Management of a Chronic Lumbar Disk Herniation with Chiropractic Biophysics Methods After Failed Chiropractic Manipulative Intervention

Case Report 

A 23-year-old woman, 5′6″ (167.6 cm) tall and weighing 120 lbs (54.6 kg), had an insidious onset of lower back and left-leg pain that began approximately 6 years before seeing the author (G.P.). She described the pain as constant in her left lower back, with pain and tingling down the posterior left leg to the lateral aspect of her left foot. The pain was aggravated by sitting and by lying down and she remarked that it, “feels like my leg is being squeezed.” The patient was a preschool teacher and had to lift small children on occasion, an activity that aggravated her pain. Her symptoms were worsened by sitting for prolonged periods and increased at night to the point that it interfered with normal sleep. She occasionally self-medicated with over-the-counter nonsteroidal antiinflammatory drugs with short-term relief.

There was no history of trauma and she did not recall a specific date of onset. The pain continued to worsen for about 1 year, leading her to seek treatment at a private chiropractic office approximately 5 years before her first visit at our clinic. Records from this office were not available. Based on the patient's recall, it was determined that she sought evaluation and treatment from a local private chiropractor in December 1996. The patient indicated that the chiropractor told her she had a vertebra “out of place” in her lower back and that the treatment would “put it back.” She stated that the treatment consisted of side-posture roll-type manipulations of her lower back and pelvis as well as general manipulations of her upper back and neck.

She denied receiving any other supportive or physical therapy treatment during her first course of chiropractic care. At her previous chiropractor, she was treated 3 times a week for the first month, 2 times a week for 1 month, and 1 time a week for 1 month. She indicated that she had no relief of her symptoms during this course of care but continued her treatment in hopes that she would improve. The doctor encouraged her to continue care during this regimen. In February 1997, the patient was informed by her treating chiropractor that he had done all that he could do, and she was released from his care.

The patient's conditioned worsened throughout that year and she sought a medical orthopedic consultation in December 1998. The medical records provided by the patient indicated a magnetic resonance imaging study of the lumbar spine and a nerve-conduction velocity test of the lower extremities were performed. The magnetic resonance imaging study showed disk degeneration and a moderately sized central disk herniation at the L5/S1 level. The result of the nerve-conduction velocity test was negative. The patient was advised that surgery was not indicated and was given no treatment options.

At this clinic, on July 27, 2001, the patient's lower back pain was rated 5 on a 10-point numerical rating scale (NRS) (0 = bedridden, 10 = no symptoms) with the leg pain rated the same. Objectively, there was restriction of thoracolumbar range of motion in extension and left rotation with pain on motion. Sitting straight-leg raise test was positive on the left for back and leg pain; however, Lasegue's (supine straight-leg raise) was negative. Deep tendon reflexes were slightly diminished for the left patellar and Achilles' reflexes. The patient reported a weakness in her left lower extremity but her muscles tested normal. Palpable tenderness was elicited at the L4 and L5 spinous processes with mild myospasm noted on the right lumbar paravertebral region. All other tests were within normal limits.

Postural evaluation showed a left rotated pelvis in relation to the feet (+Ryp), a right thoracic translation in relation to the pelvis (−Txt), and a right lateral flexion of the thorax in relation to the pelvis (+Rzt) with an anterior head (+Tzh) and an anterior pelvis (+Tzp).

Using the chiropractic biophysics (CBP) technique radiographic protocol, the following radiographic views were obtained: lateral lumbar, anterior-posterior lumbar, and anterior-posterior Ferguson's. Evaluation of the plain films showed a mild lumbar levoscoliosis with mild degeneration of the L5/S1 disk space. Using the posterior tangent method, which has high reliability and small absolute differences of observers' measurements,14., 18. segmental angles were calculated for T12-L1, L1-L2, L2-L3, L3-L4, L4-L5, and L5-S1. Total lordosis between L1-L5 (ARA) was determined to be approximately 2 standard deviations below normal (25° compared with 40°).19 The sacral base to horizontal was measured. There was a retrolisthesis of L5 on S1, which was less than 25%, at the level of the disk herniation. An angle of pelvic tilt was determined as the angle between horizontal and a line from posterior-inferior S1 to the superior margin of the acetabulum. A negative sign was used to designate extension or lordosis and a positive value for flexion or kyphosis. Lastly, a measurement of sagittal translation was performed by comparing the horizontal displacement of the posterior inferior body corner of T12 to a vertical line originating at the posterior inferior of S1. Anterior translation of T12 was designated as positive whereas posterior translation was designated as negative. All radiographic measurements are reported in Table 1.

Table 1. Lateral lumbar radiographic measurements for initial and 3 follow-up radiographic examinations by using the Harrison posterior tangent radiographic method

	Levels	Normals19	Radiograph by Date	Radiograph by Date	Radiograph by Date	Radiograph by Date
			7/27/01	10/11/01	11/09/01	12/17/01
	Tz (T12-S1)	0 mm	−21	0	+2	0
	RRA T12-L1	0	0	0	0	0
	RRA L1-L2	2.9	0	2	0	2
	RRA L2-L3	7.4	3	4	4	6
	RRA L3-L4	11.9	9	10	11	11
	RRA L4-L5	16.6	13	19	20	17
	RRA L5-S1	32.4	42	32	34	28
	ARA (L1-L5)	39.7	25	33	35	36
	Ferguson*	39.2	37	37	37	37
	Arcuate†	48.9	51	50	51	50

ARA, total curve angle formed by posterior vertebral body tangents on L1 and L5; RRA, segmental angle formed by posterior vertebral body tangents; Tz, absolute value of differences in horizontal distance (mm) of T12 posterior-inferior body corner to posterior-inferior of S1.

* Sacral base angle compared to horizontal. † Arcuate angle from posterior S1 to top of acetabulum to horizontal (pelvic tilt).

The main intervention in this case involved the use of a new method of lumbar traction by using a 3-point bending design as developed by D.E. Harrison (Littlefield Distribution, Alhambra, Calif).20 For this traction (Fig 1), the patient is placed supine, with an anterior pull applied between the upper torso and the lower pelvis by means of a posterior padded strap at the level of the greatest deviation of the patient's lumbar spine from the normal lumbar elliptical curve.19 If the pelvic sagittal plane rotation angle is decreased, a second strap to allow pelvic forward rotation is applied just caudal to the level of the femur heads and attached to the table to provide a component of the traction force with the weight of the patient's upper torso providing the other posterior force. Tension is afforded by increasing the anterior pull by means of a winch attached to the traction device. Pressure is applied to patient tolerance with an increase of pressure and duration of traction over time. Harrison et al20 recommend a patient start at 3 minutes of traction duration at maximum tolerated pressure and increase the time until he/she reaches 20 minutes per session.

View Large Image Download to PowerPoint

Fig 1. Harrison extension lumbar traction. The patient is positioned in a form of 3-point bending. The weight of the upper torso is posterior, and the lumbar traction strap, while positioned just above the iliac crests, is pulling anterior, and a strap is placed around the femur head area to hold this area posterior. This allows the pelvis to flex forward when traction force is applied to the anterior strap. If the pelvis is already in forward flexion as a radiographic finding, then the pelvic strap is placed around the anterior superior iliac spines to eliminate pelvic flexion. If the sagittal balance of T12 is posterior to S1, then Harrison recommends a foam block be placed under the thoracic cage to translate this area anteriorly. The amount of tension in the anterior strap is varied to patient tolerance.

CBP technique adjustment intervention consisted of the application of mirror-image chiropractic adjustments with the intent of reversing abnormal postures (global subluxations) by using drop-table maneuvers.17., 21. The patient had 36 visits at a 3 to 4 visit a week frequency with visits consisting of mirror-image adjustments and lumbar traction. The traction time started with 5 minutes' duration and increased incrementally, based on the patient's tolerance, to 16 minutes duration at the time of her first radiograph reevaluation.

This radiograph reevaluation revealed an ARA L1-L5 of 33° and a reduction in the translated thorax to 0.0 mm (Table 1). Physical examination at this follow-up showed a NRS of 8 with sitting straight leg raise test being negative and only mild tenderness at the L5-S1 area.

This patient was prescribed postural exercises that were to be performed at home. These exercises were designed to improve strength and flexibility and to reduce postural distortions through neuromuscular reeducation.17., 21., 22. These exercises are termed mirror image and have been advocated by Harrison since the early 1980s. Global abnormal postures were ascertained by examination, and the patient was instructed in proper mirror-image exercise protocols that were to be performed several times a day with increasing repetitions and intensity through her course of care.

The patient continued care at the same frequency for 16 more visits with the same protocols; the duration of traction progressed to 18 minutes. She was reexamined on November 9, 2001, and the lateral lumbar radiograph showed an ARA of 35° with sagittal displacement of T-12 at +2.0 mm. Her NRS score was rated at 9, and the patient complained of only occasional discomfort in her back and leg.

The patient elected to continue care and was seen for an additional 17 visits, with adjustment and traction protocols remaining consistent. Traction duration during this time remained consistent at 18 minutes per session. A follow-up radiograph on December 17, 2001, showed a slight improvement of the ARA to 36° with sagittal displacement of T-12 compared with S-1 at 0.0 mm (Fig 2B).

View Large Image Download to PowerPoint

Fig 2. Initial and follow-up lateral lumbar radiographs. Pre-treatment (A) and follow-up (B) radiographs of a woman (23 yrs, 167.6 cm tall, 54.6 kg in weight) with initial hypolordosis in the lumbar spine. Lines are drawn on the posterior body margins as visual aids. In actual practice, these posterior vertebral body lines are extended and segmental angles are measured. The normal ellipse,19 drawn from posterior-superior S1 to the height of T12, is used as a guideline to compare with the posterior vertebral body margins. Note that 3-point bending traction has increased the ARA angle between L1 and L5 (deeper lordosis) and that the sagittal balance of T12 above S1 has improved on the follow-up radiograph (B). This subject had chronic lower back pain with an initial NRS of 5 of 10, first posttreatment NRS of 8 of 10, and follow-up NRS of 9 of 10 (10 = no symptoms, no restriction to daily living).

The patient's NRS remained at 9, and she stated that she was able to function without pain and was able to sleep comfortably. Physical evaluation showed mild restriction in thoracolumbar range of motion in left rotation. Sitting leg-raise test was negative and lower extremity deep-tendon reflexes were normal. The patient reported only very mild discomfort after strenuous activity. This patient was released from care with instructions to continue her postural exercises.

Discussion 

This case was a successful management of chronic lower back pain and leg pain caused by disk degeneration/herniation and loss of the normal lumbar lordosis by using chiropractic biophysics rehabilitative procedures. Of importance is that previous chiropractic manipulative treatment for the lumbar spine had failed to resolve this patient's chronic lower back and leg pain.

We suggest that the earlier chiropractic intervention failed, in this case, because the previous clinician failed to recognize the importance of the patient's abnormal sagittal lumbar curve and abnormal posture, or possibly failed to diagnose properly. Multiple studies have documented that patients with chronic lower back pain and/or leg pain have, on average, a decrease in their distal lumbar lordosis, L4-S1.11., 12., 13., 14., 23., 24., 25. In fact, a recent publication that used the SF-36 questionnaire as an outcome tool found that low back pain, general health, physical function, emotional function, and social function all correlated to a reduction in the distal lumbar lordosis as measured on the lateral lumbar radiograph.23 The authors of this study state, “There seems to exist a link between sagittal lumbar spine radiology and subjective assessment data (SF-36) in a homogenous hardworking male population with LBP [low-back pain].”23 Our patient had a retrolisthesis at L5, and loss of the lumbar lordosis has been found to be a complicating factor with and a possible cause of retrolisthesis in the lower lumbar spine.26

Using probability theory, Harrison17 has mathematically determined that there are 130 million permutations of abnormal human postures in upright stance. In the lateral view, the skull, thoracic cage, and pelvis may translate anteriorly or posteriorly in the sagittal plane, flex or extend relative to the coronal plane, and translate up or down on a vertical axis parallel to gravity. Visually, in the lateral view, normal postural alignment is noted as balance about a coronal line or gravity line that passes through the external auditory meatus, just anterior to the acromioclavicular joints, slightly posterior to the center of the knee and through the lateral malleoi.1., 17. This case report will only address the sagittal configuration of the lumbar lordosis and the thoracic translations (Z-axis translation) of this patient.

Radiographically, the sagittal view of the normal lumbar lordosis should be minimally lordotic from T12 to L3 with L4-S1 showing an increasing amount of lordosis distally. Janik et al19 reported an average lumbar lordosis based on 552 healthy subjects and found 65% of the lumbar curve is between L4 and S1. Janik et al19 developed an average and ideal model to show that the lumbar lordosis is an ellipse with 39.7° being the normal absolute rotation angle (ARA L1-L5) of the lumbar lordosis as measured in the Harrison spinal model. CBP recommends measuring anterior/posterior displacement of the posterior inferior body of T12 (ie, Z-axis translations) by using a vertical axis line drawn superiorly from the posterior inferior body of S1. The displacement of the inferior-posterior corner of T12 on the lateral lumbar radiograph is then compared with this vertical line in millimeters to determine the patient's sagittal balance.18

Measurements in this case followed standard CBP measurement protocols that are based on geometric measurements using mechanical engineering principles.17 Ferguson's sacral base line, L1 to L5 stress lines, all intersegmental L1 to L5 posterior body lines, vertical axis line, and pelvic lines were drawn as part of the measurement in this study. This system of measurement is highly reliable and repeatable.14., 18.

Traditionally, chiropractors have assessed displaced spinal segments by using 2-dimensional radiograph films; these displaced spinal segments are termed segmental subluxations. Some opinions suggest that spinal postures and lateral curves are the cause of apparent segmental vertebral malpositions as viewed on routine chiropractic radiographs.27 Studies suggest that vertebral juxtapositions or subluxations as viewed on 2-dimensional radiographs and as accepted by traditional chiropractic methodology may only be a result of altered alignment of the head, thorax, and pelvis.27 In the lateral view, however, displacements of vertebral segments in terms of sagittal rotations and translations are considered to be valid representations of spinal displacement in this plane.27 However, this does not indicate that loss of the lumbar curve and displaced sagittal balance is a segmental dysfunction amendable by spinal manipulative therapy. For example, studies using spinal manipulative therapy have been unable to show improvements in lumbar lordosis after treatment.28

In contrast, a previous prospective nonrandomized clinical control trial on the type of lumbar traction used in this report showed significant increases in the sagittal lumbar curve (11.5° improvement) and angle of pelvic tilt (5° improvement) after 36 traction treatments.20 The reason this extension traction caused change in sagittal alignment was suggested to be caused by time-dependent viscoelastic deformation of spinal tissues. Studies indicate that lumbar creep deformation will be mostly complete during a 20 minute time of sustained loading.29., 30. This is why the current patient was worked up over consecutive visits to 18 minutes of traction load duration, which was her tolerance level.

During the course of care, she showed a continual improvement in her symptoms with her NRS beginning at 5 and resolving to a 9. In this case, the patient had a 37% loss of lumbar lordosis on her initial visit. After 69 visits, with 65 including the new 3-point bending lumbar traction, this patient improved to within 9% loss of the normal lumbar lordosis. She also had a posterior translation at of 21 mm (posterior inferior body corner of T12 relative to a vertical through S1 posterior inferior body corner), which improved to 0 mm at the conclusion of her treatment (Fig 2 and Table 1). This improvement in posterior translation (21 mm) is in contrast to the average value (1 mm) first reported by Harrison et al.20 As suggested by Harrison,20 after experiencing no improvement in this radiographic measure, our patient's improvement seems to be caused by our use of a foam block under the thoracic spine during the traction set-up (Fig 1).

This patient's improvement in overall lumbar lordosis (25° to 36° = 11° at third reevaluation) in 65 visits is in contrast with the average improvement (11°) in 36 visits reported by Harrison et al.20 This may have been caused by the pathologic condition of this patient's lumbar disks, her pain level, and/or her sex, because Harrison et al20 reported that, for overall lordosis measurement after lumbar extension traction, women changed less than men.

There are at least 2 other methods that might have been provided as conservative care for a lumbar herniation. Spinal manipulation has been shown to improve symptoms in approximately 50% to 80% of cases with disk herniation.31., 32., 33. However, this patient's previous chiropractic care used this approach without success. A second popular chiropractic alternative might have been Cox flexion-distraction.34 However, on the lateral radiograph, this patient had reduced lumbar lordosis which would be further reduced in flexion. In fact, Harrison and Harrison35 has suggested that Cox flexion-distraction is contraindicated in such circumstances.

In cases with a loss of lordosis with complication of L5 retrolisthesis, the extension traction combined with postero-anterior force at L4-L5-S1 from the traction strap appears to be the more mechanically correct set-up than flexion-distraction or torsion manipulation.

Conclusion 

This case report suggests that successful management of low-back pain symptoms, particularly when chronic, may require a close analysis of a patient's postural deviations and sagittal plane curves. During standard chiropractic evaluations, these global subluxations, altered sagittal configurations, and coupling patterns from abnormal posture, may be confused with and be seen as segmental subluxations. This study suggests that it is possible to restore lumbar lordosis in some cases and this may have an unforeseen benefit to the patient. Further study of the treatment of chronic low-back pain with lumbar disk injuries by utilizing the CBP methods is warranted.