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