Lumbar disc treatment for sciatica in Belfast

A Disc lesion means a disruption of  the annular fibers and displacement of nuclear material in the intervertebral disc. This can lead to symptoms of inflammation and chemical irritation of the nerve or true compression of the nerve roots. Expected symptoms include pain, loss of sensation and numbness or weakness in the area of the body the effected nerve supplies

Lumbar disc lesion begins with repetitive disc strain which leads to disc herniation and ends in disc degeneration. Multiple factors contribute to the development of lumbar disc herniations. A very important systematic review and meta-analysis published in 2017 of more than 1700 patient cases determined that patients with a reduction of the normal curve in their lower back  have significantly higher levels of lumbar disc herniation and lower back pain (1).

Over 90% of disc lesions occur at L4/5 or L5/S1, with the latter being most prevalent (2). The lumbar disc damage is accompanied by an inflammatory reaction capable of producing a “chemical radiculopathy”. Large disc disruption can lead to disc herniation or bulging resulting in mechanical compression of nearby nerves. 

Other risk factors associated with the development of disc herniations include: a sedentary lifestyle, long periods of driving, long term smoking, previous full-term pregnancy, increased body mass index, and a tall stature (3).

Disc herniation is most likely to occur in the 40-50 years old age group and the condition is very uncommon in children (4). Approximately 35-45% of adults will experience lumbar disc lesions at some point in their lifetime and the condition is more common in men (5).


The presentation to the Chiropractor's office for lumbar disc herniations really depends on the degree of neurologic involvement. Disc lesions with no mechanical compression may present with only local discomfort and pain, or we may see pain that radiates into the buttock or upper leg.

Disc bulges with mechanical compression of a nerve can present with all of the above symptoms but also with decreased muscle strength and abnormal reflexes. Referred pain into the limbs is described by the patient as sharp and sometimes accompanied with pins/needles or altered sensation. As a Chiropractor our job is to rule out "Red Flags"  such as Cauda Equina where the patient will present with numbness or altered sensation in the saddle area, they may also report loss of bowel or bladder function and this is deemed a medical emergency situation and the patient will likely require immediate surgery.


Disc herniation with limb pain can be successfully managed via conservative Chiropractic treatment (6). In fact, the majority of disc herniations will reduce over time without the need of surgery. (7,8) . The goal of conservative Chiropractic management is to centralize symptoms, reduce pain and inflammation in the area, decrease mechanical compression of the nerve and improve functional core stability. 

McMorland reported that the main technique carried out by the Chiropractor produced results equal to surgical decompression in 60% of lumbar disc lesion patients who had failed earlier medical management. He concluded: “Patients with symptomatic lumbar disc herniation should consider spinal manipulation before surgery" (9). An other study of 148 patients demonstrated significant and lasting improvement in all outcome measures (with no adverse events) when spinal manipulation was applied to the level of the disc lesion (10). Chiropractic patients with disc herniation who undergo spinal manipulation at the level of disc involvement demonstrate a significant decrease in radicular symptoms (pain in the limbs) (11).

A study of 1271 lower back pain patients determined that patients with related leg pain and signs of nerve root involvement will have a worse prognosis than patients with low back pain only. Chiropractic clinical outcomes  with low back pain are very impressive.

After two weeks of treatment, patients with local lower back pain only - 77% had improved.

Patients with lower back pain and pain above the knee - 72 % improved after just 2 weeks.

Average outcomes for Chiropractic patients, regardless of the location of pain were significantly better than those who sought treatment from their GP’s at 2 weeks (74% improved vs 36% improved), 3 months (82% improved vs. 60% improved), and 12 months (73% improved vs. 54% improved). (12)


References:

1.The relationships between low back pain and lumbar lordosis: a systematic review and meta-analysis. Chun, Se-Woong et al. The Spine Journal , Volume 17 , Issue 8 , 1180 - 1191

2. Frymoyer JW. Back pain and sciatica. N Engl J Med 1988;318: 291-300.

3. Nachemson AL: Prevention of chronic back pain. The orthopaedic challenge for the 80's. Bull Hosp Jt Dis Orthop Inst 44:1-15, 1984.

4. Hoffman HJ: Childhood and adolescent lumbar pain: differential diagnosis and management. Clin Neurosurg 1980; 27:553-576.

5. Hurwitz EL, Shekelle P. Epidemiology of low back syndromes. In: Morris CE, editor. Low back syndromes: integrated clinical management. New York: McGraw-Hill; 2006. p. 83-118.

6. Saal JA, Saal JS: Nonoperative treatment of herniated lumbar intervertebral disc with radiculopathy an outcome study. Spine 1989; 14:431-436

7. Chiu CC, Chuang TY, Chang KH, Wu CH, Lin PW, Hsu WY. The probability of spontaneous regression of lumbar herniated disc: a systematic review. Clin Rehabil. 2015 Feb;29(2):184-95.

8. Zhong M, Liu JT, Jiang H, Mo W, Yu PF, Li XC, Xue RR. Incidence of Spontaneous Resorption of Lumbar Disc Herniation: A Meta-Analysis. Pain Physician. 2017;20(1):E45–E52.

9. McMorland G, Suter E, Casha S, du Plessis SJ, Hurlbert RJ.
Manipulation or microdiskectomy for sciatica? A prospective randomized clinical study . J Manipulative Physiol Ther. 2010 Oct;33(8):576-84. doi: 10.1016/j.jmpt.2010.08.013

10. Serafin Leemann, Cynthia K. Peterson, Christof Schmid, Bernard Anklin, and B. Kim Humphreys. 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. JMPT 01/2014; DOI:10.1016/j.jmpt.2013.12.011.

11. Ehrler M, Peterson C Leemann S et al. Symptomatic, MRI 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. JMPT Mar-April 2016, Volume 39, Issue 3, Pages 192–199.

12. Hartvigsen L. et al. Leg pain location and neurological signs relate to outcomes in primary care patients with low back pain. BMC Musculoskeletal Disorders 2017, 18:133