ChangesinaLumbarDiscExtrusionAfterCoxTechnicFlexionDistraction

Therapyina44yearoldOfficeWorker

Submittedby

DrJoelDixonB.App.Sc(Chiropractic)J.P.MelbourneSpineClinicMelbourne,Australia

DrChloeWilkinsonBBiomedSc,BHsc(Chiro),MClinChiro(Dist)

MalvernChiropracticClinicMelbourne,Australia

History

MrJD

DOB:24.03.71

Thepatientisa44yearoldmalewhopresentedtotheMalvernChiropracticCliniconApril2nd,2015withright-sidedlowbackpainradiatingintotheposteriorthigh,legandfoot,withnumbnessdistributedoverthesamepattern.

ThepainstartedthreeweeksprioronMarch11,2015;hewasadmittedtotheAlfredHospital,Melbourne,Australia,forpainmanagementandwasdischargedthesameday.Hisconditionhadbeendescribedasadiscbulgewithsciaticradiation.

Thepatientdescribedthepainintensityasa3/10VASscalewithastablenature,aggravatedwithtennis,whengettingoutofhisvehicleandliftingandonlyrelievedbylyinginasupineposition.Hereportedthatthepainwasinterferingwithhisnormaldailyroutineincludingsleep,workandexercise.

Thereisaprevioushistoryoflowbackpain20yearspriorfollowingafootballinjury,believedtobethesamespinalvertebrallevel,withprevioustreatmentadministeredbyanosteopathandphysiotherapist.

Hislasttherapypriortoconsultationwasbyaphysiotherapist3weeksprior.ThepatienthadconsultedwithaneurosurgeonwhohadrecommendedmicrodiscecomyatL5/S1level.

PhysicalExamination(02.04.15)

Palpation: BilateralspinalmusclecontracturefromlevelsL3toS1withrightleg,posteriorthigh,posteriorcalfandfootpain.

RangeofMotion:

Activeandpassivelumbo-sacralrangeofmotionwasdiminishedbyupto50%inall3planesofmovement.

Orthopaedicexamination:

Seatedstraightlegraise-rightsidepositiveat60degreesand70degreesontheleft.

Kempstestwaspositiveontherightsideandafunctionalshortlegwaspositiveontherightsidebyupto20mm.

Neurologicalexamination:

L4deeptendonreflex-right+1,left+2 L5deeptendonreflex-right0,left+1

Myotomes-Extensorhallucislongus(EHL)rightsideweaknesscomparedwithleftside

Dermatomes-rightsidedermatomaldistributiondemonstratesparaesthesiaandanaesthesiapatterns

Imaging

Threelumbo-sacralspineMRI’swereconductedonthe30thMarch2015,6weekslateron14thMay2015and5monthslateronthe25thNovember2015.

TheinitialfilmsrevealedaverylargediscextrusionofL5/S1,lyingposteriortotheS1nerveatdisclevel,compressingitanteriorlyagainstthedisc.ThereisalargevolumeofabnormaltissuefollowingtheS1nervedownintotheS1/2lateralrecess.Figure1

Figure1.1

Figure1.2

ThefollowingMRItaken6weekslateronMay14th,2015,foundamoderatelyreduceddischeightofL5-S1discwithdiscophyteanteriorlyandaspurintherightL5foramennotcontactingtheL5nerve.Thiswasmuchimprovedincomparisonwithpreviousimaging.Figure2

Figure2.

ThemostrecentMRIconductedonNovember25th,2015showedamildbroadbasedL5/S1discbulgewithrightpostero-lateralannularfissure.TherewasmildcontactanddisplacementoftherightS1nerve.ScarringandthickeningaroundtherightS1nervehaddecreasedsincepreviousimaging.DegenerativeendplatechangeanddesiccatedL5/S1discwereevident.Figure3.

Figure3

Treatment

ThepatientwastreatedwithCoxTechnicflexion-distractionspinaldecompressiontherapyprotocol1consistingoflongaxis/yaxisdistractionandprotocol2includingcircumductionmotions(5x4decompressionsets),bothfocusingontherightsideddiscalcompartment.Softtissuetherapyandaprescriptionofcorestabilizingexerciseandstretchingroutinewerealsoadministered.

Theinitialcourseofcarewastwiceweeklyfor5weeks,onceweeklyforafollowing4weeksandoncefortnightlybetweenApril2015andJanuary2016,with40treatmentsintotal,maintainingan80-100%reductioninpain.

Coxflexiondistraction,discdecompressiontherapyhasbeendemonstratedtobothdiminishthesizeandpainimpactofthediscalpathologyanditsfurtherimpactonthecompromisedDRG.

Prognosis

PatientprogresshasbeenexcellentandheisexpectedtoreturntoallnormalADL’sincludingnonballisticrecreationalactivity.

Itwasexplainedtohimthatlongtermsuccesswasaresultofabalancebetweenanactiveandpassivemobilityprogrammeandhencehehasbeengivenappropriatestretchingandcorestrengtheningroutines.

Wehavealsoassessedandmodifiedworkplaceanddomesticergonomics.

IamconfidentthatselfmanagementalongwithsupportiveCoxDecompressiontherapywillmaintainthispatient’slowbackconditionwellandhelphimgetonwithpainfreeADL’s.

ConclusionTheappropriateapplicationofCoxflexion-distractiontherapyprotocolsinthiscasehas:1.SignificantlyreducedbothsignsandsymptomsassociatedwithdiscalcompartmentpathologyandtheassociatedDorsalrootganglioncompressionconsequences.2.ResultedintheMRIchangesdemonstratedoverthreeseparateimagesoveraperiodofsome7months.3.SignificantlyreducedintradiscalpressuresatL5-S1levelandatighteningoftheposteriorlongitudinalligament(Gudavallietal1998)mayexplainthereductionindiscalmassextrusionposterolaterallyintospinalrecessesatthislevel.

References1-CoxJM:LowBackPain:Mechanism,Diagnosis,Treatment,6thedition,Baltimore;LippincottWilliams&Wilkins,1990,Chapter8,AppendixB.2-GudavalliMR:Estimationofdimensionalchangesinthelumbarintervertebralforamenoflumbarspineduringflexiondistractionprocedure.Proceedingsofthe1994InternationalConferenceonSpinalManipulation,June10-11,1994,PalmSprings,CA,pp81.3-GudavalliMR,CoxJM,BakerJA,CramerGD,PatwardhanAG:IntervertebralDiscPressureChangesDuringaChiropracticProcedure.ProceedingsofBioengineeringConference,Phoenix,19974-GudavalliMR,CoxJM,BakerJA,CramerGD,PatwardhanAG:IntervertebralDiscPressureChangesDuringTheFlexion-DistractionProcedureforLowBackPain,ProceedingsoftheInternationalSocietyfortheStudyoftheLumbarSpine,Singapore1997