Case Studies:

Sciatica, Leg Pain, Slipped Disc Herniation

By Dr. Yoon Jeon. MChiro, MB, BSc, Dip.TCM, PGCert.

CASE PRESENTATION

A 46-year-old house wife, presented with pain in her low back and right leg which started about 8 weeks before her visit. There was no reported or remembered traumatic incident. She described pain and numbness in her right leg and lower back region. She denied any bladder or bowel changes. The pain became worse as the day goes by and by the afternoon, she found that walking, standing and even lying down were almost impossible to perform due to severe pain. She also reported numbness and weakness of her right foot and toes.

On physical examination, lumbar range of motion (Low back movement) was diminished and painful. A decrease in sensation over the dorsum (back) of the right foot and toes and a mild weakness of the right extensor hallucis longus muscle (extend your big toe) were noted. Palpatory tenderness was noted over the right sacroiliac joint, right gluteus maximus muscle and right lower lumbar paraspinal muscles (low back & buttock muscles). Right straight leg raising was positive to 30 degrees (raising your leg leads sharp leg pain). Other neurological exams are unremarkable. Spinal examination demonstrated joint dysfunction and palpatory pain at the L4-L5 functional unit and right sacroiliac joint.

A magnetic resonance image (MRI) of the patient’s lumbar spine was also available. The review of the MRI findings helped on reaching a diagnosis of mechanical dysfunction at the L4-L5 functional unit, including posterior joint dysfunction and probable disc disruption.

TREATMENTS

  • Flexion-distraction mobilization
  • Chiropractic Spinal Manipulation/ Adjustment
  • Dry needling (Acupuncture)
  • Self-home exercises. (inc. McKenzie’s exe)

Flexion-distraction mobilization was performed on the patient by placing a hand contact over the L4 spinous process (2nd lowest backbone) and using the pelvic section of the table to distract the lumbar spine between the L4-L5 segment. Chiropractic spinal adjustment was applied to the L5 mamillary process (Lowest backbone) with a high velocity and low amplitude thrust. Many studies reported that flexion distraction (Cox, 1990), extension (McKenzie, 1981) and rotation manipulation (Quon, 1989) were successful in the treatment of intervertebral disc herniation. Hession and Donald (1998) also reported on a case of lumbar disc herniation that was treated successfully with flexion-distraction and rotation manipulation. This further supports the use of varying forms of manipulation as the patient’s condition changes.

Dry needling (Acupuncture) was applied to the tender points & spasmed muscles directly. Putting a needle into a spasmed muscle causes the muscle to relax. This can be seen with an electromyogram. (Cummings & White,  2001).

OUTCOME

The patient came back  two days later and reported improvement in the pain; sensation was nearly equal over the dorsum of both feet and toes, but the extensor hallucis longus was still weak.  On the third visit, she still reported improvement and demonstrated better ability to stand and walk. The extensor hallucis longus was still weak. These findings were still present at the 4th visit.  At the following treatment , she reported that her low back pain was almost gone and that her leg pain no longer bothered her. The extensor hallucis longus  strength improved at this stage. She was seen four more times over the course of the next 6 weeks and reported only an occasional sense of low back pain and aching pain in her leg that was activity related. She was last seen for this complaint three months after onset and was asymptomatic.

DISCUSSION

A constant demand exists for more research in both the basic sciences and the treatment efficacy of low back pain; first, however, we must question the whole approach to low back disorders.

The rate of  lumbar spine surgery in the United States is three to eight times higher than in most European countries, which suggests that it is overused in the United States or underused in Europe. The major benefit of surgery for a herniated lumbar disc is the relief of sciatica. However, complete relief of all pain symptoms occurs in only half of the group of patients undergoing lumbar discectomy (Deyo, 1991). Although surgery may slightly accelerate the resolution of neurological deficits, the main benefit is pain relief. Complications associated with lumbar spine surgery are infrequent, but include death (0.2%), thromboembolism (1.7%) and infections (2.9%) (Deyo, Loeser and Bigos, 1990; Beiner et al., 2003; Gorgulu, Simsek et al., 2004). The failed back surgery syndrome has been described as a complex condition with many possible contributing factors. These include incorrect diagnosis, incorrect indication for surgery, psychological distress, compensation claims and surgical complications (Jonsson, 1993; Beiner et al., 2003).

Acute sciatic episodes run a relatively brief course in most cases despite the treatment administered. Furthermore, the results of operative and conservative therapy are almost identical 6 months after the start of treatment. The main differences between the two seem to lie in the suggestion that, with surgical intervention, the time factor in reducing severe sciatic pain may be less. However, the complication rate from conservative therapy is far less than that of surgery ( Fairbank et al., 2005; Rivero-Arias et al., 2005). When considering that the rate of mortality from surgery is slightly less than 1%, it is difficult to understand how surgical procedures could not be considered prohibitive for a condition considered self-limiting, especially because there are no systematic reports on complication or risks of spinal manipulation for low back pain.

There are times in when surgery is appropriate; therefore, Deyo identifies four indications for surgical referral for a patient with sciatica (Table 1).

Although there is clearly always a place for surgical decompression for patients suffering from cauda equina syndrome or multiradicular neurological deficit (Bush et al., 1992), conservative management should always be considered a viable first option for treating acute herniated nucleus pulposus with sciatica.


  • Cauda equina syndrome, a surgical emergency characterised by bowel and bladder dysfunction, saddle anaesthesia, bilateral leg weakness and numbness.
  • Progressive or severe neurologic deficit
  • Persistent neurometer deficit after 4-6 weeks of conservative therapy
  • Persistent sciatica, sensory deficit or reflex loss after 4-6 weeks in a patient with positive straight leg raising sign, consistent clinical findings and favourable psychosocial circumstances

Table 1: Typical conditionsindicating surgical referral. 

Shvartzman et al. (1995) found no significant difference in outcome between surgically and conservatively treated groups of individuals. They found a success rate of 80% for both groups. They did not identify any complications from either treatment. Conservative care in this study included bed rest with possible traction, oral medications, physiotherapy and instructions on proper lower back hygiene.

Bozzao et al. (1992) report a randomized study of 120 patients who received MRIs for back and/or leg pain. In this study, 22 were treated by surgery and 98 by conservative methods (bed rest, education, manipulative therapy). Afterwards, 69 of the 98 treated without surgery agreed to follow-up MRIs. The 29 who refused did so primarily because they had experienced complete recovery. Of the 69 patients, 43 had experienced leg pain for 1 to 3 months before the first MRI, and 26 had experienced lumbar pain for longer than 3 months. As discovered on the follow-up MRI on the conservatively treated patients, nearly 65% of the patients had evidence of a reduction in the size of disc herniation ranging from30 to 70%. Another 30% had no appreciable change in the disc herniation on MRI, and 8% had an increase in size of the disc herniation. There was, however, no relationship found between the natural history of the herniation and age, location of herniation or continuing symptoms or clinical results. In all, 71% of the patients re-examined had good clinical results under conservative care, although this percentage would have been higher if the 29 patients who refused to participate on the grounds of complete improvement had been included. In their conclusion, these authors found that lumbar disc herniation is primarily a nonsurgical disease that should be treated by conservative methods ( Bozzao, 1995).

CONCLUSION

This case study supports the idea that the presence of lumbar disc herniation with neurological deficit and radicular pain does not contraindicate the judicious use of manipulation. Furthermore, it provides evidence that manipulation may be an effective form of treatment for many patients with lumbar disc herniation and sciatica with neurological deficit.

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