Efficacy of Chiropractic Treatment for Post-Surgical Continued Low Back and Radicular Pain
FEATURE
81% of chiropractic postsurgical patients showed greater than 50% reduction in pain.
Mark Studin
William J. Owens
DC, FASBE(C), DAAPM, DAAMLP and
DC,
DAAMLP
A report on the scientific literature
Park et al. (2016) reported that low back pain radiating into the lower extremities has a greater impact on disability and time off work than any other medical condition. VleggeertLankamp, Arts, and Jacobs (2013) reported, “The term ‘failed back surgery syndrome’ (FBSS) is used to describe a clinical condition defined by persistent or recurrent complaints of leg pain and/or back pain regardless of one or more surgical procedures of the lumbar spine. Some authors modify the definition of FBSS (failed back surgery syndrome) by adding that at least one surgical intervention was to be performed, and that pain should persist after the last surgical intervention for at least one year. 1 The term implies that the surgery plays a role in the cause of the pain, although in most cases the surgical intervention was technically successful. It is known that nearly 20% of patients undergoing spine surgery will require secondary surgery for persistent pain or surgeryrelated complications during the subsequent years” (pg. 48). El-Badawy and El Mikkawy (2016) reported that failed back surgery syndrome occurs with lateral disc surgery upward of 17%, spinal stenosis 29%, and instability 14.8%.
Perhaps the reason for FBSS is what the surgeons have considered their “gold standard” fusion and the ensuing loss of mobility of the spinal motor unit. Mulholland (2008) reported, “Spinal fusion became what has been termed the ‘gold standard’ for the treatment of mechanical low back pain, yet there was no scientific basis for this” (pg. 619). The history of spinal fusion is both fascinating and disturbing. It reveals why chiropractic helps postsurgical cases and should be considered prior to surgery as an option.
Mulholland (2008) continued:
In 1962, Harmon presented a review paper at the western orthopedic association meeting in San Francisco, in
which the term “instability” appears.
However, Harmon’s description of what he meant by instability (unfortunately in a footnote) is revealing. “Spinal instability refers to a low back-gluteal-thigh clinical triad of symptoms that may be accompanied (overt cases) by incapacitating regional weakness and pain. This is the effect of disc degeneration with or without disc hernia. Some may be asymptomatic or slightly symptomatic when instability is compensated by muscle or ligament control. It does not refer to spinous process or laminal hypermobility, which some surgeons like to demonstrate at the operating table, nor does this clini-
cal concept parallel the common spinal hypermobility, which is the product of intervertebral disc degeneration, demonstrable in flexion-extension filming of the region, since the anatomic hypermobility is not always productive of symptoms.”
Sadly, this description of instability appears to have been ignored, and the concept of mechanical instability as a cause of back pain was progressively accepted. Harmon’s view of the effect of fusion was that it cured pain by reducing the irritation of the neural contents produced by movement. His paper was influential as he emphasized the importance of appropriate investigations prior to fusion and the segmental nature of back pain, but unfortunately his use of the term instability was interpreted as supporting the view that segmental abnormal movement was the cause of the pain.
In 1965, Newman, in an editorial concerning lumbosacral arthrodesis (surgical immobilization), refers to the need to stabilize the lumbar spine in patients with back pain after discectomy for a lumbar root entrapment. At the beginning of the seventies, the perception was that disc degeneration led to abnormal translational movement, and this was painful.
McNab in 1971, who had done much work on the
disturbance of movement in the degenerated disc, described what he termed the “traction spur,” a particular type of anterior osteophyte, which he said was related to an abnormal pattern of translational movement. This view again supported the concept of instability. He added the important caveat that it “was impossible to establish the clinical significance of the traction spur as a statistically valid investigation the traction spur was revisited in the late eighties and was shown to be no different to claw osteophytes, and often both would be present in the same patient. It was not related to abnormal movement.”
Although McNab used the term instability, he used it in the sense that the spine was vulnerable to acute episodes of pain because the degenerated disc rendered it more easily injured. He did not view it as a cause of chronic back pain.
Kirkaldy-Willis set out his views on instability in 1982. In “Instability of the Lumbar Spine,” he described the process of disc degeneration as passing through a stage of dysfunction, (intermittent pain), instability, which caused more persistent pain but then with time stabilizing to a painless state. This was his explanation for the observed fact that many very degenerated discs were painless. However, he, at that stage, was somewhat unhappy with an entirely mechanistic view for pain. Hence, he writes,
“Instability can be defined as the clinical status of the patient with a back problem who with the least provocation steps from the mildly symptomatic to a severe episode.” Further, he writes, “Detectable increased motion does not always solicit a clinical response, and that abnormal motion may be abnormal increase or abnormal decrease.” He further writes, “It is insufficient to detect the abnormal increased motion, but the mechanism by which it precipitates the symptomatic episode must also be identified.” Indeed in the seven cases he reported, only one patient had backache alone, the others were all radicular problems. His paper shows that identifying abnormal movement establishes the fact that the segment is disordered, but he does not in that paper indicate that movement itself is the cause of pain.
Subsequently in his very influential book Managing Back Pain, in 259 pages just one page is devoted to the rationale of lumbar fusion. The only reason for fusion appeared to be that other treatments had failed, that it was reasonable from the psychological viewpoint, and that instability was present. Instability is defined elsewhere in the book as increased abnormal movement, and this is illustrated by X-rays purporting to show abnormal rotations and various types of abnormal tilt. He accepts that such appearances may be entirely painless, but in the patient with back pain, they identify the causative level,
and fusion is justified.
However, in a joint paper with Depuis in 1985 entitled “Radiological Diagnosis of Degenerative Lumbar instability” they write, “A lumbar motion segment is considered unstable when it exhibits abnormal movements. The movement is abnormal in quality (abnormal coupling patterns) or in quality (abnormal increase of movement). Pain is a signal of impending or actual tissue damage, and when present it indicates that a mechanical threshold has been reached or transgressed. Repeated transgressions will damage the stabilizing structures beyond physiological repair, thus putting abnormal demands on secondary restraints.”
Hence, from being a method of identifying an abnormal degenerated disc, abnormal motion itself became the injurious agent.
In 1985, Pope and Panjabi in a paper entitled “Biomechanical Definition of Spinal Instability” wrote, “Instability is a mechanical entity and an unstable spine is one that is not in an optimal state of equilibrium...In the spine, stability is affected by restraining structures that if damaged or lax, will lead to altered equilibrium and thus instability. Instability is defined as a loss of stiffness.” Panjabi’s views were generally accepted by basic scientists interested in this field.
Subsequently, Panjabi concluded that increased movement was not necessarily a feature of what he termed instability, but reduction in the neutral zone was. However, in a more recent paper, he has abandoned the concept of instability altogether and ascribes chronic back pain as being caused by ligament sub-failure injuries leading to muscle control dysfunction.
However, throughout the period from the fifties to the nineties, the Panjabi view held sway, and the term instability evolved from being a useful term to denote a segment that was abnormal due to a degenerated disc, to a term denoting a diagnosis of an abnormal (usually increased) pattern of movement with a translational component. The abnormal movement was thought to be the cause of the pain, and, clearly, fusion or stopping movement was a logical treatment.
However, the inability to show that abnormal or increased movement was a feature peculiar to the painful degenerated disc, combined with the fact that despite more rigid fusions using pedicle fixation the clinical results of fusion had not improved, was increasingly casting doubt on the concept of instability. The paper by Murata combining MRI examination with flexion and extension films in patients with back pain showed that increased angular and translational movement was a feature of the normal or mildly degenerated disc, not of the markedly degenerated disc, where movements were reduced. In
1998, Kaigle et al. demonstrated that comparing patients with normal subjects, there was always less movement present in the degenerated spine. It was therefore generally accepted that the effect of disc degeneration was to reduce movement not to increase it, as the term “instability” would imply. It may be argued that, unfortunately, this reduction of movement is associated with abnormal patterns of movement, and this is the meaning of “instability.” However, despite considerable efforts over many years, using flexion/extension films, no clear relationship has been established between pain and such abnormal movements. In other words, patients with degenerative disc disease may exhibit abnormal patterns of movement yet have no pain.
By the mid-nineties, instability was still the term used to describe the disorder that we treated by fusion, but the failure to improve results by the introduction of pedicle fixation caused many surgeons to question the concept of instability, but surgeons were all aware that fusion although unpredictable in terms of clinical result, was the best surgical treatment for chronic low back pain. It was well recognized that clinical success was unrelated to the success of the fusion, pseudarthrosis was as common amongst successful patients as in those who had failed. Was there anything else that a fusion did to the intervertebral disc unrelated to the fact that it stopped
FEATURE
movement? (pgs. 619-623)
Mulholland (2008) concluded with a powerful statement that perhaps sums up why chiropractic realizes significant results when treating postsurgical cases.
Abnormal movement of a degenerated segment may be associated with back pain but is not causative. The concept of instability as a cause of back pain is a myth. The clinical results of any procedure that allows abnormal disc loading to continue are unpredictable, (pg. 624)
To underscore the point of fusion being a failed surgical paradigm in many patients, Gudavalli, Olding, Joachim, and Cox (2016) reported:
Surgical decompression of the lumbar spine in older patients had a 24% reoperation rate, and a 20-fold increase in lumbar surgical fusion rates among Medicare enrollees is reported. Lumbar cage fusion rates increased from 3.6% in 1996 to 58% in 2001, and the result was increased complication risk without improved disability or reoperation rates. Adjacent segment degenerative changes and instability at the level immediately above single-segment fusion with clinical deterioration are shown in up to 90% of the cases. The incidence of radiographic adjacent segment disease following fusion has been reported to be as high as 50% in the cervical spine and 70% in the lumbar
spine at 10 years. However, the incidence of clinically relevant symptomatic adjacent segment disease is quite lower, estimated at 25% in the cervical spine and 36% in the lumbar spine at 10 years.
Comparing surgery with nonsurgical treatment for back and radicular pain shows that intensive rehabilitation is more effective than fusion surgery, and nonsurgical treatment of low back and radicular pain patients is reported to reduce lumbar disc surgery by approximately two-thirds. Chronic low back pain in 349 patients aged 18-55 years found no evidence that surgery was any more beneficial than intensive rehabilitation.27 A study of 600 single-operated low back patients showed that 71% did not return to work four years after surgery, and 400 multiple-operated backs showed that 95% did not return to work four years later, (pg. 124)
Gudavalli, Olding, Joachim, and Cox (2016) went on to report what has been found clinically effective in both preand postoperative cases:
Treating lumbar disc herniation and spinal stenosis patients successfully with conservative care is documented. Chiropractic manipulation prior to spine surgery is appropriate. Previous reports of the biomechanical changes in the spine when CTFD (Cox technique, flexion-traction) spinal manipulation is applied include decreased intradis-
cal pressure; intervertebral disk foraminal area increase; increased intervertebral disk space height; and physiological range of motion of the facet joint, (pg. 124)
Regarding postsurgical care, Gudavalli, Olding, Joachim, and Cox (2016) concluded:
81% of the (postsurgical chiropractic) patients showed greater than 50% reduction in pain levels at the end of the last treatment. At 24-month follow-up, 78.6% had continued pain relief of greater than 50%. (pg. 121)
Although one of the goals of chiropractic care is pain relief, there are still underlying biomechanical pathologies to consider that are concurrently treated while under chiropractic care. The more pressing issue in the postsurgical cases is could these surgeries been avoided in the first place by correcting the underlying biomechanical pathologies prior to surgery This underscores the overwhelming need for chiropractic as primary spine care providers being the first treatment option. It goes back to the adage “dragless first, drugs second, and surgery last.” It’s just common sense and chiropractic has been verified in numerous outcome studies to be the most effective first treatment option for the spine.
References:
1. Park, K. B., Shin, J. S., Lee, J., Lee, Y. J., Kim, M. R., Lee, J. H., & Ha, I. H. (2017). Minimum clinically important difference and substantial clinical benefit in pain, functional, and quality of life scales in failed back surgery syndrome patients. ⅝>/>7^,42(8), E474-E481.
2. Vleggeert-Lankamp, C. L., Arts, M. P., Jacobs, W. C., & Peul, W. C. (2013). Failed back (surgery) syndrome: Time for a paradigm shift. British journal ofpainjl(X), 48-55.
3. El-Badawy, M. A., & El Mikkawy, D. M. (2016). Sympathetic dysfunction in patients with chronic low back pain and failed back surgery syndrome. The Clinical journal of pain,32(3), 226-231.
4. Mulholland, R. C. (2008). The myth of lumbar instability: The importance of abnormal loading as a cause of low back pain. European spine journal,17(5), 619-625.
5. Gudavalli, M. R., Olding, K., Joachim, G., & Cox, J. M. (2016). Chiropractic distraction spinal manipulation on postsurgical continued low back and radicular pain patients: A retrospective case series. Journal of chiropractic medicine,15(2), 121-128.
of chiropractic Chiropractic; University-Kansas Mark Studin at the is an an University adjunct City, adjunct professor College associate of Bridgeport at of Chiropractic; professor College Cleveland an of adjunct professor of clinical 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. He teaches MRI spine interpretation, spinal biomechanical engineering, and triaging trauma cases. He is 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 atDrMarkjjAcademyofChiropractic.com or at 631-786-4253.
William J. Clw’ens, DC, DAAMLP, is presently in private practice in Buffalo and Rochester, New York and generates the majority ofhis new-patient referrals directly fi’om 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. ow enslipcademyqfchiropractic. com, via www.mdreferralprogram.com, or at 716-228-3847.
