September 5th – 8th 2013 Nottingham Conference Centre, United Kingdom www.nspine.co.uk

Osteopathic Management of Patients with Disc Herniations and Recurrent Disc Problems

Disc Disorders Traumatic disc herniation can occur. Disc herniation can also occur secondary to degenerative disc disease. A herniated nucleus pulposus is most common in those aged <40yrs, whilst degeneration of discs tends to affect those aged >40yrs, with the prevalence increasing with advancing age. Disc lesions of Lsp>Csp>Tsp(rare). Possible link with spinal curves, load bearing structures and segmental mobility.

Disc Disorders Herniated disc  Radicular pain Degenerative disc  Axial pain Discitis  Severe back pain

Degenerative Disc Disease Discs dry out, losing flexibility & shock absorption. Annular tears, internal disc disruption & resorption, disc space narrowing, disc fibrosis & osteophyte formation can all occur. Exact cause is not known – may be a natural part of ageing, but can occur in young people. Cause is likely to be multifactorial – genetic, environmental, traumatic, inflammatory, infection. Degenerative disc disease may lead to disc herniation.

Disc Herniation Presentation Isolated back pain which may radiate in a dermatomal pattern. Muscle spasm & change in posture. Pain exacerbated by coughing, sneezing or twisting. May present with myelopathy  sensory disturbances e.g. numbness below level of compression, difficulty with balance & walking, lower extremity weakness, or bowel or bladder dysfunction.

Thoracic Disc Herniation Often no symptoms! May be pain, paraesthesia or dysaesthesia in a dermatomal distribution. Herniation of T2-T5 with cord compression can mimic cervical disc disease. Thoracoabdominal sensory examination can help determine the level of lesion: nipple is innervated by T4, xiphoid by T7, umbilicus by T10 and inguinal region by T12. Testing abdominal and cremasteric reflexes can help identify myelopathy & cord compression.

Lumbosacral Disc Herniation Nerve root compression causes numbness, paraesthesia, weakness &/or loss of tendon reflexes in 1 nerve root distribution. Unilateral leg pain that radiates below knee to foot. Leg pain is worse than back pain. Positive SLRT/slump Large herniations can compress the cauda equina  saddle anaesthesia, urinary retention, faecal incontinence, unexpected laxity of anal sphincter, severe/progressive neurological deficit in LEX.

Diagnosis Scans are important in identifying pathology, but are not as meaningful in determining the cause of pain as a patients specific symptoms and the results of a physical examination. Many people over age of 30 will have some level of a disc problem, but few will have pain associated with it. Physical examination findings and symptoms need to match the MRI/test findings to arrive at an accurate medical diagnosis, and thereby formulate an effective treatment plan. MRI can help identify constituents of bulge and therefore inform prognosis

Treatment Strategy Acute – highly inflamed : Foraminal gapping techniques to reduce load on disc and encourage fluid exchange around area. Reduce muscle spasm. Chronic : Treat above and below affected level, as well as the affected level specifically. Encourage better global functioning in order to reduce the load at the chronic disc level and to prevent recurrence. Bulge is much more ‘incidental’ than in acute setting.

Treatment Considerations Disc may not be causing pain per se, but altered spinal mechanics influence the level of pain. Key junctional areas – SIJ, L/S, T/L & C/T are commonly affected mechanically with degenerative Lsp disc disease. In treating the widespread segmental restrictions, the degenerate discs are the levels that are really stubborn to clear. Multi-level (4 or 5) disc problems can take a long time to change – high failure rate. More reactive to treatment, & commonly take longer to recover from treatment – necessitates good communication & adherence to treatment plan.

Case Presentation Pt: M, 77yrs Presentation: 5 month history of low back pain following a fall PMH: AAA. L1 nerve root block. Diagnosis: Degenerate Lsp. L1/2 disc herniation compromising L1 nerve root on left. Osteopathic Evaluation: L3-SIJ restrictions in flexion. L3/4 restriction in extension. TTT given: Articulation of Lsp & SIJ - avoiding prone positioning & long lever extensions. Mobilisation of hips & stretching hamstrings & gluteals. Pre TTT ODI: 70% Post TTT ODI: 20%

Case Presentation Pt: M, 53yrs Presentation: Axial low back pain & bilateral LEX pain, >3yrs. Unable to walk more than 30-40yds before pain made him stop. PMH: Extensive physio, pain management, Gabapentin, Pregabalin, Caudal epidural & bilateral L5 root block (x2). Diagnosis: Degenerative L4/5 disc disease with foraminal stenosis. Surgical plan: L4/5 decompression. Osteopathic Evaluation: Restricted flexion left L5 & SIJ. Restricted extension L1-4. TTT given: Articulation of Lsp & L/S junction. Soft tissue stretching through hips and LEX. Encouraged extension through Lsp. Pre TTT ODI: 40% Post TTT ODI: 8% Able to walk >40 minutes and has returned to normal activity levels.

Case Presentation Pt: M, 42yrs Presentation: Chronic neck & low back pain (4-5yrs). LBP radiating to right leg. PMH: Physio. Pain management (analgesia, Gabapentin). Diagnosis: Multi level disc degeneration in Csp & Lsp, with foraminal stenosis at C6/7 & L4/5. Osteopathic Evaluation: Flexion & extension restrictions at T9-SIJ & C1-T5 left. TTT given: Articulation of Csp, Tsp & Lsp. Mobilistaion of hips and stretching of LEX soft tissues. Pre TTT ODI: Pre TTT NDI: 60% 66% Post TTT ODI: Post TT NDI: 8% 11% Patient resumed full employment.