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Prolapsed Discs, Neurogenic Claudication and Sciatica: Non-surgical treatment approach.

This patient came into the practice with a 3 week history of worsening low back and leg pain. He had suffered previously with back pain episodes over the past 20 years but nothing that had involved pain into the legs. This episode had started the morning after an enthusiastic game of tennis. Since then it had been getting progressively worse, was effecting his walking, starting to wake him at night and caused a lot of stiffness first thing in the morning.

The leg pain was provoked when walking for more than 150 yards (140 meters) making it very difficult to carry out his normally active daily routine. The leg pain would ease within minutes of sitting down and leaning forward, but prolonged sitting would worsen his back symptoms. This would continue through out the day.

The physical exam found weakness in both legs, with pain being provoked at the base of his back. The right leg was the worst effected. Vibration sensation in the legs were reduced equally on both sides and the right foot was not as sensitive as  the left to pin prick testing. The right patella tendon reflex was absent. General muscle weakness existed around the pelvis. Other findings were unremarkable.

When considering any case with a sudden change or worsening to a longstanding problem it is important to determine why that is, or if it is actually something new but masquerading as an old problem.  The main priority here was to understand his difficulty walking and if those new leg symptoms related to the low back.

The history gave vital clues as to not only the source of the problem but the structures that could be involved. The physical examination was then used to test this.

One thing that stood out from the history was the clockwork way that the leg pain would come on with walking a set distance, and how it was then relieved by sitting down and leaning forward. This suggested a condition called neurogenic claudication.

Neurogenic claudication is a common symptom of longterm low back problems. It is seen where gradual or sudden changes cause narrowing of the structures around the spinal nerves. Neurogenic means that the problem originates with a problem at a nerve, and claudication, from the Latin for limp, because the patient feels a painful cramping or weakness in the legs. It is thought to be caused by reduction of blood supply to the nerves that exit from the spine. Nerves like all tissues off the body need the nutrients that are provided by the blood to work. If this supply is reduced or stopped it can cause lots of different and often painful sensations. Compression of these blood vessels can be caused by structures such as arthritic spinal joints, calcified spinal ligaments, scar tissue and bulging or herniated discs.

Neurogenic claudication can effect one or both legs causing calf, buttock, or thigh discomfort, pain or weakness. In some patients with severe compression it is not intermittent but painfully persistent. The pain is classically relieved by a change in position particularly bending forward at the waist.People with intermittent symptoms have less disability in climbing steps, pushing carts and cycling.

In order to treat it correctly it is important to determine what structures are causing the problem. An MRI is a type of diagnostic imaging that gives this information; it provides details about the bones and the soft tissues like discs, muscles and nerves.

The MRI results showed a broad bulge of the L4/L5 disc and its encroachment into the exit points of the spinal nerves at that level. This meant, as was suspected, the leg symptoms were related to a worsening of the longterm low back problem. This gave the working diagnosis of an “Intermittent neurogenic claudication secondary to an L4/L5 disc protrusion”.

Disc protrusions/bulges can be the result of longterm degenerative changes, particularly common at the base of the spine. Where episodes of recurrent low back pain exist it is a common to see discs becoming progressively damaged with each episode.

The disc protrusion here was causing problems for the legs only when walking for a set distance. So with each step, the pressure would cause the bulge to obstruct the blood vessels to the nerves. As a point of interest, most MRI scans at the moment are ones where the patient is laying down. The next generation of MRI scans are called “Standing MRI” where as the name suggests the patient is able to stand, but also sit or hold different positions to reproduce symptoms that are not necessarily present when laying flat. This next generation of MRI scans will be much more specific at pinpointing the extent of disc bulges in different positions.

The first objective of treatment was to reduce the pain and stiffness at the base of the spine. This is done using very specific spinal adjustments and soft tissue techniques to loosen the structures around the injured area to reduce the physical tension. Understanding the body’s response to an injury like this helps to guide treatment. The body has what is known as the “pain spasm pain” cycle when nerves are damaged. This means with each sensation of pain the response is a spasm, which unfortunately causes more pain. The use of ice is very helpful in dealing with this, as it reduces down unwanted nerve discharges and helps with the inflammation in the damaged area.

Inflammation is the body’s response to injury (see my post on Hot Vs. Cold), it follows a common pattern. It causes joints to be more stiff first thing in the morning and then as the day progresses (with gentle movement) the stiffness will ease to a point. The effects of inflammation are most notable with less activity. This is one of the reasons why bed rest is not recommended. Interestingly sleep has an effect on how the body regulates its inflammatory response to damage; as you sleep the hormones in the body that keep inflammation under control are less effective and swelling becomes much more pronounced.

Simple changes to daily routine are also an important part of treatment; in particular the length of time spent sitting at his desk. Even though sitting relieved his leg symptoms, it aggravated his low back, a true Catch 22. The solution here is to use active sitting techniques; this limits total sitting time to less than half an hour before getting up and moving around briefly (not to the point of provoking the leg pain) as well as using air cushions where possible. Incorporating a gentle low back stretch routine across the day further benefits recovery. It is important also to stop over enthusiastic activity (running, tennis etc) where the likelihood is to antagonise the problem further rather than help.

The outcome at the four week review for this  case was very positive. The patient is able to walk now without bringing on the leg pain and his low back is no longer tender when sitting. His routine of active sitting and self stretches have continued as a long term strategy to strengthen his low back and core muscles. He is now being encouraged to swim to further the improvement.

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Hot or Cold, what is the best thing to use for aches and pains?

I am often asked by people, coming to the practice, should they use a heat pack or a cold pack or both to give themselves some relief from their pain. The answer I normally give is to use cold. The reply to this is “I was told to use heat by a friend”.

The simple reason for using ice is that it helps to reduce inflammation. It can be applied directly to the area needed and helps to control the body’s own response to the injury. When people think of swelling they imagine a swollen knee or ankle; in the case of back pain there is usually no obvious swelling as it is deeper and therefore hidden.

Inflammation is a perfectly normal response the body has to any injury, be it a broken arm, a stubbed toe or a bad back. Its purpose is to allow the body’s repair teams access to the damaged area by widening the spaces and channels between the tissues. In some cases this response can be a mixed blessing, as it puts pressure on structures around the injury that may not have been harmed in the first place. They then become displaced, strained or damaged by the subsequent swelling. Just think how close nerves passing out of the spine are to the discs and spinal joints. This can be made worse over time if the injury keeps on happening, as is often the case with recurrent back and neck problems.

Using ice, or cryotherapy as it is sometimes called, helps to calm things down. Cold does not just help to control inflammation, it also plays an important part in reducing the pain-spasm-pain cycle that is the hallmark of back complaints. It does this by slowing down the rate of nerve discharge, which causes the muscles to spasm less, reducing pain.

Heat on the other hand does quite the opposite. It may feel good while it is on and for half an hour afterwards, but in the longterm it can prolong, if not worsen the injury. Heat feels good as it reduces superficial muscle spasm (it can only reach about 1 cm down into your skin) while it is being used. Once it is taken away this effect quickly fades, leaving an area with yet more inflammation to deal with.

There are minor risks to using cold, namely freeze burns. From my experience, with the correct instruction and routine this has never been an issue.

So to your well-intentioned friend if they are still not convinced by your conversion to cold I give you this: a study which tested the use of heat and cold on ankle injuries showed cold to improve recovery by an average of 15 days over heat.

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Medical X-ray Safety: Radiation, Myths and Misconceptions.

We are surrounded by radiation from materials in the earth, air, space and even from within ourselves. Radiation is part of our natural environment, put simply, the whole world is radioactive. In this article I will not talk too broadly on radiation as this is a vast subject, but will relate it mainly to its use in diagnostic imagery and the risks associated to the patient.

An x-ray is a form of radiation that is produced as a side effect of an electron interacting with an atom at speed. Think of it as the noise made when a bunch of bricks is thrown at a wall at high speed (the electrons are the bricks, the wall is the atom and the noise is the x-rays). Now imagine that you can focus the noise on one point on the other side of the street to the wall.  Lets say there is something standing in the path of this focused beam of noise. A hand for example. (For argument’s sake it is nice and still).  Immediately behind the hand also just happens to be a special photographic plate. Some noise is absorbed by the hand, but the majority of it carries on through into the photographic plate and then is finally absorbed by the building behind. You develop the photographic plate and you see a picture of the bones of the hand.

I know that this is a very simplified example of how a radiographic image is made. The important thing to remember is that an x-ray is a form of ionising radiation that can pass through an object and be detected on the other side.

X-rays, for their short existence, are radioactive. When talking about radiation’s effect on organic tissues, in our example the hand, the unit used is a sievert (In the US they use the rem: 100 rems = 1 sievert). Exposure to medical radiation is measured in millisieverts (mSV) (the equivalent to changing meters into millimetres: 1SV is 1000mSV).

The amount of radiation the hand received is known as the “equivalent dose”. This is a measure of the amount of radiation received to the type of tissue that has been exposed. This also allows for the “different relative biological effects that different types of ionising radiation have”: in other words different types of tissues respond differently to the same amount of x-rays.

Radiation received from plain film medical x-ray is very low. The risk of developing cancer is based on theoretical models, that use results from higher exposures (from the studies made after Hiroshima and Nagasaki) and then make assumptions about what happens at lower levels. No one is certain that any real risks actually exist as the exposures are normally comparable to what we receive routinely from natural sources of radiation all year round. Further, there is no direct evidence of radiation ever causing any harm at the exposure levels from these examinations. Therapeutic uses such as radiotherapy in treating cancer, involve many magnitudes of radiation higher than diagnostic.

According to the United Nations Scientific Committee on the Effects of Atomic Radiation (UNSCEAR) the average person over the course of a year will be exposed to around 3 mSV. It is not, however, uncommon for any of us to receive less or more than that in a given year (largely due to flights, where we live and medical procedures that we may undergo). International Standards allow additional exposure to radiation to workers in the nuclear industry to 20 mSV. The additional level set for exposure by man made sources for the general public is 1mSV (excluding medical procedures). 

So how many mSV are you exposed to when you are x-rayed? This will depend upon some variable factors: location (arm, neck, low back etc), the physical size of what is being x-rayed (a small person vs. a big person) and to the type of equipment being used. The average for spinal x-rays is between 0.3mSV and 0.7mSV.

So where does the concern come from: Public perception and knowledge? Fear of the unknown? The Cold War Generation (fear of all things nuclear)? The media? The Big C? It would seem everywhere.

Public perception and knowledge is influenced by lots of things, often that are contradictory which leads to greater confusion. In my mind the biggest contradiction is “Radiation causes cancer” which in the same breath is followed by “you treat cancer patients with Radiotherapy”. Undoubtedly high doses of radiation causes cancer. The levels of radiation required to produce or treat cancer are very high but the later is used in a controlled manner. Therapeutic radiotherapy levels vary between 20 to 80 gray per treatment (a gray is equivalent to 1000 mSv, so 20,000 mSV to 80,000 mSV)   which are administered as a course of 1.8 to 2 gray per day (1800 mSV to 2000 mSV) until the level is reached. Compared to  plain film diagnostic X-ray exposure levels of 0.3 to 0.7 mSV the difference is huge.

With the above in mind, the benefits of diagnostic x-ray far exceed any perceived health risk.

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I strongly agree with the statement “the routine use of ordinary x-rays for simple low back pain is not recommended”

In deciding whether or not to take an x-ray of a patient a chiropractor or medical practitioner has to weigh the benefit gained from the information the x-ray might give against the costs of taking the x-ray. The benefits referred to in this equation are the improved outcomes from a more accurate diagnosis and better treatment. The costs are both the financial costs as well as the physical costs of potential harm caused by exposing the patient to radiation. The decision is based on the age, health and medical history of the patient, how their pain presents (things like how long it’s been there, whether it is getting worse, whether it is worse on activity or at night, whether it is radiating anywhere or accompanied by other symptoms like weakness or numbness, bowel or bladder incontinence). From this information and the results of a physical examination, the chiropractor will decide if the x-ray is needed (ie if the benefits of the x-ray is likely to outweigh the costs).

The National Institute of Clinical Excellence (NICE) has recommended against the routine use of x-rays for non-specific low back pain. This was based on studies from the 1970’s which showed that in most cases ‘ordinary x-ray films’ of these patients do not reveal the reasons for the pain and do not influence the subsequent treatment decisions by the Doctor.

I strongly agree that x-rays should not be routinely given to patients suffering from simple low back pain.  However, this statement has produced some confusion amongst medical professionals and the public. One of the reasons for the confusion is the ambiguity of the word “simple” in “simple back pain”. Clinically ‘simple’ low back pain is characterised as a first time one off event of less than six weeks duration. This would be treated by a medical doctor conservatively with anti-inflammatories, muscle relaxants and painkillers. In the majority of cases of simple low back pain, the pain would resolve within two weeks (even if medication had not been used or a doctor consulted). X-rays taken in this scenario would not improve care or the clinical outcome as it would not alter the treatment or advice the doctor would give.

Recurrent episodes of non-specific low back pain are not by this definition “simple”, nor are episodes that have failed to resolve within 6 weeks with medical treatment. These make up the majority of cases that chiropractors see. In most of these cases GPs would still be unwilling to refer for an x-ray as it would still not help them in deciding how to treat these patients. In these cases however, chiropractors can make use of information from x-rays that wouldn’t be of use to a GP.  This is reflected in the way chiropractors take x-rays:

X-rays of the low back taken in hospitals are normally taken with the patient lying down. Taking x-rays of the spine lying down will show diseases and fractures but may mask other problems that become more apparent when the spine is upright. This is why chiropractors normally take x-rays of the spine with the patient standing:- with the spine bearing weight  postural changes, disc compression and spondylolisthesis (slippage of the spinal bones) are shown at their fullest extent. This structural information is important for a chiropractor in deciding whether and how to treat a problem (i.e. which manipulative technique to use, which part of the spine to manipulate). Standing views of the (lower back) lumbopelvis can also be used to assess the height of the femoral heads and so accurately measure structural leg length differences which can play a part in recurrent back problems. X-rays can also reveal congenital abnormalities (abnormalities of the spine you are born with) where the spinal bones have fused together or have formed abnormally – both are quite common and obviously important for the chiropractor to be aware of before starting manipulative treatment.

To finish I know I have not touched upon the safety of medical x-rays in this blog, but I will do soon. The subject is really interesting, and there are plenty of popular misconceptions out there about its safety and the perceived effects of radiation etc. so it deserves its own space.

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