| Dural Connection Internet Edition Volume 2, Number 2 This is the sixth of a series of abstracts of published articles relating to Sacro Occipital Technique and Cranial Manipulation. Please use these for educating insurance companies, the judiciary, the legislature, the colleges and the interested public. How often do we Sacro Occipital Technique (SOT) practitioners treat patients with herniated lumbar discs? Category three treatment when properly applied is a very effect method of treatment for herniated lumbar discs, as we all know. Unfortunately insurance companies, our courts, and other health practitioners (even chiropractors !) often believe that surgery is the only alternative for disc herniation(s). Just recently I received a notice from an insurance company, which was sent to my patient. The notice informed him that because he had a diagnosed lumbar disc herniation and did not have it treated surgically, hewas considered to be in a high risk category and was denied their general health coverage. Ironically he received SOT treatment from me approximately 3 years prior, using SOT procedures, and was relatively symptom free regarding any low back discomfort. He was functioning without any limitations or disability for over three years. Please review the following: In a study entitled 'Lumbar Disc Herniation' published in Spine 1992, August, 17(8), pp 927-33, by Delauche, M; Budet, C; Laredo, J; Debie, B; Wybier,R,; Mdorfmann, H; Ballner, I. , they stated in their abstract that, "In 21 patients with computed tomography-diagnosed lumbar herniated pulposus, nerve root pain resolved after conservative treatment. A subsequent computed tomography scan was performed 6 months or more after presentation. This follow-up computed tomography scan was compared with the initial one. A definite decrease in size of the herniated nucleus pulposus was observed in 14 patients: disappearance in 5, obvious decrease in 5, and moderate decrease in 4. No definite change was observed in seven patients. Major computed tomography scan changes occurred significantly more frequently inlarge herniated nucleus pulposus than in small ones (p.<0.05). This study suggests that large lumbar herniated nucleus pulposus can decrease and even disappear in some patients treated successfully with conservative care." In another study by Weber, H, entitled "Lumbar disc herniation a controlled, prospective study with ten years of observation" published in Spine 1983 , 8, pp 131-40, it was noted that, "Two hundred eighty patients with herniated lumbar discs, verified by radiculography, were divided into three groups. One group, which mainly will be dealt with in this paper,consisted of 126 patients with uncertain indication for surgical treatment,who had their therapy decided by randomization which permitted comparisonbetween the results of surgical and conservative treatment. Another group comprising 67 patients had symptoms and signs that beyond doubt, required surgical therapy. The third group of 87 patients was treated conservatively because there was no indication for operative intervention. Follow-up examinations in the first group were performed after one, four, and ten years. The controlled trial showed a statistically significant better result in the surgically treated group at the one-year follow-up examination. After four years the operated patients still showed better results, but the difference was no longer statistically significant. Only minor changes took place during the last six years of observation." The alternative to conservative management of lumbar disc herniations and canal stenosis are questionable when conservative methods are successful. Another study entitled, Efficacy of conservative treatment of lumbar disc herniation, by Zentner J, Schneider B, Schramm J, which was published in J Neurosurg Sci, 1997 Sep, 41:3, 263-8 noted that," In conclusion, conservative treatment is effective and in our opinion mandatory in the setting of sciaticacaused by lumbar disc herniation except for patients presenting with severe, or progressive neurological deficits." The side effects from surgical intervention and incidence of failed back surgery are necessary considerations when considering conservative care for the patientwith a lumbar herniated disc. Fritsch EW, Heisel J, Rupp S, The failed back surgery syndrome: reasons, intraoperative findings, and long-term results: a report of 182 operative treatments, Spine, 1996 Mar 1;21(5):626-633. Fiume D, Sherkat S, Callovini GM, Parziale G, Gazzeri G, Treatment of the failed back surgery syndrome due to lumbo-sacral epidural fibrosis, Acta Neurochir Suppl, (Wien) 1995;64:116-118. Davis RA, A long-term outcome analysis of 984 surgically treated herniated lumbar discs, J Neurosurg, 1994 Mar;80(3):415-421. Tronnier V, Schneider R, Kunz U, Albert F, Oldenkott P, Postoperative spondylodiscitis: results of a prospective study about the aetiology of spondy lodiscitis after operation for lumbar disc herniation, Acta Neurochir (Wien), 1992;117(3-4):149-152. Conservative care is an effective alternative to aggressive surgical intervention to lumbar herniated disc sequelae. Most research studies evaluating failed back surgery assume that a 50% improvement is considered a success. The complications of surgical intervention and the incidents of failed back surgery years following surgery make conservative care a necessary and viable option. Contraindications for treating patients with low back pain resembling a lumbar herniated disc(s) is determined, by history or examination, whether the patient has a condition related to a history of cancer, fever(s), unexplained weight loss, urinary tract infection, bowel disturbance, intravenous drug use, saddle anesthesia, or prolonged use of corticosteroids. Specific chiropractic treatmentfor herniated discs and canal stenosis is "broadly accepted professionally as effective, appropriate and essential to the treatment of disease or injury." Please see the following references: Troyanovich S, Harrison D, Harrison D, Low back pain and the lumbar intervertebral disc: Clinical considerations for the doctor of chiropractic, J Manipulative Physiol Ther , 1999 Feb, 22:2. Polkinghorn BS, Colloca CJ, Treatment of symptomatic lumbar disc herniation using activator methods chiropractic technique, J Manipulative Physiol Ther , 1998 Mar, 21:3, 187-96. Bergman, T, Jongeward, B, Manipulative therapy in low back pain with leg pain and neurological deficit, J Manipulative Physiol Ther , 1998May;21(4). Floman Y, Liram N, Gilai AN, Spinal manipulation results in immediate H-reflex changes in patients with unilateral disc herniation, EurSpine J , 1997;6(6):398-401. BenEliyahu DJ, Magnetic resonance imaging and clinical follow-up:study of 27 patients receiving chiropractic care for cervical and lumbar disc herniations, J Manipulative Physiol Ther , 1996 Nov;19(9):597-606. Drum, D, Conservative management of lumbar disc degeneration: part 2. Journal of the Canadian Chiropractic Association 1971 Mar; 15(1): 18-21. Drum, D Conservative management of lumbar disc degeneration: part3. Journal of the Canadian Chiropractic Association 1971 Jul. 15(2). pp 12-5. Robertson, J Intermittent lumbar flexion-distraction applied in the closed reduction of virgin intervertebral nuclear prolapse: a case study. J Manipulative Physiol Ther . 1979 Jun. 2(2). pp 103-8. Bergemann, B; Cichoke, A Cost effectiveness of medical vs. chiropractic treatment of low-back injuries. J Manipulative Physiol Ther 1980 Sep. 3(3). pp 143-7. Mior, S; Cassidy, J Lateral nerve root entrapment: pathological, clinical, and manipulative considerations. Journal of the Canadian Chiropractic Association 1982 Mar. 26(1). pp 13-20. Cox, J Lumbosacral disc protrusion: A case report. J ManipulativePhysiol Ther . 1985 Dec. 8(4). pp 261-6. Sanders, M; Stein, K Conservative management of herniated nucleuspulposus: Treatment approaches. J Manipulative Physiol Ther . 1988 . 11. pp309-313. Barrale, R; Diamond, R; Filson, R; Wittmer, M Manipulative management of lumbar disc bulge. Chiropractic Technique 1989 . 1. pp 79-87. Richards, G; Thompson, J; Osterbauer, P; Fuhr, A Low force chiropractic care of two patients with sciatic neuropathy and lumbar disc herniation. American Journal of Chiropractic Medicine. 1990 Mar. 3(1). pp 25-32. Richards, G; Thompson, J; Osterbauer, P; Fuhr, A Use of pre- and post-CT scans and clinical findings to monitor low force chiropractic care of patients with sciatic neuropathy and lumbar disc herniation: a review. J Manipulative Physiol Ther 1990 Jan. 13(1). pp 58. Hubka, M; Taylor, J; Schultz, G; Traina, A Lumbar Intervertebral Disc Herniation: Chiropractic Management Using Flexion, Extension, andRotational Manipulative Therapy. Chiropractic Technique 1991 Feb. 3(1). pp 5-12. Schneider, M The traction methods of Cox and Leander: the neglected role of the multifidus muscle in low back pain. Chiropractic Technique . 1991 Aug. 3(3). pp 109-15. BenEliyahu, D Infrared thermographic assessment of chiropractic treatment in patients with lumbar disc herniations: an observational study. Chiropractic Technique . 1991 Aug. 3(3). pp 126-33. Robinson, G Use of Magnetic Resonance Imaging in the Decision-Making Process for Lumbar Intervertebral Disc Syndrome. J Manipulative Physiol Ther . 1992 Feb. 15(2).pp 129-32. Correction of Multiple Herniated Lumbar Disc by Chiropractic Intervention. Journal of Chiropractic Case Reports. 1993 Jan. 1(1). pp 14-7. Ping, Z; You, F Correlation Study on Infrared Thermography and Nerve Root Signs in Lumbar Intervertebral Disk Herniation Patient: A Short Report. J Manipulative Physiol Ther 1993 Mar 16(3). pp 150-4. DuPriest, C Nonoperative Management of Lumbar Spinal Stenosis. J Manipulative Physiol Ther . 1993 Jul. 16(6). pp 411-4. Gluck NI, Passive care and active rehabilitation in a patient with failed back surgery syndrome, J Manipulative Physiol Ther , 1996 Jan;19(1):41-47. Stern PJ, Cote P, Cassidy JD, A series of consecutive cases of low back pain with radiating leg pain treated by chiropractors, J Manipulative Physiol Ther , 1995 Jul;18(6):335-342. Pustaver MR, Mechanical low back pain: etiology and conservative management, J Manipulative Physiol Ther, 1994 Jul;17(6):376-384. Cox JM, Hazen LJ, Mungovan M, Distraction manipulation reduction of an L5-S1 disk herniation, J Manipulative Physiol Ther, 1993 Jun;16(5):342-346. Hession EF, Donald GD, Treatment of multiple lumbar disk herniations in an adolescent athlete utilizing flexion distraction and rotational manipulation, J Manipulative Physiol Ther, 1993 Mar;16(3):185-192 Cassidy JD, Thiel HW, Kirkaldy-Willis WH, Side posture manipulation for lumbar intervertebral disk herniation, J Manipulative Physiol Ther, 1993 Feb;16(2):96-103 Neault CC, Conservative management of an L4-L5 left nuclear disk prolapse with a sequestrated segment, J Manipulative Physiol Ther, 1992 Jun;15(5):318-322. Quon JA, Cassidy JD, O'Connor SM, Kirkaldy-Willis WH, Lumbar intervertebral disc herniation: treatment by rotational manipulation, J Manipulative Physiol Ther, 1989 Jun;12(3):220-227. Based on the above articles it appears that there is rationale for conservative chiropractic care of lumbar herniated discs. Please review the articles in your spare time and note how many were published in the Journal of Manipulative and Physiological Therapeutics (JMPT). As I have performed literature searches I am thankful again and again that chiropractic has such fine peer review journals such as JMPT, Chiropractic Technique (last published 12/1999), the Journal of the Neuromusculoskeletal System (JNMS), Topics in Clinical Chiropractic and the Journal of Chiropractic Research exist. |