Attempted Radiological (CT)
and Clinical Correlation
in Discopathies Treated by ChiropracticThis section is compiled by Frank M. Painter, D.C.
Send all comments or additions to: Frankp@chiro.org
Dr. Jean Paul Jolivet
"Centro Righi"
Via A. Righi,17
40126 Bologna Italy
Tel&Fax: (051) 23 39 70
Doc.Jolivet@chiropratica.it
http://www.nettuno.it/btw/chiropratica
Professor Giovanni RUGGIERO
Head Emeritus,
Departement of Neuroradiology, Bellaria Hospital, Bologna.
Honorary President, European Society of Neuroradiology
Dr. Renata RICCI
Neuroradiology Assistant,
Bellaria Hospital, Bologna.ABSTRACT
The purpose of the study is to assess the anatomical modifications through computerised tomography and the clinical evolution of discopathies before and after a chiropractic treatment. After a critical analysis of the literature, the authors present 13 cases controlled with a rigorous technique. The chiropractic treatment proved always useful and in most cases led to recovery. A favorable clinical evolution can be confirmed by modifications of the CT aspect of the disk. In such cases the advisability of surgical treatment can be questioned.
INTRODUCTION
The literature abounds in papers showing the good results of the conservative treatment of discopathies. A recent comprehensive study of Bozzano et al. analyses in particular the role played by magnetic resonance (MR) in assessing the natural history of lumbar disk hernation in non-surgically treated patients. From this work it appears that:
1- The reduction of a lumbar disk hernia occurs frequently.
2- There is a clinical improvement of 70% to 90%
Bozzao et al.(1) tried to correlate the clinical evolution and anatomical evolution (change in appearance of the disk) in 69 cases of interverbral disk pathology (focalised protrusion of the disk or presence of a fragment of disk in the intervertebral canal) confirmed by MR. In all these cases, a control MR examination was done 6 to 15 months after the first examination.
In 4 cases, this control examination showed a recurrence of the problem, at various levels, and these 4 cases were excluded. The final material of 65 cases was randomly analyzed and subsequently divided into 4 groups according to the MR results (> 70% hernia reduction; 30% to 70% hernia reduction; no change; increase in hernia size) and into 3 groups according to the clinical evolution (complete recovery; partial recovery; deterioration).
The results of Bozzao et al. study can be summarized as follows:
1- There is no correlation between disk hernia reduction and the location of the lesion.
2- There is no correlation between disk hernia reduction and the interval between the first MR and the control MR, performed at and after the acute clinical stage.
3- There is a correlation between disk hernia reduction and the size of the hernia.
4- There is a significant correlation between hernia reduction and a slow progression of the disease.
5- There is a very significant correlation between morphological changes and long-term clinical results.
Bozzao et al.'s study, which is excellent in other respects, refers non specifically to all non-surgical therapies, including bed rest, manipulations and other symptomatic therapies.
In a very long article, Wiesel (5) analyses the reliability of the imaging techniques (computerized tomography (CT), MR, myelography) in determining the cause of pain.
He concludes that each of the techniques is useful, especially if used in conjunction with others to confirm the clinical impression derived from the objective examination, but that it would be best to refrain from using them until an invasive treament is considered. However because, as Wiesel himself also points out, a false positive clinical result can be due to non-compressive lesions (inflammatory, degenerative, etc.), we are of the opinions that a precise anatomical knowledge (and therefore the use of imaging techniques- CT or MR) is essential also in choosing a non-surgical type of therapy.
Quon et al.(3) reported a case of serious intervetebral disk herniation showed by CT where chiropractic treatment was followed by clinical recovery without any changes in CT results.
We were surprised by the absence in the medical literature of any other papers specifically devoted to the assessment of the anatomical effects of chiropractic treatment, so we asked Dr. Pierre Louis Gaucher-Peslherbe(2) if he knew of any in the more specific field of the chiropractic literature. He answered in the negative. To his knowledge, there are no existing studies on the respective parts played, among non-surgical therapies, by manipulations, rest or drug treatment in the recovery or improvement of patients. Nor have, as far as he knows, the types of manipulations used ever been documented. That is the aim of our study.
MATERIAL AND METHOD
Demonstrating the changes, however small, in the appearance of the disk is important. In order to be able to do so, it is essential to be extremely rigorous in the selection of patients. In theory, all patients should be examined by the same doctors using the same radiological technique and material.
In addition, the intervals between the CT or MR examinations performed before and after the chiropractic adjustment should be the same. These conditions are rarely satisfied in our material. Although there are numerous cases of lumbar spondylo-arthrosis, we were only able to collect 9 that had been studied in close to ideal conditions. To those were added 4 others in which the CT done before the chiropractic adjustment had been performed by a different department, but where our examination of the CT results showed there were sufficient guarantees for the 4 cases to be included in our study.
A statistical analysis can obviously not be attempted from a material of 13 cases. It seems to us that such an analysis is not necessary either.
Given the very rigorous technique used and the aim of our study, these cases constitute valid clinical documents. We shall therefore examine them separately.
The difficulties encountered in selecting the material are mentioned in detail in the literature. They are mainly caused by the reluctance of patients who are feeling better to attend the control examination. Conversely, it is also difficult to get patients whose conditions have not improved to come back for a second examination. They will rather go and see other doctors until they find a surgeon who is willing to operate on them. Another difficulty in collecting enough usable data is the necessity to perform pre-and post-chiropractic radiological examinations which are technically superimposable.
The imaging technique we use is CT. MR equipment is not yet available in our department, but the diagnostic results obtained by CT in intervertebral disk pathology are, in our opinion, very reliable and in any case, not inferior to those obtained by MR. This also seems to be Wiesel(5) opinion. One of the advantages which are usually attributed to MR is the possibility to obtain sagittal and coronal images direcly, but that is also possible with CT, when used expertly, by means of high precision and high resolution electronic reconstructions. Besides, with the use of densitometrical analyses (Ruggiero et al.(4).), which whiten the disk, the CT and the MR images are almost superimposable.
CHIROPRACTIC TECHNIQUE
As in the CT examination, the technique used in the chiropractic treatment must be rigorous and, as much as possible, the same for all the cases. Chiropractic should not be considered as some vague technique involving manipulations, but a science derived from the study of the statics, dynamics and mechanics of the locomotor system, the vertebral column in particular.
The term =B3manipulation=B2 itself is vague; the word adjustment, which defines as much the aim of the chiropractic treatment as the type of intervention concerned, should be preferred.
In lumbalgia and/or sciatica due to disco-radicular conflict, the aim of the chiropractic treatment is to restore the complete functional ability of the affected joint. The affection frequently creates a dysfunction in which the joint function is limited, more or less seriously, and which, if it persists, will lead to continued alteration of the axial tension to which the spinal structures-bones and nerves-are submitted.
In our cases of intervertebral disk herniation, the osteo-articular adjustment aims at correcting a double pathology which we (J.P.J.) think is always present: a sacro-iliac subluxation on the same side as the the pain and a subluxation of the posterior joint of the vertebra situated above the affected disk. The patient is asked to lie on his/her side with the painful side up. The painful leg is bent as much as possible, knee and hip, so as to create as much tension in the affected joint as possible, within physiological limits. The pisiform bone of the chiropractors hand (the left hand if the patient is on his/her left side, the right hand if the patients is on his/her right side) is in contact with the poster-superior sacro-iliac spine and the fingertips are in contact with the mamillary process of the articular facet situated above the disk. The chiropractor first asks the patient to inhale and exhale deeply, to eliminate the intra-abdominal pressure, then pushes forward and upward following the articular facet orientation. At this moment a cracking sound may be heard, and the chiropractor can feel the complete or partial release of the affected joint. After the adjustment the pain decreases considerably, but it is essentially that the patient should observe complete rest, with any forward bending of the body strictly prohibited.
In intervertebral disk herniation cases, a secondary cervical subluxation is also frequently observed, in addition to the saco-iliac and lumbar vertebral subluxations. It is due to the body trying to compensate for the alteration in the axial tension which is a consequence of the first two subluxations. The resulting cervical subluxation is different from a patient to another, and the level of the affected vertebra can be discovered by palpation. The spinous process of the subluxed vertebra is in rotation (to the left or to the right), and its articulation with the vertebra below is always painful. For the adjustment we use mainly two techniques. The first one called cervical break: the patient sits with his/her back firmly against the back of the seat. The chiropractor places his/her middle finger on the lamina on the side opposite to the subluxation (the right hand is used if the subluxation is on the right, the left hand is used if the subluxation is on the left). The patient=B9s head is the extended and rotated towards the side opposite to the subluxations, and the chiropractor pushes in the direction of the rotation following the articular facet orientation. The other technique is as follow: the chiropractor=B9s forefinger (again the right hand is used if the subluxation is on the right, the left hand if the subluxation is on the left) is placed on the lamina on the side of the subluxation, and remain in contact with the spinous process. The patients head is extended and slightly rotated towards the side of the subluxation. The chiropractor then pushes in the direction of the lower articular facet. The choice between these two techniques is subjective.
One of the explanations for radicular pain is root edema, due to the irritation of the root itself. The irritation is caused by pressure, or even by the mere contact of part of the herniated disk or possibly a fragment of the disk, regardless of how much the disk protudes and/or how much the hernia has been reduced after the chiropractic treatment. When the pressure or contact is interrupted, the root ceases to be stimulated? the edema resorbs itself and the pain disappears.
CASE REPORTS
Case 1 - B.L., male, 32 years old.
Three months of subacute left lumbosciatalgia with localized pain in the buttock and lower external third of the calf.
CT (19/07/91)
Left postero-lateral L5-S1 disk herniation, with a rather irregular posterior contour and a very slight upward migration.
Chiropractic treatment (16/07/91-29/08/91)
Pelvic correction with adjusment of the left sacro-iliac joint and of L5-S1on the left as it is in a postero-inferior postion. Specific correction of C1-C2, on the left.
Control CT (26/09/91
unchanged.
Comment:
Following the chiropractic treatment, the symptoms decreased then disappeared completely until January 1992 when the patient suffered a new lumbago and did not come back. The sagittal reconstructions in the two CT examinations are not exactly superimposable, but the examinations are technically correct and the diagnostic conclusions valid. This is an exemple of an unchanged anatomical aspect with clinical improvement, then recovery for 6 months.
Case 2 - G.A., female, 43 years old.
Seven months of subacute right L5-S1 lumboscitalgia with pain from the buttock down the popliteal fossa: paresthesia of the last three toes of the left foot.
CT (1/09/88)
L4-L5 degeneration (with a slight protusion predominantely on the left). Right paramedian and infraforaminal L5-S1 disk herniation.
Chiropractic treatment (06/09/88-10/10/88)
Pelvic correction with adjustment of the right sacro-iliac and of L5-S1 on the right as it is in a posterro-inferior position. Specific correction of C1-C2, on the left.
Control CT (21/01/91):
L4-L5 disk degeneration with presence of a vacuum phenomenon. Reduction of the median and left paramedian disk protrusion. L5-S1 disk degeration with presence of a vacuum phenomenon inside. The aspect of the disk is different: the protrusion is slighly reduced at the level of the right lateral recess, which is now partly obliterated.
Comment: Following the chiropractic treatment the pain disappeared. The patient has been re-examined every five weeks for three years. She is still asymptomatic. This an example of clinical recovery with anatomical improvement.
Case 3 - C.M. , female, 23 years old.
One month of acute left lumboscitalgia with pain in the antero-lateral side of the thigh. Dorsal dextro-convex scoliosis with lumber compensation curve.
CT (26/12/89): Median and especially left paramedian L5-S1 disk herniation. The upper part of the disk is flattened, whereas its lower part can be seen as far down as a third of S1.
Chiropractic treatment (29/01/90-22/02/90): Pelvic correction with adjustment of the left sacro-iliac joint and of L5-S1 on the left side as it is in a postero-inferior position. Specific correction of C1-C2, on the left.
Control CT (10/02/91): The flattening of the disk has increased. The shape of the hernia has changed, its upper part is no longer pointed. However, in its lower part, the posterior contour of the disk seems a little more regular when compared with the previous examination.
Comment: Following the chiropractic treatment the pain stopped. The patient has found to be asymptomatic in the various monthly checkups which are still being carried out. This is an example of clinical recovery with marked anatomical improvement.
Case 4 - L.S., male, 42 years old.
Five months of a right lumbosciatalgia, acute at the onset, with pain on the external third of the calf and lumbar blockage. Slight impairment of the extensor digitorum longus muscle.
CT (21/12/90) (Fig. 1 ab): Right paramedian, foraminal L5-S1 disk hernation. The disk has an irregular aspect and seems to have migrated upwards. Slight median and right paramedian L4-L5 disk herniation.
Chiropractic treatment (14/01/91-14/02/91): Pelvic correction with adjustment of the right sacro-iliac joint of L5-S1 on the right as it is in a postero-inferior position. Specific correction of C1-C2, on the right.
Control CT (06/03/91) (Fig. 1cd): Marked change in L5-S1 disk aspect. The irregularity has disapeared, the posterior part of the disk can know be seen, smooth and clearly flattened. Even the L4-L5 disk hernia seems reduced and regular.
Comment: The conditions of the patient improved immediately after the adjustements, but he failed to attend the control examination requested by the chiropractor. However, this patient has been regularly followed from a clinical point of wiew by one of us (G.R), who notes his complete and so far (March 1992) permanent recovery. This case is an example of clinical recovery with anatomical changes.
Case 5 - L.S., female, 47 years old.
Three months of left lumbosciatalgia, acute at the onset, with pain in the buttocks, the external lateral part of the thigh and the external inferior third of the calf; paresthesia of the peronaeus longus and brevis muscles and of the extensor digitorum longus muscle. Absent left Achilles reflex.
CT (10/05/91) (Fig. 2ab): Left postero-lateral L5-S1 disk herniation with narrowing of the lateral recess due to an osteophyte of L5. Slight L4-L5 protrusion.
Chiropractic treatment (12/07/ 91-26/07/91): Pelvic correction with adjustment of the left sacro-iliac joint and of L5-S1on the left as it is in a postero-inferior position. Specific correction of C1-C2, on the left.
Control CT (16/09/91): Identical to the 19/06/91 examination.
Comment: Following the chiropractic adjustments, the conditions of the patients gradually improved until she recovered, after three months. She was found to be asymptomatic in subsequent examinations. Her case is an example of gradual improvement and recovery without any retraction of the herniated disk, but with a change in its consistency.
Case 6 - G.N., female, 46 years old.
Five years of bilateral sacro-iliitis with acute episodes of blockage. Right scapulo-humeral periarthritis.
CT (28/10/90): Slight L4-L5 disk protrusion, slighly more pronounced on the right. Reduced intersvertebral space L5-S1.
Chiropractic treatment (19/03/91-30/04/91): Pelvic correction with adjustment of the right sacro-iliac joint on the right as it is in a postero-inferior position. Specific correction from C4 to C6 on the right.
Control CT (16/09/91): Large right postero-lateral L4-L5 disk hernia, with a slight upward displacement.
Comment: After the chiropractic treatment the patient recovered. Then, five months later, she suffered a new lumbago caused by exertion. The control CT was done at that time. We have not heard from this patient since, except that she might have had a plaster-cast. This case has little scientific value as no post-chiropractic control CT was done at the time when the patient was well.
Case 7 - M.M.? male, 45 years old.
One month of subacute right lumbosciatalgia with pain in the buttock and the external inferior third of the calf.
CT (12/10/90): Right postero-lateral L4-L5 disk hernation.
Chiropractic treatment (30/10/90-05/12/90): Pelvic correction with adjustment of the right sacro-iliac joint and of L5-S1 on the right as it is in a postero-inferior position. Specific correction of C1-C2, on the right.
Control CT (16/09/91): Unchanged.
Comment: Following the chiropractic treatment the lumbalgia stopped. However, certain leg movements have remained painful, at the level of the inferior third of the peroneus longus muscle and the extensor digitorum longus muscle. This is a usable case even though ther are real differences in the techniques used: in the first CT examination, which was not performed in our department, the orientation of the ray is not strictly parallel to the disk. This is an example of clinical improvement with no anatomical modification.
Case 8 - C.P., male, 24 years old. Three months of acute left lumbosciatalgia with lumbar blockage, pain in the buttock, in the external lateral part of the thigh and the external inferior third of the calf.
CT (18/03/91) : Small right postero-lateral L5-S1 disk hernia which partially fills the intervertebral foramen.
Chiropractic treatment (11/06/91-18/07/91): Pelvic correction with adjustment of the left sacro-iliac joint and of L5-S1 on the left as it is in a postero-inferior position. Specific correction of C1-C2, on the left.
Control CT (16/09/91): The hernia is slighly smaller anr its aspect is modified: the most lateral part, which was obstructing the intervertebral foramen has disappeared.
Comment: Following the chiropractic treatment the patient has recovered. This is an example of clinical recovery with anatomical modifications.
Case 9 - G.R., male, 70 years old.
Three monthsof acuet left lumbosciatalgia, with pain on the external inferior third of the calf and difficulty in walking. Paresis of the left extensor digitorum longus and extensor hallucis longus muscles. Absent left Achilles reflex.
CT (25/07/91): Median and left paramedian L4-L5 disk hernation, calcified with an irregular profile of the posterior contour.
Chiropractic treatment (28/08/91-25/09/91): Pelvic correction with adjustment of the left sacro-iliac joint and of L4-L5 on the left as it is in a postero-inferior position.
Control CT (16/10/91): The hernia seems slightly smaller and its profile now appears to be very regular. However, we must remember that the first examination was not performed in our department.
Comment: The pain stopped immediately after the chiropractic treatment. The paresis gradually regressed and disappeared completely after a few weeks. This is an example of anatomical improvement and of a considerable clinical improvement.
Case 10 - D.M., female, 53 years old.
Two months of acute left lumbosciatalgia with pain in the buttocks, the external lateral part of the thigh and the external inferior third of the calf.
CT (no dated, was not done or examined by us; our comment is based on the CT report). Slight left paramedian L4-L5 disk herniation.
Chiropractic treatment (21/09/90-05/10/90): Pelvic correction with adjustment of the left sacro-iliac joint and of L4-L5 on the left as it is in a postero-inferior position. Specific correction of C1-C2, on the left.
CT (18/02/91): Severe left postero-lateral L4-L5 disk herniation, with an irregular posterior profile.
Comment: Following the chiropractic treatment the pain stopped but the control CT examination was not done. After 7 months, the hernia reappeared as shown by the second CT and cause a blockage. This is an example of a case of little scientific value, as the post-chiropractic CT is missing.
Case 11 - G.G., male, 40 years old.
One month of acute right lumbosciatalgia with pain in the buttock, the external lateral part of the thigh and the external inferior third of the calf.
CT: Large median and right postero-lateral L5-S1 disk hernia.
Chiropractic treatment (01/02/89-20/03/89): Pelvic correction with adjustment of the right sacro-iliac joint and of L5-S1 on the right as it is in a postero-inferior position. Specific correction of C1-C2, on the left.
CT (08/04/91): The hernia is smaller and is now mainly in a right postero-lateral position. The posterior contour of the disk is flattened.
Comment: Following the chiropractic treatment the patient recovered. This is an example of discrepancy between a very positive clinical evolution (the patient play tennis three times a week !!!), and a persistent serious anatomical alteration. The aspect of the disk as neverthless changed.
Case 12 - F.G., female, 37 years old.
One month of acute left lumbosciatalgia with pain in the buttock, the external lateral part of the thigh and the external inferior third of the calf. Cervicalgia. slightly diminished left Achilles reflex.
CT (June 1990): Left postero-lateral L5-S1 disk herniation. Slight left paramedian L4-L5 disk herniation.
Chiropractic treatment (18/06/90-31/07/90): Pelvic correction with adjustment of the left sacro-iliac joint and of L5-S1 on the left as it is in a postero-inferior position. Specific correction of C1-C2, on the left.
Control CT (25/01/91): Median and left postero-median L4-L5 disk herniation. Irregular posterior profile of the herniated disk, especially on the median line. Median end left postero-median L5-S1 disk herniation, less severe than that of the L4-L5 disk.The shape of the L5-S1 hernia is different from that obseved in the first examination, and the disk seems to have migrated upwards.
Comment: Following the chiropractic treatment the pain stopped. The patient has been found asymptomatic in the subsequent examinations performed until today (11/03/92). This is an exemple of a modified hernia aspect, without regression, with clinical recovery.
Case 13 - S.A., male, 41 years old.
Three months of chronic bilateral lumbosciatalgia, with episodes of acute lumbar blockage. Diffuse pain in the inferior part of the buttock, the postero-median and postero-lateral parts of the thighs, the postero-median part of the calf and the antero-external part of the calf.
CT (was not done or seen by us): L3-L4 disk protrusion. More pronounced median and left paramedian L4-L5 protrusion. Slight L5-S1 protrusion.
Chiropractic treatment (21/09/90-20/10/90): Pelvic correction with adjustment of the left sacro-iliac joint and of L5-S1 on the left as it is in a postero-inferior position. Specific correction of C2-C3, on the right.
CT (25/01/91): Very narrow vertebral canal. Osteophytic degeneration of the poerior margins of the bodies of the vertebrae. median and bilateral paramedian L4-L5 disk protrusion. Postero-median and left lateral L5-S1 disk herniation.
Comment: Following the chiropractic treatment, the pain stopped. This an exemple of clinical recovery with no anatomical modifications.
DISCUSSION
As we already pointed out,the small number of case reports does not justify a statistical analysis with the presentation of percentages. However, several interesting considerations emerge from our study.
1- The necessity of a rigorous selection was confirmed. Two cases (Cases 6 and 10) where this was not possible, but which nonetheless seems to us to be useable cases because of the validity of the data, proved to be of no scientific value because of the lack of post-chiropractic control CT examination. In case 13, the first CT was not done or seen by us. This case is therefore not usable for the anatomical evaluation. It was nevertheless included in the case reports because of the concordance between the anatomical report, the symptoms and the exellent results of the chiropractic treatment.
2- A clinical improvement assiociated with an obvious disk hernia reduction was observed in only three cases (2,3,8). In two cases (4,9) the reduction was small. In case (7) the anatomical aspect was unchanged, with a slight clinical improvement.
3- A clinical improvement associated with modifications of the aspect of the disk (even without an obvious hernia reduction) was observed in three cases (4,9,12). In one case (case 5), only the densitometric aspect was modified, but the modification was considerable.
4- A clinical improvement associated with an unchanged anatomical aspect was observed in three cases (1,7,13).
5- The chiropractic treatment was followed by clinical improvement in all 13 cases. Recovery was the most frequent outcome and was observed in 11 cases. In one of the remaining two cases (case 9), the improvement was considerable and in the other case (case 7) it was relative. In two cases (6,10) the patient had seemed to recover but the symptoms reappeared after about six months. However, for one of them (case 6), the recurrence of the symptoms was caused by exertion, which created a new disease pattern.
CONCLUSION
Chiropractic is very useful in the treatment of lumbosciatalgia due to intervertebral disk pathology. Modifications of the aspect of the disk (with or without hernia reduction) are frequently observed on the CT performed after the chiropractic treatment. In our opinion, these CT examinations are extremely useful, but for them to be valid rigorous technical conditions need to be met. We think that it is well worth pursuing in-depth research in this area, particularly as far as objective (ie non pain- related) symptomatology and radiological comfirmation of bone pathology are concerned.
The fact that clinical recovery can be associated with a modified but not retracted disk aspect seems to us to be particularly important. It indicates the interruption of the contact between disk and root. This means that the root is no longer irritated, which is why the edema and the pain have disappeared. We might then question the advisability of surgical removal of the hernia, but this is beyong the scope of our study.
References
1- Bozzao A., Galluci M., Masciocchi C., Aprile I., Barile A., Passarello R (1991) The natural history of lumbar disk herniation in non-surgically treated patients: assessment by RM. Proceedings of RSNA conference, Chicago (shortly to be published in Radiology).
2- Gaucher-Peslherbe P.L. (07/03/92) Communication personnelle.
3- Quon J.A., Cassidy J.D., O=B9Connor S.M?; Kirkaldy-Willis W.H. (1989) Lumbar intervertebral disk herniation: treatment by rotational manipulation, Journal of manipulative and Physiological Therapeutics 12, 3 : 220-227.
4- Ruggiero G., Cristi G., Ricci R. (1988) Tecnica e protocolo desame dell imaging dell hernia del disco cervicale, Ricerca Neurochirurgica 2 : 1-7.
5- Wiesel S. (1992) The reliability of imaging (computed tomography, magnetic resonance, myelography), Journal of Manipulative and Physiological Therapeutics 15, 1 : 51-53.
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