Case Studies & Featured Topics

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

Case Presentation

A 46-year-old housewife presented with low back pain and right-sided leg pain, which had developed approximately 8 weeks prior to her visit.

There was no history of trauma or specific incident associated with the onset of symptoms.

She reported pain and numbness in the lower back and right leg, which progressively worsened throughout the day. By the afternoon, the pain became severe, making walking, standing, and even lying down increasingly difficult.

She also reported numbness and weakness affecting the right foot and toes.

No bladder or bowel dysfunction was reported.

Clinical Examination

On physical examination:

• Lumbar range of motion was reduced and painful
• Decreased sensation was noted over the dorsum of the right foot and toes
• Mild weakness of the right extensor hallucis longus (EHL) muscle was identified
• Palpatory tenderness was present over:
  • Right sacroiliac joint
  • Right gluteus maximus
  • Right lower lumbar paraspinal muscles

Orthopaedic and neurological findings included:

• Positive Straight Leg Raise at 30° on the right side, reproducing sharp leg pain
• Other neurological findings were unremarkable
• Segmental joint dysfunction and tenderness at the L4–L5 functional unit and right sacroiliac joint

Imaging Findings

Magnetic Resonance Imaging (MRI) of the lumbar spine was available and reviewed.

Findings were consistent with:

• Mechanical dysfunction at the L4–L5 segment
• Posterior joint dysfunction
• Probable lumbar disc herniation (disc disruption)

These findings correlated with the patient’s clinical presentation of sciatica with neurological involvement.

Clinical Impression

The overall presentation was consistent with:

• Lumbar disc herniation (slipped disc)
• Right-sided sciatica (radicular pain)
• Associated neurological deficit (sensory change and motor weakness)

Treatment

A structured conservative treatment plan was implemented, including:

Flexion-Distraction Mobilisation
Flexion-distraction technique was applied with contact over the L4 spinous process, using a specialised table to decompress the L4–L5 segment.

Chiropractic Spinal Manipulation / Adjustment
High-velocity, low-amplitude (HVLA) manipulation was applied to the L5 segment to restore joint mobility and reduce mechanical stress.

Dry Needling (Medical Acupuncture)
Dry needling was applied to hypertonic and tender muscles to reduce spasm and pain. Needle insertion into spasmed muscle tissue has been shown to produce relaxation effects, supported by electromyographic findings (Cummings & White, 2001).

Rehabilitation Exercises
A home exercise programme was prescribed, including McKenzie-based extension exercises and progressive mobility work.

Clinical Rationale

Previous studies have demonstrated the effectiveness of:

• Flexion-distraction techniques (Cox, 1990)
• Extension-based rehabilitation (McKenzie, 1981)
• Rotational manipulation (Quon, 1989)

in the management of lumbar disc herniation.

Combined approaches, adapting treatment to the patient’s stage of recovery, have shown favourable outcomes (Hession & Donald, 1998).

Outcome

The patient returned 2 days later and reported a reduction in pain.

• Sensory function over both feet had nearly normalised
• Weakness of the extensor hallucis longus remained present

By the third visit:

• Further improvement in pain and mobility
• Improved ability to stand and walk

At the fourth visit:

• Continued improvement, although mild weakness persisted

At subsequent treatments:

• Low back pain had almost completely resolved
• Leg pain was no longer present
• Muscle strength improved significantly

Over the following 6 weeks:

• Only occasional mild low back discomfort and activity-related leg aching were reported

At 3-month follow-up:

• The patient was asymptomatic

Discussion

Low back pain and sciatica remain conditions with high clinical prevalence and ongoing debate regarding optimal management strategies.

Lumbar spine surgery rates vary significantly across regions, with rates in the United States reported to be 3–8 times higher than in Europe, raising concerns regarding potential overuse.

While surgical intervention for lumbar disc herniation can provide relief of sciatic pain, complete symptom resolution occurs in approximately 50% of cases (Deyo, 1991).

Although complications are relatively uncommon, they may include:

• Mortality (0.2%)
• Thromboembolism (1.7%)
• Infection (2.9%)

(Deyo et al., 1990; Beiner et al., 2003)

Failed back surgery syndrome is a recognised complication, often associated with factors such as misdiagnosis, inappropriate surgical indication, psychological factors, or postoperative complications.

Importantly, outcomes of surgical and conservative management are often comparable at 6 months (Fairbank et al., 2005; Rivero-Arias et al., 2005), while conservative care carries significantly lower risk.

Studies have shown that:

• Approximately 80% of patients improve with either surgical or conservative treatment (Shvartzman et al., 1995)
• Up to 65% of disc herniations reduce in size over time under conservative care (Bozzao et al., 1992)

These findings support the role of conservative management as a first-line approach in most cases of lumbar disc herniation with sciatica.

Indications for Surgical Referral

Surgical evaluation may be necessary in the presence of:

• Cauda equina syndrome (bowel/bladder dysfunction, saddle anaesthesia)
• Progressive or severe neurological deficit
• Persistent neurological deficit after 4–6 weeks of conservative care
• Persistent severe sciatica with consistent clinical findings

Conclusion

This case demonstrates that lumbar disc herniation with associated neurological deficit and radicular pain does not contraindicate the use of carefully applied conservative treatment.

Chiropractic care, combined with acupuncture and rehabilitation, may provide effective symptom relief and functional recovery in patients with sciatica.

Conservative management should be considered a primary treatment option before surgical intervention in the absence of red flag conditions.

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