Efficacy of Chiropractic Treatment for Post-Surgical Continued Low Back and Radicular Pain


81% of chiropractic post-surgical patients showed greater than 50% reduction in pain.


Mark Studin DC

William J. Owens DC


A report on the scientific literature


Park et. Al (2016) reported that low back pain radiating into the lower extremities have greater impact on disability and time off work that any other medical condition. Vleggeert-Lankamp, Arts and Jacobs (2013) reported “The term ‘failed back surgery syndrome’ (FBSS) is used to describe a clinical condition defined by persistent or recurrent complaints of leg pain and/or back pain regardless of one or more surgical procedures of the lumbar spine. The definition of FBSS (failed back surgery syndrome) is modified by some authors by adding that at least one surgical intervention was to be performed and that pain should persist after the last surgical intervention, for at least one year.1 The term implies that the surgery plays a role in the cause of the pain, although in most cases the surgical intervention was technically successful. It is known that nearly 20% of patients undergoing spine surgery will require secondary surgery for persistent pain or surgery-related complications during the subsequent years.” (pg. 48) El-Badawy and El Mikkawy (2016) reported that failed back surgery syndrome occurs with lateral disc surgery upwards of 17%, spinal stenosis 29% and instability 14.8%.


Perhaps the reason for failed back surgery syndrome is what the surgeons have considered their “gold standard, fusion and the ensuing loss of mobility of the spinal motor unit. Mulholland (2008) reported “Spinal fusion became what has been termed the “gold standard” for the treatment of mechanical low back pain, yet there was no scientific basis for this.” (pg. 619) The history of spinal fusion is both fascinating and disturbing and reveals why chiropractic both helps post-surgical cases and should always be considered first, prior to surgery as an option.

Mulholland (2008) continued:

In 1962 Harmon presented a review paper at the western orthopaedic association meeting in San Francisco, in which the term “Instability” appears.

However, Harmon’s description of what he meant by instability (unfortunately in a footnote) is revealing “Spinal instability refers to a low back-gluteal-thigh clinical triad of symptoms that may be accompanied (overt cases) by incapacitating regional weakness and pain. This is the effect of disk degeneration with or without disc hernia. Some may be asymptomatic or slightly symptomatic when instability is compensated by muscle or ligament control. It does not refer to spinous process or laminal hypermobility which some surgeons like to demonstrate at the operating table nor does this clinical concept parallel the common spinal hypermobility, which is the product of intervertebral disc degeneration, demonstrable in flexion-extension filming of the region, since the anatomic hypermobility is not always productive of symptoms”

Sadly this description of instability appears to have been ignored, and the concept of mechanical instability as a cause of back pain was progressively accepted. Harmon’s view of the effect of fusion was that it cured pain by reducing the irritation of the neural contents produced by movement. His paper was influential as he emphasized the importance of appropriate investigations prior to fusion and the segmental nature of back pain but unfortunately his use of the term instability was interpreted as supporting the view that segmental abnormal movement was the cause of the pain.

In 1965 Newman in an editorial concerning lumbo-sacral arthrodesis (surgical immobilization) refers to the need to stabilize the lumbar spine in patients with back pain after discectomy for a lumbar root entrapment.

At the beginning of the seventies the perception was that disc degeneration led to abnormal translational movement, and this was painful.

McNab in 1971 who had done much work on the disturbance of movement in the degenerate disc described what he termed the “traction spur,” a particular type of anterior osteophytes which he said was related to an abnormal pattern of translational movement. This view again supported the concept of instability. He added the important caveat that it “was impossible to establish the clinical significance of the traction spur as a statistically valid investigation the traction spur was revisited in the late eighties and was shown to be no different to claw osteophytes, and often both would be present in the same patient. It was not related to abnormal movement.”

Although McNab used the term instability, he used it in the sense that the spine was vulnerable to acute episodes of pain, because the degenerate disc rendered it more easily injured. He did not view it as a cause of chronic back pain.

Kirkaldy Willis set out his views on instability in 1982. In “Instability of the Lumbar Spine” he described the process of disc degeneration as passing through a stage of dysfunction, (intermittent pain), instability which caused more persistent pain but then with time stabilizing to a painless state. This was his explanation for the observed fact that many very degenerate discs were painless. However, he at that stage was somewhat unhappy with an entirely mechanistic view for pain. Hence, he writes “Instability can be defined as the clinical status of the patient with a back problem who with the least provocation steps from the mildly symptomatic to a severe episode”. Further he writes “Detectable increased motion does not always solicit a clinical response, and that abnormal motion may be abnormal increase or abnormal decrease”. He further writes “It is insufficient to detect the abnormal increased motion, but the mechanism by which it precipitates the symptomatic episode must also be identified”. Indeed in the seven cases he reported only one patient had backache alone, the others were all radicular problems. His paper shows that identifying abnormal movement establishes the fact that the segment is disordered, but he does not in that paper indicate that movement itself is the cause of pain.

Subsequently in his very influential book “Managing Back Pain” in 259 pages just one page is devoted to the rationale of lumbar fusion. The only reason for fusion appeared to be that, other treatments had failed, that it was reasonable from the psychological viewpoint, and that instability was present. Instability is defined elsewhere in the book as increased abnormal movement, and this is illustrated by x-rays purporting to show abnormal rotations and various types of abnormal tilt. He accepts that such appearances may be entirely painless, but in the patient with back pain they identify the causative level, and fusion is justified.

However, in a joint paper with Depuis in 1985 entitled “Radiological Diagnosis of Degenerative Lumbar instability” they write “A lumbar motion segment is considered unstable when it exhibits abnormal movements. The movement is abnormal in quality (abnormal coupling patterns) or in quality (abnormal increase of movement...) Pain is a signal of impending or actual tissue damage-and when present it indicates that a mechanical threshold has been reached or transgressed. Repeated transgressions will damage the stabilizing structures beyond physiological repair, thus putting abnormal demands on secondary restraints”.

Hence from being a method of identifying an abnormal degenerate disc, abnormal motion itself became the injurious agent.

In 1985 Pope and Panjabi in a paper entitled “Biomechanical definition of spinal instability” wrote “Instability is a mechanical entity and an unstable spine is one that is not in an optimal state of equilibrium. (...In the spine stability is affected by restraining structures that if damaged or lax will lead to altered equilibrium and thus instability. Instability is defined as a loss of stiffness”. Panjabi’s views were generally accepted by basic scientists interested in this field.

Subsequently Panjabi concluded that increased movement was not necessarily a feature of what he termed instability, but reduction in the neutral zone was. However, in a more recent paper he has abandoned the concept of instability altogether and ascribes chronic back pain as being caused by ligament sub-failure injuries leading to muscle control dysfunction.

However, throughout the period from the fifties to the nineties, the Panjabi view held sway, and the term instability evolved from being a useful term to denote a segment that was abnormal due to a degenerate disc, to a term denoting a diagnosis of an abnormal, (usually increased) pattern of movement with a translational component. The abnormal movement was thought to be the cause of the pain and clearly fusion or stopping movement was a logical treatment.

However, the inability to show that abnormal or increased movement was a feature peculiar to the painful degenerate disc, combined with the fact that despite more rigid fusions using pedicle fixation, the clinical results of fusion had not improved, was increasingly casting doubt on the concept of instability. The paper by Murata combining MRI examination with flexion and extension films in patients with back pain, showed that increased angular and translational movement was a feature of the normal or mildly degenerate disc, not of the markedly degenerate disc, where movements were reduced. In 1998 Kaigle et al. demonstrated that comparing patients with normal subjects there was always less movement present in the degenerate spine. It was therefore generally accepted that the effect of disc degeneration was to reduce movement not to increase it, as the term “instability” would imply. It may be argued that, unfortunately, this reduction of movement is associated with abnormal patterns of movement, and this is the meaning of “instability”. However despite considerable efforts over many years, using flexion/extension films, no clear relationship has been established between pain and such abnormal movements. In other words, patients with degenerative disc disease may exhibit abnormal patterns of movement yet have no pain.

By the mid-nineties, instability was still the term used to describe the disorder that we treated by fusion, but the failure to improve results by the introduction of pedicle fixation, caused many surgeons to question the concept of instability, but surgeons were all aware that fusion although unpredictable in terms of clinical result, was the best surgical treatment for chronic low back pain. It was well recognized that clinical success was unrelated to the success of the fusion, pseudarthrosis was as common amongst successful patients as in those who had failed. Was there anything else that a fusion did to the intervertebral disc unrelated to the fact that it stopped movement? (pgs. 619-623)

Mulholland (2008) concluded with a powerful statement that perhaps sums up why chiropractic realizes significant result when treating post-surgical cases.

Abnormal movement of a degenerated segment may be associated with back pain but is not causative. The concept of instability as a cause of back pain is a myth. The clinical results of any procedure that allows abnormal disc loading to continue are unpredictable. (pg. 624)

To underscore the point of fusion being a failed surgical paradigm in many patients, Gudavalli, Olding, Joachim, & Cox (2016) reported,

Surgical decompression of the lumbar spine in older patients had a 24% reoperation rate, and a 20-fold increase in lumbar surgical fusion rates among Medicare enrollees is reported. Lumbar cage fusion rates increased from 3.6% in 1996 to 58% in 2001, and the result was increased complication risk without improved disability or reoperation rates. Adjacent segment degenerative changes and instability at the level immediately above single-segment fusion with clinical deterioration are shown in up to 90% of the cases. The incidence of radiographic adjacent segment disease following fusion has been reported to be as high as 50% in the cervical spine and 70% in the lumbar spine at 10 years. However, the incidence of clinically relevant symptomatic adjacent segment disease is quite lower, estimated at 25% in the cervical spine and 36% in the lumbar spine at 10 years.


Comparing surgery with nonsurgical treatment for back and radicular pain shows that intensive rehabilitation is more effective than fusion surgery, and nonsurgical treatment of low back and radicular pain patients is reported to reduce lumbar disk surgery by approximately two-thirds. Chronic low back pain in 349 patients aged 18-55 years found no evidence that surgery was any more beneficial than intensive rehabilitation. A study of 600 single-operated low back patients showed that 71% did not return to work 4 years after surgery, and 400 multiple-operated backs showed that 95% did not return to work 4 years later. (pg. 124)


Gudavalli, Olding, Joachim, & Cox (2016) went on to report what has been found clinically effective in both pre and post-operative cases, "Treating lumbar disk herniation and spinal stenosis patients successfully with conservative care is documented. Chiropractic manipulation prior to spine surgery is appropriate. Previous reports of the biomechanical changes in the spine when CTFD (Cox technique, flexion-traction) spinal manipulation is applied include decreased intradiscal pressure; intervertebral disk foraminal area increase; increased intervertebral disk space height; and physiological range of motion of the facet joint." (pg. 124)


Regarding post-surgical care, Gudavalli, Olding, Joachim, & Cox (2016) concluded,


81% of the (post-surgical chiropractic) patients showed greater than 50% reduction in pain levels at the end of the last treatment. At 24-month follow-up, 78.6% had continued pain relief of greater than 50%. (pg. 121)


Although one of the goals of chiropractic care is pain relief, there are still the underlying biomechanical pathologies to consider that are concurrently treated while under chiropractic care. The more pressing issue in the post-surgical cases are “could these surgeries been avoided” in the first place with correcting the underlying biomechanical pathologies prior to surgery This underscores the overwhelming need for chiropractic as Primary Spine Care providers being the first treatment option. It goes back to the adage “drugless first, drugs seconds and surgery last.” It’s just common sense and chiropractic has been verified in numerous outcome studies proven to be the most effective 1st treatment option for spine.





  1. Park, K. B., Shin, J. S., Lee, J., Lee, Y. J., Kim, M. R., Lee, J. H., ... & Ha, I. H. (2017). Minimum clinically important difference and substantial clinical benefit in pain, functional, and quality of life scales in failed back surgery syndrome patients. Spine42(8), E474-E481.
  2. Vleggeert-Lankamp, C. L., Arts, M. P., Jacobs, W. C., & Peul, W. C. (2013). Failed back (surgery) syndrome: time for a paradigm shift. British journal of pain7(1), 48-55.
  3. El-Badawy, M. A., & El Mikkawy, D. M. (2016). Sympathetic dysfunction in patients with chronic low back pain and failed back surgery syndrome. The Clinical journal of pain32(3), 226-231.
  4. Mulholland, R. C. (2008). The myth of lumbar instability: the importance of abnormal loading as a cause of low back pain. European spine journal17(5), 619-
  5. Gudavalli, M. R., Olding, K., Joachim, G., & Cox, J. M. (2016). Chiropractic distraction spinal manipulation on postsurgical continued low back and radicular pain patients: a retrospective case series. Journal of chiropractic medicine15(2), 121-128.

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Published in Low Back Problems

Chiropractic Outcome Studies on Treatment of Fragmented/Sequestered and Extruded Herniated Discs and Radicular Pain


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





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.



  1. Fardon, D. F., Williams, A. L., Dohring, E. J., Murtagh, F. R., Gabriel Rothman, S. L., & Sze, G. K. (2014). 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. Spine, 39(24), E1448-E1465.
  1. Leeman S., Peterson C., Schmid C., Anklin B., Humphryes B., (2014) Outcomes of Acute and Chronic Patients with Magnetic Resonance Imaging-Confirmed Symptomatic Lumbar Disc 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
  2. McMorland, G., Suter, E., Casha, S., du Plessis, S. J., & Hurlbert, R. J. (2010). Manipulation or microdiscectomy for sciatica? A prospective randomized clinical study. Journal of Manipulative and Physiological Therapeutics, 33 (8) 576-584
  3. Ehrler M., Peterson C., Leeman S., Schmid C., Anklin B., Humphreys B. K., (2016) Symptomatic, MRI Confirmed, Lumbar Disc Herniations: A Comparison of Outcomes Depending on the Type and Anatomical Axial Location of the Hernia in Patients Treated with High-Velocity, Low-Amplitude Spinal Manipulation, Journal of Manipulative and Physiological Therapeutics, 39 (3) 192-199
  4. Whedon, J. M., Mackenzie, T. A., Phillips, R. B., & Lurie, J. D. (2015). Risk of traumatic injury associated with chiropractic spinal manipulation in Medicare Part B beneficiaries aged 66-69 years. Spine, 40(4), 264-270

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Published in Low Back Problems

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


  • Significant degenerative changes throughout the lumbar spine including multi-level degenerative disc changes at all levels.
  • Transverse Annular Fissures at L1-2 (17.3 mm), L2-3 (29.5 mm), L4-5 (14.3 mm) and L5-S1 (30.8 mm) and broad based disc bulging at all levels except L5-S1.    The fissures at L2-3 and L5-S1 both have radial components extends through to the vertebral endplate.    
  • Facet osteoarthritic changes and facet effusions at all levels.  
  • Grade II spondylitic spondylolisthesis is confirmed at L5-S1 with severe narrowing of the right neural foramen compressing the right exiting L5 nerve root.
  • Degenerative retrolisthesis at L1-2.
  • Modic Type II changes at L2 inferior endplate, L3 superior endplate, L4 inferior endplate and L5 inferior endplate.2
  • There is a 18.9 mm wide Schmorl’s node at the superior endplate of L3.  
  • There is a 5.7 mm wide focal protrusion type disc herniation at L4-5 which impinges on the thecal sac.  



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














r. lateral flexion




l. lateral flexion

















r. lateral flexion




l. lateral flexion




r. rotation




l. rotation




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.



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



wobble chair

Loading and unloading cycles applied to injured soft tissues and


neck traction

speeds up & improves remodeling of injured tissue as well as rehydrates dehydrated vertebral discs.5  



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



Decrease inflammation through vasoconstriction



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.  



  1. Kirkaldy-Willis, W.H, Wedge JH, Young-Hing K.J.R. Pathology and pathogenesis of lumbar spondylosis and stenosis.  Spine 1978; 3: 319-328
  2. http://radiopaedia.org/articles/modic-type-endplate-changes
  3. David F. Fardon, MD, Alan L. Williams, MD, Edward J. Dohring, MD. Lumbar disc nomenclature: version 2.0 Recommendations of the combined task forces of the North American Spine Society, the American Society of Spine Radiology and the American Society of Neuroradiology. The Spine Journal 14 (2014) 2525–2545
  4. Low Level Laser Therapy to Reduce Chronic Pain:  https://clinicaltrials.gov/ct2/show/NCT00929773?term=Erchonia&rank=8
  5. https://pettibonsystem.com/blogentry/need-two-types-traction
  6. Shealy CM, Decompression, Reduction and Stabilization of the Lumbar Spine: A cost effective treatment for lumbosacral pain.   Pain management 1955, pg 263-265
  7. Shealy, CM, New Concepts of Back Pain Management, Decompression, Reduction and Stabilization.   Pain Management, a Practical guide for Clinicians.  Boca Raton, St. Lucie Press: 1993 pg 239-251
  8. https://pettibonsystem.com/about/how-pettibon-works
  9. Bland, John MD, Disorders of the Cervical Spine WB Saunders Company, 1987 pg 84

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Published in Case Reports