient was 5 feet 8 inches at 156 pounds, well-developed with a body temperature of 99.2°F. His blood pressure was slightly elevated at 149/81 mm Hg and a heart rate at 72 beats per minute. On examination, the eyes, ears, and throat appeared normal.
Gait analysis reveals complete loss of normal gait pattern greatly favoring his left leg.
The patient’s range of motion was decreased in all ranges with pain and spasm in the erector spinae muscles including the iliocostalis lumborum and iliocostalis thoracics muscles bilaterally. Muscles of the lower extremity were 5 out of 5 for all muscles in the left leg. A 3 out of 5 test was noted in right anterior tibialis muscle and right extensor hallucis longus muscle. No atrophy was noted. The patient’s deep tendon reflexes of the upper and lower extremities were noted to be a 2+ rating bilaterally for patellar and Achilles. Cranial nerve testing also showed to be normal. The patient had normal sensation symmetrically and bilaterally.
Orthopedic testing showed positive straight leg raise test both in the supine and seated position (slumps) with reproduction of patient shooting pain along the posterior aspect of the right leg with a patient audible response due to the severity of pain. Bechterew’s test also showed positive on the right side.
Palpation of the lumbar spine showed tenderness along L3-L5 facet joints and surrounding musculature. Spasming noted in during palpation of the erector spinae muscles bilaterally. Edema is noted in this region as well.
A full spine weight bearing radiographic study was taken (utilizing views: APOM, AP cervical, AP Thoracic, AP lumbopelvic, lateral cervical, lateral thoracic, and lateral lumbar). An MRI of the lumbar spine was also ordered immediately before beginning treatment. See figures below.
The radiographic study showed loss of normal lumbar lordosis consistent with an acute injury. No degenerative changes are present. Neural foramina appear patent. No evidence of fracture or dislocation. A moderate left list of the lumbar spine is noted consistent with a disc injury. Acetabular joints appear normal. The adjacent soft tissue appears normal.
Image 1 – loss of lumbar lordosis with left list, Antalgia, seen on radiograph.
Magnetic Resonance Imaging:
MRI Study was reviewed, and findings included: Marrow edema was normal with no signs of fracture. The vertebral alignment showed loss of normal lumbar lordosis and caddy lever appearance of L3 on L4. Hemangiomas noted at L1 and L5 in trabecular bone vertebral bodies. Conus medullaris and cauda equina appear normal. There is a T2 hyperintense signal cystic structure noted at the posterior aspect of the conus medullaris at T12-L1. This is incompletely evaluated in this study. L1-L2 appears normal with no stenosis of the neural foramina or central canal. L2-L3 shows posterior central annular fissure. The high signal in this fissure indicates it is acute. No central canal or neural foraminal stenosis. L3-L4 showed mild disc bulging with a superimposed right paracentral disc extrusion1 at L3-L4 with migration inferior-ward displacing the thecal sac and the fourth lumbar nerve root before it reaches the L4-L5 neural canal on the right. L4-L5 shows moderate disc bulging with a superimposed posterior left paracentral disc protrusion type herniation with an annular fissure. Due to the high signal in this fissure, it is most likely acute. L5-S1 appears normal with no central canal or neural foraminal stenosis. Recommendations included a thoracic spine study to assess cystic lesion as noted above. Immediate neurosurgical consultation is also recommended. See Images 2 through 5 below.
Image 2 – extrusion herniation with inferior migration.
Image 3 – displacement of thecal sac posteriorly on the right side.
Image 4 – compression occurring just before neural canal but displacing L4 nerve.
Image 5 – Neural Canals are patent.
After MRI results were reviewed patient was immediately referred for a neurosurgical consult. Neurosurgical consultation recommended that the patient is removed from his repetitive occupation for 2 weeks and begin oral steroid treatment. After a few weeks, the patient reported that he had significantly improved and is now able to perform all activities of daily living including work with no discomfort. Based upon the neurosurgeon’s recommendation, collaborative care with chiropractic treatment will commence ensuring biomechanical stability.
NOTE ON STEROID USE WITH MECHANICAL SPINE ISSUES: Goldberg et al. (2015) reported: Despite conflicting evidence, epidural steroid injections are frequently offered under the assumption that radicular symptoms are caused by inflammation of the affected lumbar nerve root. Epidural steroid injections are invasive, generally, require a pre-procedure magnetic resonance imaging (MRI) study and expose patients to fluoroscopic radiation. Also, the US Food and Drug Administration recently warned of rare, but serious neurologic sequella from [epidural steroid injections]. Oral administration of steroid medication may provide similar anti-inflammatory activity, does not require an MRI or radiation exposure, can be delivered quickly by primary care physicians, carries less risk, and would be much less expensive than an [epidural steroid injection]. Oral steroids are used by many community physicians, have been included in some clinical guidelines, and are noted as a treatment option by some authors. However, no appropriately powered clinical trials of oral steroids for radiculopathy have been conducted to date. To address this issue, we performed a parallel-group, double-blind, randomized clinical trial of a 15-day tapering course of oral prednisone vs. placebo for patients with acute lumbar radiculopathy associated with a herniated lumbar disk... (p. 1916).
Results showed that “participants in both blinded treatment groups showed an improvement in symptoms over the initial 6 weeks, with more gradual reductions until the 24-week visit, after which changes were more variable. Baseline ODI [Oswestry Disability Index] scores were 51.2 and 51.1 in the prednisone and placebo groups, respectively; corresponding ODI scores at 3 weeks were 32.2 and 37.5” (Goldberg, 2015, p. 1919-1920). This indicates that both at 3 and 6 weeks there was no difference in the placebo vs. oral steroid groups. “Among patients with acute radiculopathy due to a herniated lumbar disk, a short course of oral steroids, compared with placebo, resulted in modest improvement in function and no significant improvement in pain” (Goldberg, 2015, p.1922)
Although the patient presented with some classical signs of disc injury, some signs of disc injury were not present: Antalgia, numbness or tingling in the lower extremity or loss of bowel or bladder control. The outstanding feature of this case was the motor deficit noted in the right anterior tibialis and right extensor hallux longus muscle both having their roots in L4 and L5. It is important to note, however, that positive orthopedic testing with production radicular pain without motor or sensory loss is still an indication for advanced imaging particularly with straight leg raise (SLR) and slumps test3. One study showed that adding hyperextension test and Bell test to the straight leg raise test have shown to be more sensitive and specific than the SLR test alone4. The patient had not been evaluated by any other physician before being evaluated by us. This is a clear example although the patient did not have all the signs indicating acute disc injury, severe disc injury indeed occurred. The patient’s inability to axial load during a range of motion testing is also demonstrated by the two acute annular fissures as noted above. Chiropractic manipulation is contraindicated in this case due to the severe extruded disc at L3-L4 with migration. Advanced imaging, particularly Magnetic resonance imaging, in this patient’s case significantly improved our ability to give an accurate diagnosis and prognosis of their condition.
Falls Chiropractic and Injury
6009 Falls of Neuse Road Raleigh, NC 27609
(919)876-9472 (919)876-9478 FAX
RE: Sample Patient
RE: Age dating C4-C5 herniated disc in a low speed crash
To whom it may concern:
Specific to Sample Patient’ case, when looking at the images there is no infiltration of calcium at the area of the protrusion type herniation of the C4-C5 disc. Wolfe law states that a bone will adapt to the loads upon which it is placed. When there is a herniation of an intervertebral disc, there is abnormal mechanical shearing thus creating an increase in negative charge within the joint capsule as compared to the osseous structures above and below. As a result, the trabecular bone will give a positive charge by means of calcium (Ca+) that infiltrates into the injured joint1. This is called the piezoelectric effect1. This can be usually visualized beginning at a minimum of 6 months’ post trauma2. The osteophytic changes noted in other parts of the cervical spine as well as other aspects of the C4-C5 joint itself indicate previous injury. However, the lack of calcium infiltration and osteophytic changes around the protrusion type herniation at C4-C5 indicates that this herniation is acute in nature, is causally related to the accident, and clinically correlates with the patient’s injury. A clear contrast of this can be seen in the C3-C4 old protrusion type herniation above.
In addition, there were Modic type 1 changes present on the inferior end plate of C4 and the superior end plate of C5.
According to Xiong, Huang, Cun, Aghdasi and Zhou (2012)3
Histologic studies have shown that Type 1 Modic changes are characterized by edema, vascularization, and inflammation… (pg. 1943)
The presence of Modic type 1 changes is a direct response to the trauma and indicates a recent injury due to the presence of inflammation still present in the bone.
Therefore, the herniation at C4-C5 is acute and is causally related to her accident on 5/20/2017.
Lastly, it is important to note that low impact motor vehicle collisions can and do cause serious injury to the cervical spine. It has been clearly shown in the literature that injury to the cervical spine can occur at speeds as little as 4km/h (2.49 miles per hour)4. To completely ascertain the amount of force that was invoked on Mrs. Patient, one needs to bring into account many factors of the dynamics of the crash. One obvious fact in Mrs. Patient case is that the bullet car’s mass was significantly greater than the target car’s mass; Mrs. Patient was in a Honda Sudan and the bullet car was a Ford SUV as documented by the crash report. This means that the bullet car’s mass was greater than the target car and thus increases the amount of force that was applied to the Mrs. Patient’s vehicle. In addition, the infrastructures of most vehicles are designed to bend and flex at higher speeds to create a crash zone. In Mrs. Patient’s accident, there was little damage to the vehicle infrastructure which affords no crash zone. This thus causes the occupants, such as Mrs. Patient, to receive more force and therefore, more injury with less speed.
Richard A. Laviano, D.C.
CASE REPORT: Conservative care and axial distraction therapy for the management of cervical and lumbar disc herniations and ligament laxity post motor vehicle collision.
By Josh Johnston, DC
Title: Conservative care and axial distraction therapy for the management of cervical and lumbar disc herniations and ligament laxity post motor vehicle collision.
Abstract: This middle-aged female was injured in a vehicle collision causing her to sustain disc and additional ligament injuries in the cervical and lumbar spine. Diagnostic studies included physical examination, orthopedic and neurological testing, lumbar MRI, multiple cervical MRI’s, CRMA with motion cervical radiographs and EMG studies. Typically, conservative care is initiated prior to interventional procedures, and this case study seeks to explore the usage of passive therapy for mechanical spine pain and noted anatomic disc lesions after failure of interventional procedures. She reported both short term and long term success regarding pain reduction along with improvement in her activities of daily living after initiating conservative care, and continued to report further reductions in pain with periodic pain management using conservative care.
Key Words: neck pain, low back pain, paresthesia, disc herniation, spinal cord indentation, CRMA, axial distraction therapy, DRX9000, spinal manipulative therapy, motor vehicle collision
Key: MRI (magnetic resonance imaging); EMG (electromyography study); CRMA (computerized radiographic mensuration analysis); CT (computerized topography); PTSD (Post-traumatic stress disorder); PRN (as needed); VAS (visual analog scale); HVLA (high velocity low amplitude).
Introduction: The 49-year-old married female (Spanish speaking patient) reported that on March 4th, 2014 she was the seat-belted driver of a truck that was struck by a much larger fuel truck changing lines, hitting her vehicle at the front passenger side (far side, side impact). The force of the impact caused her truck to be lifted up and the right wheel popped off. Her head hit the window after impact and the spinal pain and complaints started approximately 24 hours later. Two days after the crash she went to the emergency department. Occupant pictures were taken describing an out of position occupant injury. She did not report any additional significant trauma after the collision.
Prior to her evaluation at our clinic, she utilized multiple providers for diagnosis and treatment over the course of 11 months. She went to the emergency department, utilized 3 pain management medical doctors, neuropsychologist and a cognitive rehabilitation therapist. Imaging included radiographs and MRI of the right shoulder revealing rotator cuff tear; radiographs of the lumbar and thoracic spine, and left hand; CT of the head and cervical spine were performed; MRI cervical (3) and lumbar spine. Medications prescribed included Fentanyl, Percocet, Naprosyn, Cyclobenzaprine, Norco, Hydrocodone-acetaminophen, Soma, and Carisoprodol. Physical therapy was provided for spinal injuries and she did not respond to treatment. The neurosurgeon recommended epidural steroid injections and facet blocks. Cervical nerve blocks and cervical trigger point injections, cervical and lumbar epidural steroid injections (ESI), lateral epicondyle steroid injections were performed, none of which were palliative. Post-concussion disorder and PTSD with major depressive disorder were diagnosed.
On February 12th, 2015, she presented to our office with neck pain (average 6/10 VAS) that affected her vision, with paresthesia’s in both upper extremities radiating to the hands with numbness. She had low back pain (average 6/10 VAS), and she additionally reported paresthesia at the plantar surface of feet bilaterally. She had left elbow pain, right shoulder pain, knee pain, headaches and “anxiety” along with anterior sternal pain.
Her injuries were causing significant problems with her activities of daily living. Summarily she had increased pain with lifting, increased pain and restricted movement with bending, walking and carrying. She had been unable to perform any significant physical activity from the time of the crash in March 2014 until March 2015. Her right hand was always hurting and her forearms. She was not able to clean windows or do laundry, difficulty using stairs, problems with mopping, ironing and cleaning. She had to limit her walking and jogging primarily due to neck pain and right arm pain. She was not able to sit for long periods of time and sleeping was disrupted due to numbness in her hands. She was only able to walk on a treadmill for 10 minutes before having to stop due to pain, prior to the crash she would exercise for an hour.
Prior History: No significant prior musculoskeletal or contributory medical history was reported.
Clinical Findings (2/12/15): She had a height of 5’2”, measured weight of 127 lbs.
Visual analysis of the cervical spine revealed pain in multiple ranges of motion including flexion, extension, bilateral rotation and bilateral side bending. On extension pain was noted in the upper back, on rotation pain was noted in the posterior neck, and on lateral flexion pain was noted contralaterally.
Visual analysis of the lumbar spine revealed pain in the low back on all active ranges of motion, including flexion, extension and side bending, pain primarily at L5/S1.
Dual inclinometer testing was ordered based on visual active range of motion limitations with pain.
Sensory testing was performed of the extremities, C5-T1 and L4-S1. No neurological deficits other than right sided C5 hypoesthesia.
Foraminal compression test produced pain in the cervical spine. Foraminal distraction test caused an increase in pain in the neck. Jackson’s test on the right produced pain bilaterally in the neck. Straight leg raise bilaterally produced low back pain, double Straight leg raise produce pain at L5/S1 at 30 degrees.
Muscle testing of the upper extremities was tested at a 5/5 with the exception of deltoid bilaterally tested at a 4/5. The patient’s deep tendon reflexes of the upper and lower extremities were tested including Triceps, Biceps, Brachioradialis, Patella, Achilles: all were tested at 2+ bilaterally, equal and reactive. No evidence of clonus of the feet and Hoffman’s test was unremarkable.
C3-C5 right sided segmental dysfunction was noted on palpation. T5-T12 spinous process tenderness on palpation. Low back pain on palpation, particularly L5/S1.
I reviewed the cervical MRI images taken May 2014 with the following conclusions (images attached):
Fig. 1 (A) T2 Axial C5/6, 2 months post injury Fig. 1 (B) Sag T2 C5/6
I reviewed cervical MRI images taken September 17th, 2014 approximately 6-months post injury, and rendered the following conclusions:
I reviewed the cervical MRI dated October 24th, 2015 (images attached):
Fig. 2 (A) 3D Axial C4/5, 19 months post injury Fig. 2 (B) Sag T2 C4/5
IMPRESSIONS: C4/5 herniation noted on 10/24/15 was not noted on prior images. The patient reported no additional injury or symptoms between MRI studies, so it is postulated that initial slices revealed a false negative; or due to the severity of abnormal cervical biomechanics, it is possible that the C4/5 disc herniated between the pre/post MRI’s with no significant increase in symptomatology. There was improvement at C5/6 related to disc abnormality and cord involvement (see below).
Fig. 3 (A) 3D Axial C5/6, 19 months post injury Fig. 3 (B) Sag T2 C5/6, 19 months post injury
Functional Radiographic Analysis (Computerized Radiograph Mensuration Analysis):
The cervical flexion/extension images were digitized February 2016 and interpreted by myself and Robert Peyster MD, CAQ Neuroradiology, revealing a loss of Angular Motion Segment Integrity at intersegment C6/C7 measured at 19.7 degrees (maximum allowed 11 degrees), indicating a 25% whole person impairment according to the AMA Evaluation of Permanent Impairment Guidelines 5th edition1. CRMA provided from Spine Metrics, independent analysis.
Evidence of significant ligament injury causing functional subfailure was measured at C3/4 at 10.4 degrees and at C4/5 measuring 10.9 degrees regarding angular motion. Abnormal paradoxical translation motion measured at C6/7 and C7/T1.
Initial Max 4 months later % Improvement
Cervical Extension 44 42 -5%
Flexion 40 62 55%
Cervical Left 25 41 64%
Lateral flexion Right 12 26 117%
Cervical Left 46 59 28%
Rotation Right 43 73 70%
Conservative treatment rendered: A neurosurgical referral was made for assessment and surgical options. Conservative care was initiated despite failure of other medical procedures since there is “further evidence that chiropractic is an effective treatment for chronic whiplash symptoms”2-3. The patient was placed on an initial care plan of 2-3x/week for 5 months, with a gap in passive care for 1 month.
Prior to being placed at maximum medical improvement she had persistent low back symptoms, continued tingling in the fingertips and occasional neck pain at a 4/10, with her upper extremity paresthesia’s improved 50%. She continued with pain management chiropractic care after MMI, approximately 1 visit every 3-4 weeks with axial distraction to the cervical and lumbar spine, chiropractic adjustments as needed (PRN). 2 years/9 months post collision, and 1 year/9 months after initiating conservative care at our clinic, she reports only slight (1-2/10 VAS) spinal complaints with her primary concern being a torn rotator cuff injury from the crash that still requires surgical intervention. After initiating care at our clinic, no other interventional procedures were performed, although medication usage persisted. Due to improvement in symptoms and functional status, spinal surgery was not considered. She still utilizes Aleve PRN, 1-2 tablets. No significant active spinal rehabilitation was utilized. The patient was given at home active care consisting only of cervical and lumbar stretches, walking, and ice to affected areas.
Competing Interest: 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.
By David DePaolis, DC, DAAMLP
Title: Abatement of radiculopathy clinical signs and symptoms after chiropractic treatment in an older patient with trauma induced posterolateral disc herniation, superimposed on an underlying disc bulge.
Abstract: Objective: To examine the concomitant clinical diagnosis of a lumbar disc bulge and lumbar disc herniation at the same spinal level, in an older traumatically injured patient with radicular symptoms. Diagnostic studies include physical examination, including orthopedic and neurological examination, lumbar MRI without contrast, and plain film x-rays. Treatments included low force instrument adjusting without manual manipulation, diversified chiropractic manipulation, flexion-distraction treatment, intersegmental traction, electric muscle stimulation, ice, heat and massage/trigger point therapy. The patient’s outcome was very good and resulted in complete abatement of initial L5 paresthesia and radiating symptoms into the left leg, although mild lower back pain remained upon discharge from active treatment.
Key words: Lumbar posterolateral disc herniation, nerve root compression, lumbar radiculopathy, bulging lumbar disc
Introduction: A 63 year old, 6’ 0”, 193lbs., male was seen for a chief complaint of lower back pain radiating into the left leg with numbness in the dorsum of the left foot which started immediately following a motor vehicle accident with a frontal impact. During the collision, he reported his right knee struck the dashboard and his head struck the ceiling of his vehicle causing him to briefly lose consciousness. The patient additionally reported immediate neck and right knee pain. He was taken via ambulance to the hospital where he was evaluated, x-rayed, given medications and released the same day. He was unable to work as a bailiff in a courthouse due to worsening pain and after 3 days sought treatment in my office.
The patient noted that prior to the accident he did not have any physical limitations and that he played soccer weekly. He was observed to have a trim, fit build. He reported no prior motor vehicle accidents or other serious injury. He reported no previous neck or lower back pain and denied the use of alcohol, tobacco and illicit drugs.
Clinical Findings: Lasague’s, Braggard’s and Kemps orthopedic testing was positive on the left and lumbar motion was decreased approximately 60% collectively. Lasague’s and Braggard’s revealed an increase in radiating pain into the left leg and Kemps was positive bilaterally for pain into the left lower extremity. These orthopedic tests were positive indicating nerve root irritation. Dermatomal evaluation revealed a decreased sensation in the dorsum of the left foot representing the L5 dermatome. Motor evaluation revealed a weakness when attempting to walk on the heel of the left foot and weakness of the left extensor hallicus longus muscle, again indicating possible L5 nerve root compromise. Lumbar x-rays revealed a severe decrease of the normal lumbar lordosis, mild L3-L4 spondylosis (arthritis) and a posterior misalignment of L4 in relation to L5. The patient’s review of systems, surgical and family history were all unremarkable as reported.
Therapeutic Focus and Assessment: A non-contrast lumbar spine MRI was ordered immediately with 2 mm slice thickness and no gap in between slices on a 1.5 Tesla machine for optimal visualization of pathology due to the clinical presentation of left L5 nerve root compression. Lumbar MRI’s revealed a L4-L5 broad-based left posterolateral disc herniation superimposed on an underlying disc bulge with severe left lateral recess narrowing, compressing the descending left L5 nerve root.
Note: the findings of a disc bulge AND disc herniation at the same spinal level do not contradict each other. Patients often have an underlying disc bulge (degenerative thinning of the outer fibers (annulus) of the disc causing “bulging”). When subject to trauma, a focal displacement of disc material through a tear in the annular fibers, disc herniation, then occurs through the thinned annulus of the bulging disc. Further, a bulging disc is actually more likely to herniate with trauma due to the thinning of the annulus than a normal healthy disc.
Definition –Bulging disc: A disc in which the contour of the outer anulus 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. (Ref. 2)
Definition - Herniated disc: Localized displacement of disc material beyond the normal margins of the intervertebral disc space. (Ref. 2)
Again, the key distinction is the localized (aka focal displacement) of disc material that differentiates a herniated disc from a bulging disc. Or stated this way,“The bulging disk is defined as a disk that extends diffusely beyond the adjacent vertebral body margins in all directions” (Ref. 1)
Follow-up and Outcomes: Upon discovery of a L4-L5 posterolateral disc herniation compressing the left L5 nerve root finding on MRI evaluation, the patient was referred for neurologic consult. The neurologist diagnosed a left L4-L5 radiculopathy after a positive lower extremity EMG/NCV study was performed.
Radiculopathy is a general term used to describe any disease of the nerve roots. In this case, the cause of the radiculopathy was a traumatically induced lumbar posterolateral disc herniation.
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.(Ref. 3)
The patient underwent approximately 5 months of active chiropractic treatment after which an ordered gap in treatment of approximately 7 weeks occurred. After the gap in treatment, the patient reported they continued to experience no remaining radicular symptoms and re-evaluation showed no remaining clinical findings consistent with radiculopathy. However, the patient did report continuing to experience mild, intermittent lower back pain.
DISCUSSION: It is appropriate to immediately order MRI imaging in patients with a history of trauma leading to sudden onset of obvious clinical signs and symptoms of radiculopathy to ascertain an accurate diagnosis, prognosis and treatment plan. Is it important to understand the difference between herniated and bulging disc findings on MRI evaluation and that herniation can and does occur after a pre-existing disc bulge at the same spinal level. The patient in this case experienced immediate onset of radicular symptoms after trauma and was promptly evaluated with a lumbar MRI. The lumbar MRI confirmed a disc herniation compressing the left L5 nerve root as well as an underlying disc bulge. EMG testing confirmed the radiculopathy diagnosis at L4-L5 on the left. Chiropractic treatment resulted in a very favorable outcome aided by an accurate diagnosis.
SUMMARY: Lumbar posterolateral disc herniation (interestingly, the most common type of disc herniation – Ref. 4) can affect a lumbar nerve root, causing radiculopathy. Further, “The stress of annulus circumference is higher at the posterolateral region than that of other regions of annulus circumference” – (Ref. 5). I report a case of a healthy 64 year old male who presented with lower back pain radiating into the left leg with no relevant personal or family history or previous trauma, after a front impact collision while driving in which his right knee struck the dashboard. The patient showed immediate clinical signs and symptoms of lumbar disc herniation and left L5 radiculopathy. A lumbar MRI without contrast was ordered immediately and revealed a L4-L5 left posterolateral disc herniation superimposed on an underlying disc bulge, compressing the left L5 nerve root. Subsequent EMG testing confirmed a left L4-L5 radiculopathy. The diagnosis of herniation and disc bulge does not mean the herniation was pre-existing, as bulging discs are a risk factor for disc herniation due to a thinner, weaker annulus. The patient's history of no previous trauma and sudden onset of lower back pain radiating into the left leg, confirm the traumatic cause of the posterolateral disc herniation. Conservative chiropractic treatment was effective at eliminating all radicular signs and symptoms, even after an approximate 2 month gap in active treatment. Chiropractic care has been shown to be both safe and effective in treating patients with disc herniation and accompanying radicular symptoms. (Ref. 6, 7, 8, that can be reviewed for further study and investigation)
Informed consent: The patient provided a signed informed consent.
Competing Interests: There are no competing interests writing this case report.
De-Identification: All patient related data has been removed from this case report.
Disc Herniations and Low Back Pain Post Chiropractic Care
88% of patients reported continued improvement at 1 year post-care
A report on the scientific literature
By Mark Studin DC, FASBE(C), DAAPM, DAAMLP
Robert Reiss DC
According to Hoy et. al. (2014), "Out of all 291 conditions studied in the Global Burden of Disease 2010 Study, LBP [low back pain] ranked highest in terms of disability (YLDs), and sixth in terms of overall burden (DALYs)...LBP causes more global disability than any other condition" (p. 968). Low back pain is one of the most common maladies among the general population and the incidence of occurrence was reported by Ghaffari, Alipour, Farshad, Yensen, and Vingard (2006) to be between 15% and 45% yearly. Hoiriis et al. (2004) reported it to be between 75% and 85% over an adult lifetime in the United States. Chou (2010) wrote that, "Back pain is the fifth most common reason for office visits in the US, and the second most common symptomatic reason..." (p. 388).
There are many treatment options available that fall into one of two categories, surgical or conservative care. Spinal manipulation/adjustments are one of the most widely used conservative treatment options with doctors of chiropractic performing the majority of them. There have been various studies comparing the effectiveness of spinal manipulative therapy (SMT) on low back pain (LBP) patients with disc herniations to other therapies, all of which have been inconclusive.
But now, a 2013 study by Leemann, Peterson, Schmid, Anklin, and Humphreys concluded that, “a large percentage of acute and importantly chronic lumbar disc herniation patients treated with high-velocity, low-amplitude side posture SMT reported clinically relevant “improvement” with no serious adverse events” (p. 162). The study’s purpose was to evaluate patients with low back pain and leg pain that was the result of a herniated lumbar disc which had been confirmed by magnetic resonance imaging. The patients were treated with high-velocity, low-amplitude spinal manipulations by chiropractors. The patients’ outcomes of self-reported global impression of change and pain levels were collected at various time points up to 1 year.
The results showed significant improvement for all outcomes at all of the time points. “Patients responding ‘better’ or ‘much better’ were categorized as ‘improved,’ and all other patients as ‘not improved.’ ‘Improved’ was the primary outcome measure. ‘Slightly improved’ was not considered clinically relevant improvement” (Leemann et al., 2013, p. 158). At 1 year, 88.0% were much better or better. According to the authors, “The results in this current study are encouraging when considering that it is chronic LBP patients who are a large economic burden with greater use of prescription medications and increased use of other health care resources” (Leemann et al., 2013, p. 161).
To find a qualified doctor of chiropractic near you, go to the US Chiropractic Directory at www.USChiropracticDirectory.com and search your state.
1. Hoy, D., March L., Brooks, P., Blyth, F., Woolf, A., Bain, C.,…Buchbinder, R. (2014). Extended Report, The global burden of low back pain: Estimates from the Global Burden of Disease 2010 study. Annals of the Rheumatic Diseases, 73, 968–974.
2. Ghaffari, M., Alipour, A., Farshad, A. A., Yensen, I., & Vingard, E. (2006). Incidence and recurrence of disabling low back pain and neck-shoulder pain. Spine, 31(21), 2500-2506.
3. 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.
4. Chou, R. (2010). Pharmacological management of low back pain. Drugs, 70(4), 387-402.
5. Leemann, S., Peterson, C. K., Schmid, C., Anklin, B., & Humphreys, B. K. (2013). 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, 37(3), 155-163.
Disc Surgery (Discectomy,) Sciatica (Leg Pain) & Lumbar Disc Herniation
Surgery vs. Chiropractic Care
A report on the scientific literature
Mark Studin DC, FASBE(C), DAAPM, DAAMLP
60% of Surgical Candidates Avoid Surgery with Chiropractic
According to a group at MayoClinic.com (2010), "Sciatica refers to pain that radiates along the path of the sciatic nerve and its branches — from your back down your buttock and leg. The sciatic nerve is the longest nerve in your body. It runs from your spinal cord to your buttock and hip area and down the back of each leg. Sciatica is a symptom, not a disorder. The radiating pain of sciatica signals another problem involving the nerve, such as a herniated disk" (http://www.mayoclinic.com/health/ sciatica/DS00516).
Sciatica symptoms include: Pain "…likely to occur along a path from your low back to your buttock and the back of your thigh and calf. Numbness or muscle weakness along the nerve pathway in your leg or foot. In some cases, you may have pain in one part of your leg and numbness in another. Tingling or a pins-and-needles feeling, often in your toes or part of your foot. A loss of bladder or bowel control. This is a sign of cauda equina syndrome, a serious condition that requires emergency care" (Mayo Clinic Staff, 2010, http://www.mayoclinic.com/health/sciatica/DS00516/DSECTION=symptoms).
A prime symptom of sciatica is leg pain in conjunction with herniated discs. As reported by the US Chiropractic Directory in 2010, "Pain radiating down your leg secondary to a herniated disc is a common and often disabling occurrence. A disc in your spine is comprised of 2 basic components, the inner nucleus pulposis that is gelatinous in composition and the outer annulus fibrosis that is fibro-cartilaginous and very strong. When a person experiences trauma and the forces are directed at the spine and disc. The pressure on the inside of the disc is increased (like stepping on a balloon) and the internal nucleus pulposis creates pressure from the inside out. It tears the outer annulus fibrosis causing the internal material to go beyond the outer boundaries of the disc. This has often been misnamed a ‘slipped disc’ because the disc doesn’t slip or slide, it is torn from the trauma allowing the internal material to escape.
Conversely, a bulging disc, which gets confused with a herniated disc, is a degenerative "wear and tear scenario" that occurs over time with the annulus fibrosis degenerating. This can also be a "risk factor" allowing the disc to herniate with less trauma due to the degeneration or thinning of the disc walls. This, however, is a conversation for another article.
Lifetime prevalence of a herniated disc has been estimated to be 35% in men and 45% in woman and it has been estimated that 90% of all leg pain secondary to herniated discs occurs at either the L4-5 or L5-S1 levels. It has also been reported that average duration of symptoms is 55.9 weeks, underscoring the critical necessity for finding a viable solution for these patients" (http://www.uschirodirectory.com/index.php/patient-information/item/235-herniated-discs-radiating-pain-and-chiropractic).
It was reported by McMorland, Suter, Casha, du Plessis, and Hurlbert in 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.
This 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 surfaced 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. Of those patients choosing surgery as the primary means of treatment, 15% reported a failed surgical outcome and then chose chiropractic as a secondary choice. Of those 15% with failed surgeries, all were reported to have performed worse in clinical outcomes.
While it is clear that an accurate diagnosis could dictate that many patients require immediate surgery, many also do not. The above study indicates that a conservative non-operative approach of chiropractic care prevented 60% from needless surgery. While a larger study would give us more information, based upon the outcomes, cost factors and potential increased risks of surgery, it was concluded that chiropractic is a viable, first line treatment option.
These studies along with many others conclude that a drug-free approach of chiropractic care is one of the best solutions for patients with surgical lumbar discs and sciatic pain. To find a qualified doctor of chiropractic near you go to the US Chiropractic Directory at www.USChiroDirectory.com and search your state.
1. Mayo Clinic Staff. (2010, April 22). Sciatica, Definition. MayoClinic.com, Retrieved from, http://www.mayoclinic.com/health/sciatica/DS00516
2. Mayo Clinic Staff. (2010, April 22). Sciatica, Symptoms. MayoClinic.com, Retrieved from http://www.mayoclinic.com/health/sciatica/DS00516/DSECTION=symptoms
3. Studin, M. (2010). Herniated discs, radiating pain and chiropractic. US Chiropractic Directory. Retrieved from http://www.uschirodirectory.com/index.php/patient-information/item/235-herniated-discs-radiating-pain-and-chiropractic
4. McMorland, G., Suter, E., Casha, S., du Plessis, S. J., & Hurlbert, R. J. (2010). Manipulation or microdiskectomy for sciatica? A prospective randomized clinical study. Journal of Manipulative and Physiological Therapeutics, 33 (8), 576-584
Back and Leg Pain (Lumbar Radiculopathy) as a Result of Disc Herniation and the Long Term Effect of Chiropractic Care
90% of all low back-lumbar disc herniation patients got better with chiropractic care
A report on the scientific literature
Mark Studin DC, FASBE (C), DAAPM, DAAMLP
The term "herniated disc" has been called many things from a slipped disc to a bulging disc. For a doctor who specializes in disc problems, the term is critical because it tells him/her how to create a prognosis and subsequent treatment plan for a patient. To clarify the disc issue, a herniated disc is where a disc tears and the internal material of the disc, called the nucleus pulposis, extends through that tear. It is always results from trauma or an accident. A bulging disc is a degenerative "wear and tear" phenomenon where the internal material or nucleus pulposis does not extend through the disc because there has been no tear, but the walls of the disc have been thinned from degeneration and the internal disc material creates pressure with thinned external walls. The disc itself "spreads out" or bulges.
There are various forms and degrees of disc issues, but the biggest concern of the specialist is whether nerves are being affected that can cause significant pain or other problems. The problem exists when the disc, as a result of a herniation or bulge, is touching or compressing those neurological elements, which is comprised of either the spinal cord, the nerve root (a nerve the extends from the spinal cord) or the covering of the nerves, called the thecal sac.
With regard to the structure that we have just discussed, the doctor must wonder what the herniation of the neurological element has caused. In this scenario, there are 2 possible problems, the spinal cord and nerve root. If the disc has compromised the spinal cord, it is called a myelopathy (my-e-lo-pathy). You have a compression of the spinal cord and problems with your arms or legs. An immediate visit to the neurosurgeon is warranted for a surgical consultation. The second problem is when the disc is effecting the spinal nerve root, called a radiculopathy. It is a very common problem. A doctor of chiropractic experienced in treating radiculopathy has to determine if there is enough room between the disc and the nerve in order to determine if a surgical consultation is warranted or if he/she can safely treat you. This is done by a thorough clinical examination and in many cases, an MRI is required to make a final diagnosis. Most patients do not need a surgical consultation and can be safely treated by an experienced chiropractor.
While herniations can occur anywhere, it was reported by Jordan, Konstanttinou, & O'Dowd (2009) that 95% occur in the lower back. "The highest prevalence is among people aged 30–50 years, with a male to female ratio of 2:1. In people aged 25–55 years, about 95% of herniated discs occur at the lower lumbar spine (L4/5 and L5/S1 level); disc herniation above this level is more common in people aged over 55 years" (http://clinicalevidence.bmj.com/ceweb/conditions/msd/1118/1118_background.jsp#incidence).
It was reported by Aspegren et al. (2009) that 80% of the chiropractic patients studied with both neck and low back (cervical and lumbar) disc herniations had a good clinical outcome with post-care visual analog scores under 2 [0 to 10 with 0 being no pain and 10 being the worst pain imaginable] and resolution of abnormal clinical examination findings. Anatomically, after repeat MRI scans, 63% of the patients studied revealed a reduced size or completely resorbed disc herniation. A study by Murphy, Hurwitz, and McGovern (2009) focused only on low back (lumbar) disc herniations and concluded that, "Nearly 90% of patients reported their outcome to be either 'excellent' or 'good'...clinically meaningful improvement in pain intensity was seen in 74% of patients (p. 729)." The researchers also concluded that the improvements from chiropractic care was maintained for 14 1/2 months, the length of the study, indicating this isn't a temporary, but a long-term solution. It was reported by BenEliyahu (1996) that 78% percent of the low back-lumbar disc herniation patients were able to return to work in their pre-disability occupations, which is the result of the 90% of all low back-lumbar disc herniation patients getting better with chiropractic care as discussed above.
These are the reasons that chiropractic has been, and needs to be, considered for the primary care for low back-lumbar disc herniations with resultant pain in the back or legs. This study along with many others concludes that a drug-free approach of chiropractic care is one of the best solutions for herniated discs and low back or leg pain. To find a qualified doctor of chiropractic near you go to the US Chiropractic Directory at www.USChiroDirectory.com and search your state.
1. Jordan, J., Konstanttinou, K., & O'Dowd, J. (2009, March 26). Herniated lumbar disc. Clinical Evidence. Retrieved from http://clinicalevidence.bmj.com/ceweb/conditions/msd/1118/1118_background.jsp#incidence
2. Aspegren, D., Enebo, B. A., Miller, M., White, L., Akuthota, V., Hyde, T. E., & Cox, J. M. (2009). Functional scores and subjective responses of injured workers with back or neck pain treated with chiropractic care in an integrative program: A retrospective analysis of 100 cases. Journal Manipulative Physiological Therapy 32(9), 765-771.
3. Murphy, D. R., Hurwitz, E. L., & McGovern, E. E. (2009). A nonsurgical approach to the management of patients with lumbar radiculopathy secondary to herniated disk: A prospective observational cohort study with follow-up. Journal Manipulative Physiological Therapy, (32)9, 723-733.
4. BenEliyahu, D. J. (1996). Magnetic resonance imaging and clinical follow-up: Study of 27 patients receiving chiropractic care for cervical and lumbar disc herniations. Journal Manipulative Physiological Therapy, 19(9), 597-606.
Cervical and Lumbar Disc Herniations and Chiropractic Care
A report on the scientific literature
80% of the chiropractic patients studied had good clinical outcomes
William J. Owens DC, DAAMLP
Mark Studin DC, FASBE (C), DAAPM, DAAMLP
Disc Herniations, Bulges, Sciatic Pain and Chiropractic
A report on the scientific literature
William J. Owens DC, DAAMLP
Mark Studin DC, FASBE (C), DAAPM, DAAMLP
The authors of a recent study state, “Acute back pain and sciatica are major causes of disability, with impairment of daily living activities” (Santilli, Beghi & Finucci, 2006, ). Pain that starts in the lower back and shoots down the leg is called sciatica. This is a very common and painful condition. The most common reason for pain down the leg is a bulge or a herniation of the soft disc between the bones of the spine. These are called intervertebral discs, sometimes referred to as a “slipped disc.”
This research paper reported on 102 cases of patients and stated, “Patients receiving active manipulations [chiropractic adjustment] enjoyed significantly greater relief of local and radiating [shooting] acute lower back pain, spent fewer days with moderate-to-severe and consumed fewer drugs for the control of pain” (Santilli, Beghi & Finucci, 2006, ). If you are suffering from lower back and leg pain, a doctor of chiropractic has the training and experience to determine whether the chiropractic adjustment can help you. Determining the exact CAUSE of your pain is the first step, treating it is the second. Chiropractic care has been shown to be effective in helping people with lower back and leg pain.
1. Santilli, V., Beghi, E., & Finucci, S. (2006). Chiropractic manipulation in the treatment of acute back pain and sciatica with disc protrusion: A randomized double-blind clinical trial of active and simulated spinal manipulations. The Spine Journal 6(2), 131-137.