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.
Cervical Disc Herniation with Radiculopathy (Arm Pain): Chiropractic Care vs. Injection Therapy
85.7% decrease in pain with spinal adjustments
25% decrease in pain with injection therapy
A report on the scientific literature
By: Mark Studin DC, FASBE(C), DAAPM, DAAMLP
Mark C. Zientek, DC DAAMLP, CHCQM
William J. Owens DC, DAAMLP
There is a large portion of the population who are dealing with various pain syndromes which includes neck pain from cervical disc herniations. According to Peterson, Schmid, Leemann, Anklin, and Humphreys (2013), this occurs in 83.2 out of every 100,000 people where symptoms range from mild to severe, but all negatively affect a person’s quality of life. To improve one’s quality of life, it becomes necessary to choose ways to manage and alleviate pain while reducing the side-effects of the actual treatment. Common methods range from simple masking of symptoms with over-the-counter medications to prescription opiates and invasive surgeries. Most people look for ways to manage pain and return to daily living activities without risky procedures and their inherent complications.
The use of over-the-counter medications and narcotics such as codeine and/or an oxycodone-acetaminophen combination like Percocet, is a common form of treatment by many primary care physicians and medical specialists alike. Kuehn (2013) reported:
The announcement comes after growing calls for the agency to tighten restrictions on the use of these drugs. In July 2012, Physicians for Responsible Opioid Prescribing (PROP), a group that includes prominent specialists in addiction, public health, emergency medicine, and pain medicine, petitioned the FDA to change the labeling for this class of drugs to discourage inappropriate use (Kuehn BM.. 2012;308:1194-1196). The group argued that the drugs’ indications were overly broad and not consistent with the evidence base and may have been facilitating marketing for broader use than was appropriate. Specifically, the group argued that the agency should drop moderate chronic non-cancer pain as an indication, set a maximum daily dose, and add a maximum duration of use of 90 days. (p. 1547).
The problem, as acknowledged by the FDA, is that the AMA and many in medical academia appear to concur with the addictive qualities of the medications. The alternative option is the chiropractic spinal adjustment and it has been concluded in scientific outcomes to be a superior avenue for the relief of pain and reduction of disability with few side effects.
The earlier discussed study by Peterson et al. (2013) has confirmed that spinal adjustments (manipulations) provide significant improvement for patients with neck pain from cervical herniated discs, as well as arm pain (cervical radiculopathy) without the inclusion of opiates or surgery. In addition, this improvement was seen at all times, particularly at 3 months. In addition, in this Swiss study, it was found that the presence of radiating arm pain (radiculopathy) was not a contraindication to chiropractic treatment nor was it a negative forecaster of outcomes.
This study also found that with cervical herniated discs with radiculopathy, 85.7% of the patients experiencing acute pain reported significant improvement by three months with no patients being worse. For the sub-acute patients, 76.2% reported significant improvement by three months with no patients being worse with their disability indexes which were reduced from the onset of chiropractic care.
Another form of treatment for neck and arm pain commonly used is cervical spinal injections. In the same study compares cervical injection provided a 25% reduction in patients’ symptoms. The results of this current study of spinal adjustment (manipulation) treatments had substantially better results with more than 85% of acute patients and 76% of sub-acute patient improving, with a 65% reduction in arm pain as well as 59% reduction in neck pain at three months.
Chiropractic is one of the safest treatments currently available in healthcare and when there is a treatment where the potential for benefits far outweighs any risk, it deserves serious consideration, particularly as a first line treatment. Whedon, Mackenzie, Phillips, and Lurie (2015) based their study on 6,669,603 subjects after the unqualified subjects had been removed from the study and accounted for 24,068,808 office visits. They concluded, “No mechanism by which SM [spinal manipulation] induces injury in normal healthy tissues has been identified” (Whedon et al., 2015, p. 265). One risk factor for chiropractic care is a disc herniation. A properly credentialed chiropractor who has been trained to differentially diagnose and appropriately triage the patient is clinically indicated in this population of patients. The chiropractor can engage in co-management with medical specialists.
To best serve patients, a clear understanding of the outcomes and risks of procedures becomes necessary. Further research into the efficacy of chiropractic manipulation provides a clearly safe and effective treatment to the above-referenced condition. Examination of the research provides insight of avenues for relief of symptoms upon which physicians can undoubtedly rely.
1. Peterson, C. K., Schmid, C., Leemann, S., Anklin, B., & Humphreys, B. K. (2013). Outcomes from magnetic resonance imaging–confirmed symptomatic cervical disk herniation patients treated with high-velocity, low-amplitude spinal manipulative therapy: A prospective cohort study with 3-month follow-up. Journal of Manipulative and Physiological Therapeutics, 36(8), 461-467
2. Kuehn, B. M. (2013). FDA tightens indications for using long-acting and extended-release opioids to treat chronic pain., 310(15), 1547-1548.
3. 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.