When seeking healthcare, patients consider and prefer a physician’s qualifications and reputation for technical ability over the physician's interpersonal skills.(1) When it comes to spinal manipulation for back and neck pain care, chiropractic is foremost in the public’s eye with about 22 million Americans visiting chiropractic physicians annually, and 7.7 million seeking back pain relief.(2) Chiropractic ranks ahead of all conventional treatments for back pain.(3) Spinal manipulation is recommended by the American Pain Society and the American College of Physicians for primary care of low-back pain.(4) A growing cause of low-back pain — lumbar spinal stenosis — responds well to chiropractic flexion distraction: Patients improve by 76 percent, and 73 percent of them report improvement in disability.(5) Whether treating a postsurgical patient who has continued pain — as in the case that follows — or a newly afflicted back or neck pain patient, chiropractic is poised to produce quality clinical results with evidence-based and research-documented protocols.
The interest of this case is the persistence of this patient to look for help after multiple interventions that produced poor results. The patient had laminectomy at L4-5 on the left 40 years ago and laminectomy at L3-4 on the right 20 years ago. She has had, by her estimate, 15 epidurals including four in 2011.
She saw a doctor of chiropractic (DC) at her winter home in Florida in 2011 for bilateral leg and back pain. Side-posture manipulation was given with increased pain. She then saw a different DC in Florida two months later and again had an adverse reaction to side-posture manipulation. She was able to ambulate, but her pain was markedly worse for over a week.
She presented to this office in July 2012 complaining of persistent lower back and bilateral leg pain that is worse on the right. Her right leg pain extends into the right hamstring and also into the right quad area. The right quad pain is what really stops her when she tries to walk very far. Sitting relieves her pain quickly unless she overdoes it. She confides that her goals are to be able to maintain her independence at her house. At this point, though, her pain is making it difficult for her to stay on her feet long enough to do this.
Lower extremity pulses were normal, no signs of swelling in either extremity. Blood pressure was 134/78, pulse 72, heart was in normal sinus rhythm. The patient rated her pain as 7/10 if she pushes herself to do too much. Sitting alleviates her pain. Supine, dorsiflexion and plantar flexion were 5/5. Quadriceps strength was 4/5 on the right and 5/5 on the left. Dermatomal exam was normal. She did exhibit a limp on right leg and a slight flexion antalgia.
A 2009 MRI study (See Figures 1 to 4) and a repeat 2010 MRI study reveal similar findings but with further stenotic narrowing of the right L3-4 IVF in 2010.
L4 degenerative spondylolisthesis with a broadbased pseudodisc protrusion. Bilateral facet degeneration and ligamentum flavum hypertrophy are present, more advanced on the right side, resulting in bilateral foraminal stenosis and probable L3 dorsal root ganglion and L4 nerve root compression. This is a site of previous laminectomy.
Right-sided large L3-L4 disc protrusion with sequestration causing marked foraminal stenosis compressing the exiting right L3 nerve root and L2 dorsal root ganglion. This is the site of previous laminectomy.
- Advanced L5-S1 disc degeneration.
The neurology of the case findings would be congruous with the patient’s clinical presentation of bilateral lower extremity pain involving the femoral and sciatic nerves.
Treatment and Outcome
The treatment plan was explained to the patient as follows. Following the Cox® Technic System of Care’s 50 percent Rule, she was seen every other day with the goal of 50 percent relief in 30 days. When 50 percent relief was noted objectively (ROM, Kemp’s, Dejerine Triad) and subjectively (Oswestry, VAS, Pain Drawing), the visit frequency was also reduced by 50 percent. Protocol 1 was applied until 50 percent relief of pain as well, then Protocol 2 was instituted.(6)
So for this patient, treatment began with Protocol 1 with a spinous contact at L3 only. Protocol 1 involves the use of distraction only to the specific segment: five 4-second pumps repeated three times for a total of 20 seconds. Between each set of distraction sessions, trigger point therapy is applied. We discussed the importance of tolerance testing prior to treatment and the need to inform us of any pain during treatment or any increase in pain after treatment. We also emphasized that the goal of treatment isn’t necessarily the cure of her back pain, but rather control. The realistic goal will be to decrease her pain by 50 percent and to increase her ability to be on her feet so that she is able to maintain her independence.
She was treated three times per week for the initial two weeks. After two weeks, she reported her right leg pain was reduced 50 percent. She rated her quadriceps pain as 3/10, and she was able to be on her feet working much longer than before the pain had begun. She was now doing her yard work again.
The patient had an exacerbation in the third week of left buttock and hamstring pain while trying to pull a hose to water her flowers. This settled quickly with two treatments. Her treatment was reduced to twice per week for two weeks.
At the one-month reexamination, she experiences no leg pain. She reports being able to do all her work again and that she has learned to sit and take a break if she starts to feel fatigue in her lower back. Her treatment plan is modified by extending her treatments to once per month with instructions to return sooner if any leg pain exacerbates.
Patients such as this lady represent 25 percent of back pain patients, who account for 95 percent of the cost in suffering and dollars in the population today.(7) Her postsurgical status is not uncommon in today’s back pain specialists’ practices. These postsurgical patients are going to be commonplace in chiropractic offices, and lumbar rolls are not going to serve this population. This case is not remarkable for the result, as many patients experience such relief from care by chiropractic physicians using the system of Cox® Technic. The case is fascinating because the patient was so desperate for help that she returned to chiropractic despite two prior disappointing experiences.
Millions of Americans have confidence in chiropractic care for back pain relief, and some, like this patient, will keep trying until they find the approach that works for them. With so many back surgeries performed each year, DCs will surely see more postsurgical spines months or years later. Armed with evidence-based protocols, chiropractic physicians have the confidence to take care of them.
1) Bible J, Harrison K, Shau D, O’Neill K, SegebarthP, Clinton J. What Patient Characteristics Could Potentially Affect Patient Satisfaction Scores During Spine Clinic? Spine 01 July 2015; 40(13):1039–1044.
2) “Chiropractic care for back pain.” www.webmd.com/painmanagement/guide/chiropractic-pain-relief, retrieved 8/25/15.
3) Which alternative treatments work? Consumer Reports Aug 2005;70:39-43.
4) Chou R et al. Interventional Therapies, Surgery, and Interdisciplinary Rehabilitation for Low Back Pain: An Evidence-Based Clinical Practice Guideline From the American Pain Society. Spine 2009 May 1;34(10):1066-77.
5) Murphy DR, Hurwitz EL, Gregory AA, Clary R. A non-surgical approach to the management of lumbar spinal stenosis: A prospective observational cohort study. BMC Musculoskeletal Disorders. 2006;7:16. doi:10.1186/1471-2474-7-16.
6) Cox JM: Low Back Pain: Mechanism, Diagnosis, Treatment (7thed.). Baltimore: Lippincott Williams and Wilkins, 2011, chapter 8, pgs 362-366.
7) Carey TS, Evans A, Hadler N, Kalsbeek W, McLaughlin C, Fryer J. Care-seeking among individuals with chronic low back pain. Spine. 1995 Feb 1;20(3):312-7.
Julie Cox-Cid is the coordinator for Cox. Technic and is available at (800) 441-5571, firstname.lastname@example.org;www.coxtechnic.com. The featured case report is by Kurt Olding, DC, a Cox. Technic certified physician practicing in Minster, Ohio, with radiological interpretation input from James M. Cox, DC, DACBR, FICC, FACO(H), Hon.D.Litt.
The realistic goal will be to decrease her pain by 50 percent and to increase her ability to be on her feet so that she is able to maintain her independence.