Wednesday, October 7, 2015

Wisdom Wednesday: A Simple Case of Sciatica?

A forty-nine year old male presented at my office with complaints of chronic low back pain with radiation down the right leg into the foot. He states that the back pain began almost a year ago. He was treated 2-3 times a week by a chiropractor but noted no benefit after a month and discontinued care.

Seven weeks ago, after sneezing, the pain shot down the right leg. The leg pain has been constant ever since, but varies in intensity. His orthopedic surgeon diagnosed a herniated disc and prescribed muscle relaxants and anti-inflammatory medication that failed to provide any relief.

An MRI performed two days prior to his initial visit in my office shows desiccation of the L4/L5 and L5/S1 discs with apparent prolapse at L5/S1 impinging the thecal sac.

Based on the history and MRI, I had several questions (please review my blog “The Patient History” posted September 16, 2015):
  • Why didn’t he respond to a month of fairly intensive chiropractic care?
  •  His pain radiates along the course of the femoral nerve, not the sciatic nerve. Why was he diagnosed with sciatica?
  • If sneezing caused the prolapse at L5/S1, why isn’t the sciatic nerve affected and why are both discs desiccated? That takes at least a year, maybe as much as five years to show on imaging studies.
  • The femoral nerve does exit from L4/L5 but that disc looks much healthier than the L5/S1 disc that supplies the sciatic nerve. Is this really a disc problem?

On examination, he had great difficulty arising from a chair (Minor’s Sign – imagine an old coal miner arising from a rocking chair) and exhibited marked antalgic posture (he leaned forward and to the left about 45 degrees) favoring the right leg to walk. Both these findings are secondary to protective muscle spasm.

I put him through my QA (Quintessential Applications) protocol finding prostaglandin inflammation, some evidence of neuropathy (nerve damage), and an active injury reflex for the right iliolumbar ligament.

The working diagnosis I used was femoral neuralgia with early neuropathy. I manipulated L4 and L5, corrected the injury reflex, increased his fish oil and placed him on inositol, 6 tablets per day for 10 days. Ice was recommended for home therapy and he volunteered to stop his medication. I suggested that a 50% reduction in symptoms within two weeks was the minimum acceptable response to conservative chiropractic care.

Second Visit – He returned four days later relating a 50% reduction in pain. The back and leg pain were now intermittent and improving each day. He noted some measure of relief the day of initial treatment and continues the use the ice as directed.

The prostaglandin inflammation was down and all indications of neuropathy had resolved. The antalgia was minimal until I adjusted L4, then it instantly returned. After manipulation of the thoracic spine, the antalgic posture resolved again. The injury reflex for the right iliolumbar ligament was again active and subsequently corrected. I had him continue the inositol, fish oil, and ice.

Third Visit – He returned one week later rating his recovery at 80%. His back pain had resolved and he notes occasional “twinges” in the right leg only.

Despite his continued recovery, some indication of neuropathy was again noted but the injury reflex had resolved and no recurrent inflammatory pathways were found.

Following manipulation of the right ilium and lower thoracic spine (both compensatory) I renewed the recommendation for inositol for an additional two weeks. He was then released from active care.

The Bottom Line:
Although this patient’s chronic disc injuries left his low back unstable, they were not the source of his pain and inflammation. He was misdiagnosed with sciatica and had months of ineffective treatment. All he required was an accurate evaluation and short term treatment that addressed the inflammatory, neurological, and structural aspects of his condition. His entire treatment program was three visits over the course of eleven days.

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