Seeing a free fragment on MRI may be disconcerting, but research supports conservative care when progressive neurological deficits aren’t in play. Researchers write that free fragments absorb and decrease in size more than protruding discs,1 migration of the fragment results in greater size reduction,(1) non-operative care shrinks free fragments 50 percent to 100 percent,(2) sequestered disc material resorbs better than contained disc,(3) and conservative care brings resolution of sequestered discs in a majority of cases.(3) This case exemplifies how these published findings play out in the clinical practice of a physician not intimidated by such challenging conditions.
This case involves a 46-year-old cook who was seen on May 20, 2014, for the chief complaint of low-back pain, referring into her right groin and hip area. She rated the pain at a 10 on a visual analog scale (VAS) of 0 to 10. The pain started four days earlier while she was getting into bed. It worsened considerably the next morning, and she proceeded to go to the emergency room because of the severity. A steroid shot and Medrol Dosepack were prescribed. The medications helped very little. She slept only two hours per night because of the pain and could not sit for longer than a few minutes. She had weakness in her right leg ascending stairs and could not work due to the pain.
History revealed hypothyroidism, acid reflux and scoliosis.
Her mother has osteoporosis, and her father died of cystic kidney disease.
She was oriented x 3, alert and could not sit or move without reproduction of her pain.
The patient saw her family doctor, who ordered an MRI and referred her to an orthopedic surgeon. The appointment was scheduled for July 2, 2014. Her family doctor told her to feel free to go to her chiropractic physician until her appointment.
Examination on May 20, 2014 revealed exquisitely positive Kemp’s test on the right. SLR was negative sitting and lying. Valsalva reproduced chief complaint. Modified slump test for neuro-meningeal tract tension was negative. The deep tendon reflexes in the knee and ankle were 2+ and the toes were down going. Patient could toe and heel walk normally. Postural exam exhibited a right elevated hemipelvis and a moderate left lumbar convexity and a compensatory right thoracic spine convexity. Pain on palpation was noted with myospasm in the right lumbar paraspinal area from L1-4 and laterally 3-4 inches. Ranges of motion of the thoraco-lumbar spine were 10 degrees of extension, 40 degrees of flexion, 10 degrees right lateral flexion and 20 degrees left lateral flexion. Sensory examination of the lower extremities was within normal limits. Patrick’s test on the right hip was unremarkable. Muscle strength testing of the lower extremities revealed grade 5 of 5 strengths inversion/eversion, plantarflexion/dorsiflexion, tibialis anterior, gluteus maximus, biceps femoris and quadriceps muscles. Prone knee flexion, Nachlas, Yeoman and Ely tests were within normal limits.
Central to right paracentral L2-3 disk extrusion with caudad migration of a sequestered fragment. Central canal stenosis at L1-2 and L2-3. Left lumbar scoliosis of 26 degrees. Multilevel degenerative disc disease.
The treatment goals were to abate the groin/leg/hip pain, enable sitting and sleeping, restore right leg strength and return her to work in a timely period. In addition, we would reduce disc extrusion and spinal stenosis utilizing Cox. Technic flexion distraction and decompression manipulation. Therapeutic modalities utilized were electrical stimulation with ultrasound, Active Release Technique (ART) soft-tissue management system to release any adhesions, myofascial restrictions and nerve entrapments. The thoraco-lumbar erector spinae, quadratus lumborum and psoas were the main focus with ART.
Further care included establishment of a home exercise program utilizing Cox. Exercises to strengthen spinal musculature (multifidi) and improve biomechanics/ endurance/flexibility to the spine, ice and gradual increase in functional activities. MRI was ordered for June 5, 2014. Discat Plus with chondroitin sulfate and glucosamine sulfate for disc nutrition was prescribed. She was seen three times per week and was told if improvement wasn’t at least 50 percent after four to six weeks, we would move up her neurosurgical appointment currently set for July 2, 2014.
Following four visits, her right groin pain was totally relieved. Her sleep improved, and the right low-back pain had focalized to the paraspinal area and superior to the iliac crest. After four weeks and nine visits, she was able to walk stairs without pain, her VAS decreased 50 percent to 75 percent, and she returned to full work status.
She did keep her neurosurgical appointment, and the MD told her she was doing well considering her MRI, and he didn’t need to see her back unless her leg pain became constant.
After two months of care, the patient’s VAS was a 1 with occasional pain from bending/lifting/twisting (BLT) at work. She is still being advised on weight loss, core strengthening exercises and cardiovascular exercise. She returns monthly for treatment and tells me that the Cox. treatments keep her back pain from going above a 1 or 2 on the VAS scale.
Due to the patient’s moderate scoliosis, multilevel disc desiccation, degenerative facet joint changes and central canal stenosis, her occupation is very challenging. Fortunately, utilizing the Cox. Decompression Technique system has improved her quality of life and enabled her to continue working at a high physical level without severe pain. My feeling is that if she had been seen by a surgeon in her acute state, she would have been a likely candidate for immediate surgical intervention.
Julie Cox-Cid is coordinator for Cox® Technic and available at 800-441-5571, firstname.lastname@example.org
The featured case report is by Keith Bartley, DC, a Cox® Technic certified physician practicing in Jasper, Ind.
Sequestered discs are a challenge, combined with comorbidities as in this patient case, but a chiropractic treatment plan involving the multipronged approach brought about, and continues to deliver, relief for this patient.
1) Komori H. The natural history of herniated nucleus pulposus with radiculopathy. Spine
2) Saal JA, Saal JS, Herzog RJ. The natural history of lumbar intervertebral disc extrusions treated nonoperatively. Spine
3) McCall IW. Lumbar herniated disks. Radiol Clin North Am