Patients with and without nerve root compression secondary to cervical disk herniation can and do respond well to chiropractic care. Chiropractic management of this condition can and should be employed prior to more invasive treatment.
Conservative treatment including chiropractic manipulative therapy seems to be a reasonable alternative to surgery, for cervical radiculopathy caused by a herniated cervical disc. Clinical trials should be performed to evaluate long term success rate, risk of permanent disability, rate of recovery and cost effectiveness of this and other forms of treatment for cervical radiculopathy caused by herniated nucleus pulposus.
Magnetic Resonance Imaging and Clinical Follow-up: Study of 27 Patients Receiving Chiropractic Care for Cervical and Lumbar Disc Herniations
This prospective case series suggests that chiropractic care may be a safe and helpful modality for the treatment of cervical and lumbar disc herniations. A random, controlled, clinical trial is called for to further substantiate the role of chiropractic care for the nonoperative clinical management of intervertebral disc herniation.
Conservative chiropractic treatment may provide an effective therapeutic intervention in selected cases of cervical disc protrusion. Instrument-delivered adjustments may provide benefit in cases in which manual manipulation causes an exacerbation of the symptoms or is contraindicated altogether. Further study in this area should be made via large scale studies organized in an academic research setting.
We need a nonsurgical, conservative approach to treat lower back pain with sciatica as an alternative to and before beginning the more aggressive, and potentially hazardous, surgical treatment. There is some support for the idea that lumbar disc herniation with neurological deficit and radicular pain does not contraindicate the judicious use of manipulation. Although significant questions remain for the evaluation and treatment of lumbar radiculopathy (sciatica) with disc herniations, there is ample evidence to suggest that a course of conservative care, including spinal manipulation, should be completed before surgical consult is considered.
I am often asked by chiropractors, medical doctors and patients if manipulation of the cervical spine is safe in the presence of a cervical herniated nucleus pulposis (CHNP). I usually answer that in most circumstances it not only is safe, but it is often an essential aspect of treatment. I will clarify what this means and provide some of the evidence that supports this notion. I will also illustrate that in most of cases that require treatment, manipulation alone is not a sufficient approach, but that some form of rehabilitation is necessary.
Single-blind Randomised Controlled Trial of Chemonucleolysis and Manipulation in the Treatment of Symptomatic Lumbar Disc Herniation
Crude cost analysis suggested an overall financial advantage from manipulation. Because osteopathic manipulation produced a 12-month outcome that was equivalent to chemonucleolysis, it can be considered as an option for the treatment of symptomatic lumbar disc herniation, at least in the absence of clear indications for surgery. In this study it was shown that for managing disc herniations, the cost of treatment failures following a medical course of treatment [chymopapain injections] averaged 300 British pounds per patient, while there were no such costs following spinal manipulation.
Safety of Spinal Manipulation in the Treatment of Lumbar Disk Herniations: A Systematic Review and Risk Assessment
The apparent safety of spinal manipulation, especially when compared with other “medically accepted” treatments for LDH, should stimulate its use in the conservative treatment plan of LDH.
Chiropractic High-Velocity Low-Amplitude Spinal Manipulationin the Treatment of a Case of Postsurgical Chronic Cauda Equina Syndrome
A 35-year-old woman presented with complaints of midback pain, low-back pain, buttock pain, saddle anesthesia, and bladder and bowel incontinence, all of 6 months duration. The patient was 6 months post emergency surgery for acute cauda equina syndrome due to lumbar disc herniation. She had been released from neurosurgical care with the current symptoms considered to be residual and nonprogressive. The patient was treated with high-velocity low-amplitude spinal manipulation and ancillary myofascial release. After 4 treatments, the patient reported full resolution of midback, low back, and buttock pain. The patient was seen another 4 times with no improvement in her neurologic symptoms. No adverse effects were noted.
The finding of cervical spinal cord encroachment on magnetic resonance imaging, in and of itself, should not necessarily be considered an absolute contraindication to manipulation. However, because radicular and myelopathic complications to cervical manipulation have been reported in the literature, great care should be taken in all cases, particularly those in which anatomic conditions such as cord encroachment are present.
An elderly male patient presented to a private spine clinic with right-sided foot drop. He had been prescribed an ankle-foot orthosis for this condition. All sensory, motor, and reflex findings in the right leg and foot were absent. This was validated on prior electromyography and nerve conduction velocity testing, performed by a board certified neurologist. Patient was treated using spinal manipulation twice-weekly and wobble chair exercises three times daily for 90 days total. Following this treatment, the patient was referred for follow-up electrodiagnostic studies. Significant improvements were made in these studies as well as self-rated daily function.
This case illustrates the importance of careful interpretation of posttreatment complications of any kind, in light of the natural history of the condition under consideration. Progression of neck and/or arm pain to myelopathy that occurs after manipulative treatment cannot be automatically assumed to relate directly to the manipulation because the progression may simply be a result of the natural history of the condition. It is important for authors of reports of myelopathy-related “complications to cervical manipulation,” and editors reviewing such reports, to consider this in the reporting of these complications.
The Effect of Backpacks on the Lumbar Spine in Children: A Standing Magnetic Resonance Imaging Study
Backpack loads are responsible for a significant amount of back pain in children, which in part, may be due to changes in lumbar disc height or curvature. This is the first upright MRI study to document reduced disc height and greater lumbar asymmetry for common backpack loads in children.
Charges for preoperative care of patients with lumbar disc herniation are substantial and are split almost evenly between diagnostic charges (outpatient visits, imaging, laboratory studies, and miscellaneous) and therapeutic charges (injections, physical therapy, chiropractic manipulation, and medications). Although a large number of patients will ultimately require surgical intervention, given that many patients will improve with nonoperative therapy, a trial of conservative management is appropriate. Additional studies to identify patients who may ultimately fail nonoperative treatment and would benefit from early discectomy would be beneficial.
Most of the patients who were considered surgical candidates for the treatment of radiculopathy from LDH improved with standardized spinal manipulative care to the same degree as those who had undergone surgery. Of those who failed spinal manipulation treatment, subsequent surgical intervention provided excellent outcome. In contrast, the 3 patients who failed microdiskectomy did not benefit from further spinal manipulative care. Therefore, patients with symptomatic LDH failing medical management (failed at least 3 months of nonoperative management including treatment with analgesics, lifestyle modification, physiotherapy, massage therapy, and/or acupuncture) should consider chiropractic spinal manipulative treatment as a primary treatment, followed by surgery if unsuccessful.
The prevalence of childhood and adolescent LBP is more common than once thought. Discogenic pain from annular tears, herniation and vertebral endplate injury, must be considered particularly in cases involving chronic LBP, and lack of response to conservative manual therapy. MRI can be useful in appropriately connecting patient history, physical examination, and imaging findings to correlate the most likely cause of a patient’s LBP. It should be used particularly when conservative management and/or natural history fails to resolve the LBP disorder. Specialist referral is warranted when pain levels are intractable or when continuous pain and disability occurs after a course of conservative management. Speedy resolution of lumbopelvic function is considered important to help limit any long term deleterious effects on spinal growth and therefore improve quality of life in young persons. More research is needed regarding long-term implications of IVD injuries in people of such young age, and how best to conservatively manage them.
Outcomes From Magnetic Resonance Imaging– Confirmed Symptomatic Cervical Disk Herniation Patients Treated With High-Velocity, Low-Amplitude Spinal Manipulative Therapy: A Prospective Cohort Study With 3-Month Follow-Up
A high proportion of acute and most importantly subacute/chronic patients with MRI-confirmed symptomatic cervical disk herniations treated with high-velocity, low-amplitude cervical spine manipulation reported clinically relevant improvement at 1 and 3 months after the first treatment. There were no adverse events reported for patients in this study.
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
A large percentage of acute and importantly chronic lumbar disc herniation patients treated with high-velocity, low-amplitude side posture SMT reported clinically relevant “improvement” with no serious adverse events.
By adulthood, the IVD is a largely fibrocartilaginous structure that permits limited motion while offering resistance against compressive loading. With degenerative change, there is a disruption in homeostatic regulation of the degenerative/damaged IVD leading to increased levels of catabolic and pain-causing cytokines in addition to granular or scar tissue formation rendering it vulnerable to further injury. With respect to non-operative treatment of spinal pain, numerous studies support the use of SMT and MOB; however, this remains controversial and lumbar disc herniation (LDH) remains the number one malpractice claim made against chiropractors.  Another non-operative treatment for DDD is non-surgical spinal decompression however; there is no mechanistic, biological evidence to support the notion that this form of treatment can re-hydrate a degenerative disc. Therefore, prior to selecting a form of treatment, the clinician should be aware of the biological model of IVD and apply an evidence-based, judicious approach to the management of patients afflicted with these disorders.