Chiropractic Outcomes on Fragmented/Sequestered and Extruded Herniated Discs and Radicular Pain
RESEARCH
Mark Studin
William J. Owens
DC, FASBE(C), DAAPM, DAAMLP
DC, DAAMLP
Disc herniations are a common diagnostic entity in chiropractic practices with varied etiologies, including auto accidents, sports injuries, slips and falls, or any other type of trauma that can result in a tear in the intervertebral disc. Treatment varies from watchful waiting in conservative care to opiates and surgery. In the recent past, the latter have been the treatments of choice in mainstream health care, too often leaving a population of chemically dependent chronic pain patients. This is not to suggest that all surgeries are unnecessary, but if surgery can be avoided, it is an obvious choice.
When considering the intervertebral disc and its associated pathology, Fardon et al. (2014) described intervertebral disc nomenclature in a manner that has been widely accepted in both academic and clinical circles, ensuring that reporting and visualizing pathology is consistently reported. In the
past, lack of continuity in morphological description has been a significant barrier since many professionals have called an intervertebral disc bulge a protrusion, prolapse, or herniation. In today’s literature, Fardon et al. (2014) reported how standardized documentation has resolved many of those problems and is the academic standard in describing intervertebral disc morphology.
Fardon et al. (2014) defined the herniated intervertebral disc as follows:
...’’herniated disc” is the best general term to denote displacement of disc material. The term is appropriate to denote the general diagnostic category when referring to a specific disc and to be inclusive of various types of displacements when speaking of groups of discs. The term includes discs that may
^In the absence of neurological deficits, it should be safe to treat conservatively while the bioneuromechanical issues are treated under chiropractic care. 5 5
properly be characterized by more specific terms, such as “protruded disc” or “extruded disc.” The term “herniated disc,” as defined in this work, refers to localized displacement of nucleus, cartilage, fragmented apophyseal bone, or fragmented annular tissue beyond the intervertebral disc space. “Localized” is defined as less than 25% of the disc circumference. The disc space is defined, craniad and caudad, by the vertebral body end plates and, peripherally, by the edges of the vertebral ring apophyses, exclusive of the osteophyte formation. This definition was deemed more practical, especially for the interpretation of imaging studies, than a pathologic definition requiring identification of disc material forced out of normal position through an annular defect, (p. 2533)
Fardon et al. (2014) defined an intervertebral disc protrusion as stated here:
Disc protrusions are focal or localized abnormalities of the disc margin that involve less than 25% of the disc circumference. A disc is “protruded” if the greatest dimension between the edges of the disc material presenting beyond the disc space is less than the distance between the edges of the base of that disc material that extends outside the disc space. The base is defined as the width of the disc material at the outer margin of the disc space of origin, where disc material displaced beyond the disc space is continuous with the disc material within the disc space. The term “protrusion” is only appropriate in describing herniated disc material, as discussed previ ou sly... The term “extruded” is consistent with the lay language, meaning of material forced from one domain to another through an aperture. With reference to a disc, the test of extrusion is the judgment that, in at least one plane, any one distance between the edges of the disc material beyond the disc space is greater than the distance between the edges of the base measured in the same plane or when no continuity exists between the disc material beyond the disc space and that within the disc space, (p. 2534)
In a more detailed definition of migrati on of intervertebral disc material, Fardon et al. (2014) stated that in relation to an extruded, sequestrated, fragmented, or migrated disc:
Extruded disc material that has no continuity with
the disc of origin may be characterized as “sequestrated.” A sequestrated disc is a subtype of “extruded disc,” but, by definition, can never be a “protruded disc.” Extruded disc material that is displaced away from the site of extrusion, regardless of continuity with the disc, may be called “migrated,” a term that is useful for the interpretation of imaging studies because it is often impossible from images to know if continuity exists, (p. 2534)
Fardon et al. (2014) defined a bulging intervertebral disc in this way:
The terms “bulge” or “bulging” refer to a generalized extension of disc tissue beyond the edges of the apophyses. Such bulging involves greater than 25% of the circumference of the disc and typically extends a relatively short distance, usually less than 3 mm, beyond the edges of the apophyses. “Bulge” or “bulging” describes a morphologic characteristic of various possible causes. Bulging is sometimes a normal valiant (usually at L5-S1), can result from an advanced disc degeneration or from a vertebral body remodeling (as consequent to osteoporosis, trauma, or adjacent structure deformity), can occur with ligamentous laxity in response to loading or angular motion, can be an illusion caused by posterior central subligamentous disc protrusion, or can be an illusion from volume averaging (particularly with CT axial images), (p. 2534)
Now that there is a published foundation for understanding disc nomenclature, we can discuss the clinical management of disc pathology. It was reported by McMorland, Suter, Casha, du Plessis, and Hurlbert (2010) that more than 250,000 patients a year undergo elective lumbar discectomy (spinal surgery) for the treatment of low back disc issues in the United States. The researchers did a comparative randomized clinical study comparing spinal microdiscectomy (surgery) performed by neurosurgeons to nonoperative manipulative treatments (chiropractic adjustments) performed by chiropractors. They compared quality of life and disabilities of the patients in the study.
The study was limited to patients with distinct MRIdocumented one-sided lumbar disc herniation with associated radicular (nerve root) symptoms. Based upon the authors’ review of available MRI studies, all patients participating in the study were considered surgical candidates. Both the surgical and chiropractic groups reported no new neurological problems and had only minor posttreatment soreness. Of the patients who underwent chiropractic care, 60% reported a successful outcome while 40% required surgery, and of those 40%, all reported successful outcomes. This study concluded that 60% of the potential surgical candidates had positive outcomes utilizing chiropractic as the alternative to surgery.
Although the previous report concluded that a chiroprac-
tic spinal adjustment is an effective treatment modality for herniated discs, a more recent study by Leemann, Peterson, Schmid, Anklin, and Humphreys (2014) further clarified improved management and clinical outcomes with chiropractic care. Their study considered both herniated discs and lower extremity radiculopathy as a baseline for analysis. This study also considered acute and chronic lumbar herniated disc pain patients.
Leemann et al. (2014) found the acute onset patient (the pain just started) reported 80% improvement at two weeks; 85% improvement at one month; and 95% improvement at three months. They went on to conclude that the patient stabilized at both the six-month and one-year marks after the onset of the original complaint. Although one might argue that the patient would have gotten better with no treatment, it was reported that after two weeks of no treatment, only 36% of the patients felt better, and 73% felt better at up to 12 weeks. This study clearly indicates that chiropractic is superior to doing nothing and at the same time helps the patient return to his or her normal life without pain, drugs, or surgery, and does so in less time.
Chiropractic Care and Herniated Discs with Leg Pain
One-Month Three-Month Improvement Improvement Improvement 80.6% 84.6% 94.5%
In a prospective outcome study, Ehrler et al. (2016) studied outcomes of chiropractic care on both extruded and sequestrated disc patients:
The purpose of this study was to evaluate whether specific MRI features, specifically axial location and type (bulge, protrusion, extrusion, sequestration) of a herniated disc, are associated with the shortand long-term outcomes of patients treated with high-velocity, low-amplitnde SMT specifically to the level of the symptomatic, MRI confirmed herniation. This is the first study to address this question. Studies searching for predictors of improvement after treatment in previous low back pain patients did not target type and axial location of the herniated discs. Additionally, patients with disc sequestration were not excluded from this study...(p. 196)
Ehrler et al. continued:
Over 77% of patients with disc sequestration reported clinically relevant “improvement” compared to 66.7% of patients with extrusion. Although not statistically significant, 100% of patients with sequestration reported clinically relevant improvement
■ "The “biomechanical function” of the spine as a whole organ system is the second component, which is typically overlooked by mainstream health care as a significant clinical finding. J J
at the three-month data collection time point and at all data collection time points a higher proportion of patients with sequestration reported clinically relevant improvement. There were no significant differences for disc herniation location either by spinal level or in the axial plane for any of the data collection time points. This now calls into question the traditional thinking that disc sequestrations are more dangerous than herniations that remain attached to the parent disc and are more likely to require surgery. However, the studies reporting this did not consider chiropractic spinal manipulative therapy as a treatment option, (p. 197)
In balancing the research findings and objective evidence with clinical triage, the practitioner should be aware of both the morphological findings of disc pathology and negative neurological sequelae. In the absence of neurological deficits, it should be safe to treat conservatively while the bioneuromechanical issues are treated under chiropractic care. However, should there be any neurological deficit, there is
a risk that any delay in reducing the neural compression could lead to permanent neuromuscular functional loss. Should a question arise clinically surrounding the treatment of either sequestration or extrusions, it is suggested that the patient be comanaged with a neurosurgeon, with the chiropractor taking the lead on the biomechanical component while the neurosurgeon takes the lead on the anatomical, neural compression component.
In conclusion, the current model of spinal care is heavily weighted on the anatomical/ pathological model, which includes fracture, dislocation, infection, and intervertebral disc pathology, and that is medicine’s focus. Clinically, it is understood that the “anatomical structure” of the spine is one of only two main components of spinal pain. The “biomechanical function” of the spine as a whole organ system is the second component, which is typically overlooked by mainstream health care as a significant clinical finding. This “biomechanical function” helps explain why different levels of intervertebral disc pathology affect patients differently. Why
“Through verification with studies as listed herein, along with reported daily successes in our offices and our training, the chiropractic profession is best trained and suited to lead in bioneuromechanical treatment (biomechanical failure with neurological insult)
can a patient with a 5 mm central intervertebral disc herniation continue to function while one with lesser pathology is disabled? The answer truly lies in global spinal balance and in creating an efficient biomechanical environment. In patients with biomechanical failure, we now have outcomes as verification that that there is less need for medication and surgery with
the resultant lowering of opiate addiction, surgical complications, and significant savings within our global economy.
Through verification with studies as listed herein, along with reported daily successes in our offices and our training, the chiropractic profession is best trained and suited to lead in bioneuromechanical treatment (biomechanical failure with neurological insult) in publishing and teaching what we have been experiencing clinically for over a century. Collecting these lesions (historically and concurrently known as the chiropractic vertebral subluxation) is why chiropractic has had significant outcomes on all mechanical spine conditions (excluding fracture, infection, or tumor) with minimal to no side effects.
References:
1. Fardon, D. F, Williams, A. F, Dohring, E. J., Murtagh, F R., Gabriel Rothman, S. L., & Sze, G. K. (2014). Lumbar disc nomenclature : Version 2.0. Recommendations of the combined task forces of the North American Spine Society, American Society of Spine Radiology, and American Society of Neuroradiology. Spine, 14(11), 2525-2545.
2. McMorland, G., Suter, E., Casha, S., du Plessis, S. J., & Hurlbert, R. J. (2010). Manipulation or microdiscectomy for sciatica? A prospective randomized clinical study. Journal of Manipulative and Physiological Therapeutics, 33(8), 576-584.
3. Leemann, S., Peterson, C. K., Schmid, C., Anklin, B., & Humphreys, B. K. (2014). Outcomes of acute and chronic patients with magnetic resonance imaging-confirmed symptomatic lumbar disc herniations receiving high-velocity, low amplitude, spinal manipulative therapy: A prospective observational cohort study with one-year follow up. Journal of Manipulative and Physiological Therapeutics, 37(3), 155-163.
4. Ehr 1er, M., Peterson, C., Leemann, S., Schmid, C., Anklin, B., & Humphreys B. K. (2016). Symptomatic, MRL-confirmed, lumbar disc herniations: A comparison of outcomes depending on the type and anatomical axial location of the hernia in patients treated with high-velocity, low-amplitude spinal manipulation. Journal of Manipulative and Physiological Therapeutics, 39(3), 192-199.
Dr. Mark Studin is an adjunct associate professor of chiropractic at the University of Bridgeport College of Chiropractic; an adjunct professor ofclinical sciences at Texas Chiropractic College; and a clinical presenter for the State of New York at Buffalo, School of Medicine and Biomedical Sciences for postdoctoral education, teach-
ing MRI spine interpretation, spinal biomechanical engineering, and triaging trauma cases. He is also the president of the Academy of Chiropractic teaching doctors of chiropractic how to interface with the medical and legal communities (www. DoctorsPIProgram. com); teaches MRI interpretation and triaging trauma cases to doctors of all disciplines nationally; and studies trends in health care on a national scale (www. TeachDoctors.com). He can be reached at DrMarkixfAcademyofChiropractic.com or at 631-786-4253.
Dr. Bill Owens is presently in private practice in Buffalo and Rochester, New York and generates the majority of his new patient referrals directly from the primary care medical community. He is an associate adjunct professor at the State University of New York at Buffalo School of Medicine and Biomedical Sciences
as well as the University of Bridgeport, College of Chiropractic and an adjunct professor of clinical sciences at Texas Chiropractic College. He also works directly with doctors of chiropractic to help them build relationships with medical providers in their community. He can be reached at dr owensfiacademy of chiropractic, com, via www.mdreferralprogram.com, or at 716-228-3847.
