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Lower Back Conditions

OTHER CAUSES FOR SPINAL RADICULOPATHY
Here are two interesting studies whichsupport two other mechanisms than commonly accepted that have mostly only been the object of speculation until recently.  Both concluded that the theory of chemical radiculitis (leakage of chemical mediators or inflammatory cytokines,  which are produced in the disc), first put forth 30 years ago, is a likely process.  This means that an annular tear (or chemicals from facet joint irritation) may be the cause of radiating symptomatology that may even progress more distally than the knee, which has not been common wisdom until this point.  This is the first reference I have ever seen that suggests that facet syndrome, with its associated chemical irritation potential, can indeed produce radiculopathy. The pain typically associated with facet syndrome is thought to be scleratogenous and not dermatomal. Facet joint symptoms derive from the middle branch of the posterior primary ramus and adhere to Hilton's Law (the nerve that innervates the joint, also innervates the muscles that move that joint and the fascia that covers the muscle). This typically can result in deep pain that is local, pain secondary to muscle spasm and pain distal from the join that goes along the fascia covering. Thus, it does make sense to me that chemical changes at the nerve root level can result in true radicular pain. In most cases, facet syndrome does progress below the knee and there are no neurological changes with reflexes or muscle strength. Depending upon the level, symptoms from the lumbar area region can progress from the spine to the hips, buttocks, groin, testes in the male, abdomen, thigh but again, rarely below the knee. As facet joint presentations are among the most common seen, this may explain the significant success of manual treatment for the spine, such as manipulation and, in some cases, traction.   Tachihara H, Kikuchi S, Konno S, Sekiguchi M. (2007) Does facet joint inflammation induce radiculopathy?: an investigation using a rat model of lumbar facet joint inflammation. Spine. 15;32(4):406-12. and also this study:  Peng, B., W. Wu, et al. (2007). Chemical radiculitis. Pain 127(1-2): 11-6.   Thanks also to Dr. Tom Hyde for his additional thoughts on this article.
 

CHOOSING THE CORRECT TEST FOR SPINAL STENOSIS
In our office, we have an interest in treatment of spinal stenosis, since manipulation shows benefit in certain cases.  Spinal manipulation (particularly flexion-distraction manipulation), while it cannot affect osseous vertebral canal diameter, can decompress the disc, which is important in a multifactorial spinal stenosis, as it helps "make more room." See the article following this one for more information on this.  Magnetic resonance imaging is commonly used to diagnose lumbar spinal stenosis, but in this study, electrodiagnosis is examined.  It has been used to diagnose spinal stenosis for more than 60 years, but there have been no masked, controlled trials of the use of electrodiagnosis for that purpose until this study and it is compared with MRI.  150 symptomatic and asymptomatic volunteers underwent both MRI and electrodiagnosis, finding that imaging does not differentiate symptomatic from asymptomatic persons, whereas electrodiagnosis does, with the conclusion that MRI was improperly being selected in examination for this condition.  Haig AJ, et al. (2007) Electromyographic and magnetic resonance imaging to predict lumbar stenosis, low-back pain, and no back symptoms. J Bone Joint Surg Am. 2007 Feb;89(2):358-66.
 

EXAMINING CONSERVATIVE MEASURES IN THE TREATMENT OF LUMBAR SPINAL STENOSIS  
While it is widely held that non-surgical management should be the first line of approach in with lumbar spinal stenosis, little is known about the efficacy of non-surgical treatments for this condition.  This prospective consecutive case series with long term follow up for 57 individuals examined the use of spinal distraction manipulation (DM) and neural mobilization (NM) techniques.  Patients feedback was obtained with the Roland Morris Disability Questionnaire.  Among positive results, the mean improvement in disability was 5.2 points, which was considered to be clinically meaningful. Clinically meaningful improvement in disability was seen in 73.2% of patients.   The authors concluded that a treatment approach focusing on DM and NM may be useful in bringing about clinically meaningful improvement in disability in patients with stenosis, which is consistent with what we have noted in our office.  In our experience, predicting which patients will respond is not a simple task, but a trial treatment period of two to four weeks is not only a revealing test, but is rarely met with additional discomfort.  Any discomfort noted in this office has been fleeting, with no residuals.  Additionally, certain exercises can also sometimes be helpful, in our experience, and Bodak and Monteiro wrote an excellent article about exercises for stenosis in 2001.  R Murphy; Eric L Hurwitz; Amy A Gregory; Ronald Clary (2006).  A Non-Surgical Approach to the Management of Lumbar Spinal Stenosis: A Prospective Observational Cohort Study.   BMC Musculoskelet Disord. 7(16)   
 

SITTING ON AN EXERCISE BALL AT WORK
Does sitting on an exercise ball during the work day help strengthen trunk muscles?  These authors measured muscle activity after prolonged sitting on an exercise ball and found no differences between a ball group and non-ball group for 14 muscles examined.  S.M. McGill, , N.S. Kavcic and E. Harvey (2006) Sitting on a chair or an exercise ball: Various perspectives to guide decision making. Clin Biomech (Bristol, Avon). 2006 May;21(4):353-60.
 

TRACTION FOR THE LOWER BACK
Lumbar spine traction for resolution of lumbar spine symptoms has received low marks in the last decade.  In this retrospective study, 94 patients received 30-minute treatments daily for the first 2 weeks tapering to 1 session/week for eight weeks.  73% of these subjects with a median pain duration of 260 days had a diagnosis of herniated disc, degenerative disc disease (68%), or both (27%) confirmed by MRI.  At 31 weeks follow-up, 83% reported improvement, with a median satisfaction of 9/10.  Although randomized double-blind trials are needed, this is the first study of this type to clearly report supportable benefits from lumbar spine traction.   Another study which also validates traction is coming out this year from the Mayo Clinic.   In our office, we have used traction for many years, and we support the use of this therapy.  However, it is the same as any other treatment:  proper patient selection is one of the most important factors in achieving a desirable outcome.  Macario A, Richmond C, Auster M, Pergolizzi JV. (2008). Treatment of 94 outpatients with chronic discogenic low back pain with the DRX9000: a retrospective chart review. Pain Pract. 8(1):11-7.
 

PSYCHOSOCIAL FACTORS AND LOW BACK PAIN
This cohort study looked at the impact of psychosocial factors, both work and nonwork-related, on the prevalence of low back pain (LBP) after 6.6 years on average, using self-administered questionnaires a cohort from a larger study group. The conclusions were that psychosocial factors, both at work and in other situations, constitute definite risks for the development of low back pain.  For men this is related to low decision-making latitude and low social support  at work, and less significantly to job strain, low wages, work stress or depression. High job insecurity, work stress and depression were less significant  factors in the development of back pain in women. My observation is that external stress can be a frequent contributor in low back pain, but it is interesting how this study demonstrated the differences in effects between men and women.  Clays E, et al. (2007) The Impact of Psychosocial Factors on Low Back Pain: Longitudinal Results From the Beltress Study. Spine. vol. 32, Iss. 2, pp. 262-268.

THE RESPONSE OF CHRONIC LOW BACK PAIN TO MANIPULATION
Most studies of chiropractic spinal manipulation and the treatment of lower back conditions have dealt with acute lower back conditions, but this randomized double-blind trial comparing active and simulated manipulation for 102 patients in rehabilitation medical centers in Italy examined chronic lower back conditions as well as those with a radicular component.  The authors are rehabilitation physicians at the University of Rome.  Manipulation was performed up to 5 days per week by chiropractors, with a up to a maximum of 20 sessions, with patients' VAS scores assessed at admission and at 15, 30, 45, 90, and 180 days. At each visit, all indicators of pain relief were used.  Four times as many patients reported pain relief in the manipulation group versus the sham treatment group.  This is an interesting study which would seem to indicate much more examination of conservative measures for chronic low back pain is needed, particularly for spinal manipulation. A key point, in my experience, is that manipulation is capable of improving focal joint movement and gross range of motion, meaning that pain receptors are less likely to be stimulated.   Santilli V, Beghi E, Finucci S.  (2006)  Chiropractic manipulation in the treatment of acute back pain and sciatica with disc protrusion: a randomized double-blind clinical trial of active and simulated spinal manipulations. Spine J. 6(2):131-7.