Case Report: Congruency is Key to Clinical Outcome: Long-Term Follow-Up (2009-2015) of a Patient With a 17mm L3-4 Disc Extrusion

Case Report: Congruency is Key to Clinical Outcome: Long-Term Follow-Up (2009-2015) of a Patient With a 17mm L3-4 Disc Extrusion

Tying Research to Clinical Application

Author: Sara Miller, DC/Friday, January 8, 2016/Categories: September 2015

Rate this article:

By Sara C. Miller, DC


There are congruent patients and non-congruent patients – those who accept long-term management without cure and respond to care well and those who do not accept this reality about their condition and respond to care less favorably.(1) There are simple back pain cases and complex cases – those due to a single issue and those with multiple spine pain issues. There are contained discs and non-contained discs – those that mechanically irritate only and those that chemically irritate as well. This case involves all of these factors over a six-year period and reveals a mostly congruent patient who chooses chiropractic as his mode of care.


A 52-year-old male presents on Sept. 8, 2009 with a chief complaint of right lower-back pain with radiating pain in the right anterior thigh down to the knee, which started 11 days prior while performing a deadlift in the gym. The pain is described as constant but variable, ranging from 1-10 out of 10 VAS and tends to be worse in the morning. Forward bending, standing, prolonged sitting, driving and walking aggravate the pain. His primary care physician reportedly diagnosed him with a “pulled muscle” and prescribed pain medications, which did not provide any relief. He reports constant numbness in the right anterior thigh down to the knee but denies any weakness in the lower extremities. He denies loss of bowel or bladder control and does not have any increased pain with coughing or sneezing. Thus far, he has missed one week of work. His job as a metal fabricator/welder requires him to perform heavy lifting and “lots of climbing” on large cranes, which at this time he states he is unable to do without severe pain.

Physical Examination

The patient is able to ambulate unassisted with no apparent gait disturbance. Blood pressure in the left arm in a seated posture was 170/100 mm/Hg, and he has not taken his anti-hypertensive medication for the past two days. Deep tendon reflexes in the lower extremities were +2/4 bilaterally. Motor strength in the lower extremities was +5/5 bilaterally. Lumbosacral spine active ROM testing increased his lower-back pain at end-range bilateral lateral flexion. Straight Leg Raise Test, Hibb’s Test and Patrick’s test were negative for increased lower-back pain. Yeoman’s Test was positive on the right for right-sided lower-back pain. Palpation revealed tenderness and hypertonicity at the quadratus lumborum muscles, right piriformis and lumbar erector spinae muscles. Motion palpation revealed decreased mobility and tenderness to palpation at the right sacroiliac joint. Restricted mobility was noted at L3-L4.

Initial Impression

Right sacroiliac joint dysfunction, right-sided L3 radiculopathy. Suspected L3-L4 disc protrusion.

Treatment Plan

Following the Cox® Technic System of protocols, the following care is instituted: gentle, prone spinal manipulation to the sacroiliac joint to improve joint mobility and reduce pain; Cox® Technic Flexion Distraction and Decompression Spinal Manipulation to increase the disc height, increase in L3-L4 foraminal area(2) and decrease the intradiscal pressure;(3) electric stimulation and cryotherapy as needed to help reduce pain and inflammation; massage therapy to reduce muscle spasm; and therapeutic exercise to increase lumbosacral stability. Home instructions include avoiding exercise at the gym and forward bending from the waist, using ice and taking breaks from prolonged sitting or standing.

The recommended treatment frequency involves Cox® Technic Protocol 1 at three visits per week until pain is reduced by 50 percent. Following the Rule of 50 percent, then, the treatment frequency will be re-evaluated and reduced by 50 percent, and Protocol 2 will begin. (Though published protocols indicate daily care for such a patient, he was unable to come in daily, initially, because of financial constraints.) If at any point he fails to respond favorably to treatment as expected, additional imaging may be ordered and referral for co-management and a possible surgical consult may be made. Additionally, he was advised to take his anti-hypertensive medication as prescribed.


After four treatments, the patient reported a 60 percent overall decrease in intensity and frequency of lower-back and right anterior thigh pain and stopped taking all pain medications as a result. After five treatments, he reported an overall 80 percent improvement.

At his seventh visit, he reported an exacerbation of symptoms after riding his motorcycle. This prompted ordering of a lumbar spine X-ray series to determine the extent of degenerative changes in the lumbar spine and to look for lateral stenosis to explain the right L3 radicular symptoms.

Treatments on September 23 and 25 relieved the exacerbated symptoms. On Sept. 28, 2009, he reported an exacerbation of right anterior thigh pain, of unknown cause. The pain was described as a constant 4/10. At this point, a lumbar spine MRI for additional information and neurosurgical referral co-management was considered.

Case Outcome

OCT. 5, 2009: He returned for care reporting a “huge improvement” in lower-back pain and right anterior thigh pain with a 70 to 80 percent improvement since onset of care.

OCT. 19, 2009: He saw a pain management physician who recommended that since he received marked improvement with chiropractic care and that he is neurologically intact, no further medical intervention at that time was needed.

OCT. 28, 2009: After three more visits, he reported 100 percent improvement of lower-back and thigh pain and a 90-percent improvement in anterior thigh paresthesia since onset of care. He then discontinued treatment for an unknown reason by failing to come to his next scheduled appointment. Attempts to reschedule him were unsuccessful.

Long-Term Follow-Up Outcome

APRIL 11, 2011: He was treated for the chief complaint of neck pain and a secondary complaint of an intermittent 2/10 midline lower-back pain after returning to the gym. Since his Oct. 28, 2009 visit, he states he has a slight numbness “every now and then” in his right anterior thigh but no lower-back pain. He continues his usual work duties without discomfort. He hunts and rides his motorcycle. His lower-back pain resolved after the April 11, 2011 visit that included Cox® Spinal Decompression Manipulation.

FEB. 14, 2012: He is seen following an eight-day history of 5/10 pain in the right low back and buttock with occasional numbness and tingling in the right anterior thigh. He reports he had been symptom-free since his last visit in April 2011; however he feels his work duties caused the recurrent pain. Two visits rendered him symptom-free, and he chose to schedule another appointment if the symptoms returned.

FEB. 26, 2013: He comes with a five day history of 7/10 left-sided lower-back pain without radiation. This pain began after lifting a heavy item at work. After seven treatments, he was symptom-free and agreed to schedule another appointment if the symptoms returned.

OCT. 11, 2013: He awoke with right-sided lower-back pain with right anterior thigh pain and paresthesia, again because of work duties. After six treatments, he was symptom-free.

JUNE 18, 2014: He is seen with a 5/10 VAS sacral base pain without radiation that began on June 2, 2014, after he was involved in a collision with an automobile while riding his motorcycle. After eight visits, his lower-back was symptom-free.

AUG. 28, 2014: He suffered an exacerbation, unknown cause, described as a right-sided lower-back pain with numbness and tingling in the right anterior thigh. After 10 treatments in four weeks, he reported that his lower-back and thigh discomfort was overall 50 to 60 percent improved, unless he had to walk more than 20 yards. Work changes were instituted to limit walking. Because of continued symptomatology, a repeat MRI of the lumbar spine was ordered.

DEC. 2, 2014: He reported that he was no longer having right anterior thigh numbness or tingling and that his lower-back pain was at least 80 percent improved. He declined an orthopedic referral indicating he was satisfied with his response to Cox® Technic and not interested in medications that could impair his ability to work or an injection due to concerns about potential serious side effects. He said he would schedule another appointment if he continued to have pain.

As of Feb. 10, 2015, he has not been back for treatment.

Closing Comment

This case presentation is not unusual for physicians. Note the further degenerative changes at the L4-L5 level from 2009 to 2014 with increased stenosis. To attain optimal clinical outcomes, patient congruency with suggested ergonomics, supportive and ongoing care with activity of daily living modifications is important, along with continued chiropractic care incorporating flexion distraction. For this patient and his physician, his desire for non-surgical, non-drug care of a complex set of spinal issues keeps him congruent to the extent that he keeps coming back for relieving chiropractic care after each re-injury.


  1. Cedraschi: The role of congruence between patient and therapist in chronic low back pain patients. JMPT 19(4):244-9.

  2. Gudavalli MR: Estimation of dimensional changes in the lumbar intervertebral foramen of lumbar spine during flexion distraction procedure. Proceedings of the 1994 International Conference on Spinal Manipulation. June 10-11, 1994, Palm Springs, Ca., p 81 and Gudavalli MR, Cox JM, Baker JA, Cramer GD, Patwardhan AG: Intervertebral disc pressure changes during a chiropractic procedure. Presentation and publication at the ASME IMECE 97 Bioengineering Convention, Nov. 16-21, 1997, Dallas, Texas. – Advances in Bioengineering 1999; BED, vol. 39, p 187-188

  3. Gudavalli MR, Cox JM, Baker JA, Cramer GD, Patwardhan AG: Intervertebral Disc Pressure Changes During a Chiropractic Procedure. Abstract from the Proceedings of the Bioengineering Conference, Phoenix, 1999.

Julie Cox-Cid is a coordinator for Cox® Technic and available at 800-441-5571,; The featured case report is by Sara C. Miller, DC, a Cox® Technic certi ed physician practicing in Chesapeake, VA.


Number of views (1224)/Comments (0)

Please login or register to post comments.