Presentation
A 27-year-old man recently presented to our office complaining of sharp low-back pain along with right posterior leg pain and numbness to the fourth and fifth toes. He reported that he had lifted a 50-pound part off of the floor at work 2 days prior. When questioned about how he lifted the part, he indicated that he had flexed at the waist and slightly at his knees, lifted the part, and twisted to his left to place the part on a table. He immediately felt the sharp low-back pain. The leg pain began the next day, and the numbness followed a few hours thereafter.

He reported that his symptoms seemed to be progressively worsening. The patient said he lifted parts such as this several times each day. The patient indicated that lying on his back with his legs up helped relieve the pain. He also presented with mild left antalgic posture.

Upon examination, thoracolumbar range of motion revealed significantly decreased extension and right lateral flexion, both of which caused increased low back pain and right sciatica. The L5 segment was tender upon palpation, with mild swelling noted to the right side. Positive orthopedic tests included right straight-leg raise, Valsalva’s, Bechterew’s, and Dejerine’s triad. Pinwheel sensation test revealed diminished sensation in the right S1 dermatome. Muscle strength testing and deep tendon reflex testing revealed no significant abnormalities, with the exception of toe-walking. The patient had significant difficulty walking on his right forefoot and toes.

Because this particular injury occurred at work, the patient first visited the factory’s medical doctor on the day of the injury. The MD ordered a lumbar MRI that showed a contained right lateral recess disk protrusion at L5. The patient was not satisfied with the prescription pain medication, so he sought care at our office.

Treatment
The technique we chose to employ in this case was flexion-distraction. We have found this method to be very effective in caring for patients with similar problems in the past. In addition to flexion-distraction, we always evaluate the rest of the patient’s spine and use other chiropractic adjusting techniques as clinically indicated.

The technique requires the use of a specialized table that stretches or distracts the lumbar spine. The practitioner then applies pressure to the spinous process of the appropriate vertebra (in our case, at L5) and gently flexes the table near the patient’s waist in a series of “pumping” motions. If the patient tolerates the very first motion well, I will typically apply three sets of 10 pumps to the spine, with each pump lasting about a second. The patient rests for a few moments between sets. The amplitude of each pump is minimal, typically about 6° of motion.

The effect of the applied flexion, coupled with distraction, is to create a negative intradiskal pressure. This is similar to a vacuum effect that “sucks” the nucleus pulposus of the disk back toward the center of the disk. When the disk protrusion is minimized in this manner, the mechanical and/or chemical irritation of the nerve root is diminished. Of course, when that is accomplished, the nerve begins to function properly and the patient’s symptoms resolve.

In addition to helping disk lesions, low-back pain, and sciatica, flexion-distraction is also an extremely effective intervention for many other conditions. Spondylolisthesis, failed back-surgery syndrome, facet syndrome, transitional segments, stenosis, and more respond very favorably. Many newer tables also offer a cervical unit, allowing for the care of cervical disk lesions, arm pain, head­aches, and more. Furthermore, many flexion-distraction tables allow motion in three different planes: flexion-extension, right and left lateral flexion, and rotation. Occasionally, the practitioner may find that a combination of flexion and lateral flexion, known as circumduction, will best benefit the patient.

The patient responded very favorably to flexion-distraction technique. His tolerance test exhibited no increase in back pain, sciatica, or numbness. He was set for an acute care schedule of two treatments per day for 5 consecutive days, and he was instructed to ice the lower back and avoid any bending, lifting, or twisting of the lower back. He was taken off work until further notice. Immediately after the first session, he mentioned that he felt less pain and no longer showed antalgic posture. The patient also was instructed to take an oral supplement containing proteolytic enzymes to assist in the elimination of his inflammation.

After the third session, the patient reported that he no longer experienced numbness in his leg and that his sciatic pain had decreased by 25%. He reported good compliance with his home care instructions. Toe walking had improved, but the patient still had some difficulty walking on the right forefoot and toes. Showing an acceptable level of improvement, the patient was moved to a care schedule of once per day for the following week.

Following the seventh visit, he stated that he had no recurrence of numbness and that the lower-back pain and sciatica had improved by more than 50%. He also said that the sciatic pain was not traveling into his foot, but would stop just above the knee. This indicates a centralization of symptoms, as less nerve-root irritation results in the radicular symptoms traveling a shorter distance down the length of the nerve. This development was very positive in a relatively short period of time. However, we have had many patients respond just as quickly or even more so with similar cases.

At the end of the second week of care, the patient reported that his subjective complaints had nearly been completely eliminated. He felt no limitations in range of motion, and all orthopedic and neurologic tests were negative. At that time, the patient was given a low-back stretch and exercise pamphlet and was instructed to use this home care program. He was also given a nutritional supplement consisting of several vitamins and minerals, along with glucosamine sulfate and methylsulfonylmethane (MSM) to promote intervertebral disk health. He was instructed on proper lifting techniques and ordered back to work the following Monday with a 20-pound weight restriction.

The patient continued his care for another 2 weeks, visiting the office three times per week. His symptoms had completely resolved at the end of this phase of care with no exacerbations occurring. At that point, the patient was released from care for that incident and taken off the weight restriction.

What if flexion-distraction isn’t working? Had the patient not seen at least 50% subjective and objective improvement within the first 12 visits, I would have considered further imaging and possible referral to a neurosurgeon. We have a good working relationship with a neurosurgery center that employs minimally invasive techniques such as laser oblation. Such methods have a much higher long-term success rate than the typical invasive disk surgeries. If he experienced significant worsening of his condition at any time during care, I would have done the same. However, it has been my clinical experience that such circumstances seldom occur when patients are thoroughly examined at the beginning of care and the appropriateness of flexion-distraction is established. This technique has truly helped our practice assist literally thousands of patients recover from varying spinal conditions. I would highly recommend either learning this technique for use in your own practice, or knowing when to refer to a fellow chiropractor using flexion-distraction when this intervention is necessary.

Dan Spencer, DC, practices in Hudson, Mich. Contact him at drdan@healthchiro.com.