1. Cervical and Lumbar Disc Disease: Conservative and Surgical Management
UCERF &
NWCC
By Joseph S. Ferezy, D.C.
Sponsored By:
Copyright, 2002 © Joseph S. Ferezy, D.C.

2. Introduction
Frequently, doctors of chiropractic face the challenge of delivering health care to patients with serious spinal disorders. These conditions often require co-management which includes medical and surgical options. One such disorder is herniation of the nucleus pulposis of the intervertebral disc. You can meet the challenge of knowing when to treat and when to refer by utilizing some logical guidelines.

3. Steps in Proper Disc Management
Proper diagnosis (exam, imaging, etc.).
Conservative management.
Referral for medical/surgical options.
Long term care and follow-up.

4. Diagnosis of HNP H&P. Imaging. Other lab.
Symptoms of neurological involvement.
Signs of neurological involvement (myelopathy, radiculopathy, cauda equina).
Imaging.
Plain film.
Advanced (CT, MRI, discography).
Pitfalls.
Other lab.

5. Do Not Rely on Imaging Alone!
Pitfalls of Diagnosis
Do Not Rely on Imaging Alone!

6. 1984 Volvo Award in Clinical Sciences: A Study of Computer- Assisted Tomography: The Incidence of Positive Cat Scans in an Asymptomatic Group of Patients
Sam W. Wiesel MD, Nicholas Tsourmas, MD, Henry L. Feffer, MD, Charles M. CITRIN, MD, and N. PATRONAS, MD
Spine Vol. 9; #6 1984

7. Positive CAT Scans
In Order to Study the Type and Number of CAT Scan Abnormalities of the Lumbar Spine That Occur In Asymptomatic People, 52 Studies From a Control Population With No History of Back Trouble Were Mixed Randomly With Six Scans From Patients With Surgically Proven Spinal Disease, and All Were Interpreted by Three Neuroradiologists In a Blinded Fashion.

8. Positive Cat Scans
Irrespective of Age, 35.4% (26.6%, 51.0%, and 31.3%) Were Found to Be Abnormal.
Spinal Disease Was Identified in an Average of 19.5% (23.8%, 22.7%, and 12.5%)
Of the Under 40-year-olds, It Was a Herniated Nucleus Pulposus In Every Instance.
In the Over 40-year-old Age Group,there Was an Average of 50% (29.2%, 81.5%, and 48.1%) Abnormal Findings, With Diagnoses of Herniated Disc, Facet Degeneration, and Stenosis Occurring Most Frequently.
[Key Words: Positive Cat Scans, Asymptomatic Patients, HNP and Disc, Facet Degeneration, Stenosis]

9. Abnormal Magnetic Resonance Scans of the Lumbar Spine in Asymptomatic Subjects
SD Boden, MD, DO Davis, MD, T Dina, MD, NJ Patronas, MD, SW Wiesel, MD
J Bn Jt Surg Vol. 72-A, No. 3 March 1990

10. Abnormal Magnetic Resonance Scans
67 Patients Who Never Had LBP, Sciatica or Neurogenic Claudication.
Interpreted by 3 Independent Neuroradiologists.
1/3 had Substantial Abnormality.
< 60 Years Old
20 % HNP
0% Spinal Stenosis

11. Abnormal Magnetic Resonance Scans
> 60 Years Old.
57% Abnormal.
36% HNP.
21% Spinal Stenosis.
Degenerated or Bulging Disc at Least One Level.
35% Between Years Old.
All But One of Year Olds.
Concluded MRI Must Be Correlated To Clinical Presentation and Age.

12. Non-Surgical Treatment Outcomes
What if I Do Not Refer for Surgery?

13. Jeffrey A. SAAL, MD, and JOEL S. Saal, MD Spine Vol. 14; #4 1989
Nonoperative Treatment of Herniated Lumbar Intervertebral Disk With Radiculopathy: An Outcome Study
Jeffrey A. SAAL, MD, and JOEL S. Saal, MD
Spine Vol. 14; #4 1989

14. Nonoperative Treatment
The Functional Outcome of Patients With Lumbar HNP Without Significant Stenosis Was Analyzed in a Retrospective Cohort Study.
Inclusion Criteria:
A Chief Complaint of Leg Pain, Primarily.
A Positive Straight Leg Raising (SLR) at Less Than 60 Degrees - Reproducing the Leg Pain.
A Computed Tomography (Ct) Scan Demonstrating HNP Without Significant Stenosis by a Radiologist's Reading, Also Confirmed by Authors.
A Positive Electromyogram (EMG) Demonstrating Evidence of Radiculopathy.
Response to a Follow-up Questionnaire.

15. Nonoperative Treatment
All Patients Had Undergone Aggressive Physical Rehabilitation
Back School.
Stabilization Exercise Training.
A Total of 347 Consecutively Identified Patients.
64 Patients With Average Follow-up Time of 31.1 Months Met Inclusion Criteria.
Sent Questionnaires That Inquired About:
Activity Level
Pain Level
Work Status
Further Medical Care.

16. Nonoperative Treatment
Patients With Neurologic Loss, Extruded Discs, and Those Seeking a Second Opinion Regarding Surgery Were Identified and Subgrouped.
Results for the Total Group Included 90% Good or Excellent Outcome With a 92% Return to Work Rate.

17. Nonoperative Treatment
Subgroups With Extruded Discs and Second Opinions
87% and 83% Had Good or Excellent Outcomes, Respectively
All (100%) Returned to Work.
Sick Leave Time for These Subgroups
2.9 Months (+/-1.4 Months) and 3.4 Months (+/- 1.7 Months) Respectively.
Compared Favorably With Previously Published Surgical Studies.
Four of Six Patients Who Required Surgery Were Found to Have Stenosis at Operation.

18. Nonoperative Treatment
No Statistically Significant Difference in Outcome In Patients With Neurologic Weakness or Extruded Discs From Study Population.
Demonstrates That Lumbar HNP With Radiculopathy Can Be Treated Very Successfully Without Operation.

19. Nonoperative Treatment
Surgery Should Be Reserved for Patients Where Function Cannot Be Satisfactorily Improved by Physical Program.
Failure to Respond to Nonoperative Care Suggests Presence of Stenosis.
[Key Words: Lumbar Herniated Disc, Nonoperative Treatment, Clinical Course]

20. JEFFREY A. Saal, MD, Joel S. SAAL, MD, and RICHARD J. Herzog, MD
The Natural History of Lumbar Intervertebral Disc Extrusions Treated Nonoperatively 
JEFFREY A. Saal, MD, Joel S. SAAL, MD, and RICHARD J. Herzog, MD
Spine 15 (7) 1990 (P 683)

21. Natural History
Purpose Was to Evaluate the Natural History of Morphologic Changes Within the Lumbar Spine In Patients Who Sustained Lumbar Disc Extrusions.
All Patients in This Study Were Treated Nonoperatively for Radicular Pain and Neurologic Loss.

22. Natural History The Following Questions Were Addressed:
Does Perithecal or Perineural Fibrosis Result When Extrusions Are Not Removed Surgically
Do Disc Extrusions Spontaneously Resolve, And, If So, How Rapidly?

23. Natural History
Study Population Consisted of 11 Patients With Extrusions and Radiculopathy.
All Patients Were Successfully Treated Nonoperatively.
All Had a Primary Complaint of Leg Pain
All Had Positive Straight Leg Raising Reproducing Their Leg Pain at Less Than or Equal to 60 Degrees
87% Had Muscle Weakness on a Neurologic Basis in a Root Level Distribution Corresponding to the Site of Disc Pathology.

24. Natural History
(CT) Examinations Were Obtained on All Patients at the Inception of Treatment.
These Studies Were Compared With Follow-up MRI Studies.
The Initial Ct Scans Were Evaluated for the Following Criteria:
Disc Size and Position
Thecal Sac Effacement
Nerve Root Enlargement or Displacement
Evidence of Central or Intervertebral Canal Stenosis.

25. Natural History
In Addition to the Pathomorphology Evaluated on Ct Scans, Follow-up MRI Studies Also Evaluated:
Disc Hydration at the Herniated and Contiguous Levels
The Presence of Perithecal or Perineural Fibrosis.

26. Natural History
The Following Grading System Was Used to Evaluate Change in Fragment Size on the Follow-up Studies:
Grade to 50% Decrease in Size.
Grade to 75% Decrease in Size
Grade to 100% Decrease in Size.
Results on Follow-up MRI Examinations Were As Follows:
11% of the Patients Had Grade Residual Fragments.
36% Had Grade Fragments
46% Had Grade Fragments.

27. Natural History Associated Morphologic Changes Were As Follows:
No Patients Had Perithecal or Perineural Fibrosis.
1 Patient Had a Progression of Stenosis.
All Patients Had Disc Desiccation at the Level of Disc Herniation With Contiguous Levels Being Normally Hydrated.
All Patients Had a Decrease in Neural Impingement.
The Interval Between the Initial Presentation and Follow-up Was a Median of 25 Months With a Range of 8 to 77 Months.
[Key Words: Lumbar Disc Herniation, Nonoperative Treatment]

28. Saal J A, Orthop Rev, 19: 691-700 Aug 1990
Dynamic Muscular Stabilization in the Nonoperative Treatment of Lumbar Pain Syndromes.
Saal J A, Orthop Rev, 19: Aug 1990

29. Dynamic Muscular Stabilization
The Results of a Three-year Study of Patients With Herniated Nucleus Pulposus and Radiculopathy Are Presented.
Nonoperative Treatment Options for These Lumbar Disorders.
An Aggressive Physical Rehabilitation Program
Pain Control Methods
Exercise Training Designed to Eliminate Repetitive Intervertebral Disc or Facet Joint Injury
Dynamic Muscular Lumbar Stabilization Techniques

30. Dynamic Muscular Stabilization
Successful Outcomes Were Achieved in 50 of the 52 (96%) Nonoperatively Treated Patients.
A Subcategory of Patients With Extruded Nuclear Fragments Had an 87% Success Rate. Ninety-two Percent of the Overall Study Population Was Able to Return to Work.

31. Side Posture Manipulation for Lumbar Intervertebral Disk Herniation
J. David Cassidy, D.C., Haymo W. Thiel, D.C., And William H. Kirkaldy-Willis, M.D., F.R.C.S. (E & C), F.A.C.S.
J Manipulative Physiol Ther 1993: 16:   Key Indexing Terms: Lumbar Vertebrae, Spine, Intervertebral Disk, Low Back Pain, Chiropractic.

32. Side Posture
Abstract
The Objective of This Article Is to Review the Status of Side Posture Manipulation for Lumbar Intervertebral Disk Herniation.
The Data Presented in This Article Are From the Back Pain Clinic at the Royal University Hospital and the Articles Cited Are Those Which We Feel Are Important in Reviewing This Subject.
Conclusions: The Treatment of Lumbar HNP by Side Posture Manipulation Is Both Safe and Effective. Further Research Is Required to Understand More Fully the Effects of This Treatment on the Intervertebral Disk.

33. J Manipulative Physiol Ther 1989: 12:220-227
Lumbar Intervertebral Disc Herniation: Treatment by Rotational Manipulation
Jeffrey A. Quon, D.C., J. David Cassidy, D.C., Sandra M. O'Connor, D.C., And William H. Kirkaldy-Willis, M.D.
J Manipulative Physiol Ther 1989: 12:

34. Herniation: Treatment
We Describe the Case of a Patient With a Lumbar Disc Herniation Who Underwent a Course or Side Posture Manipulation, Despite the Appearance of an Enormous Central Herniation on the CT Scan.
The Patient Improved Considerably During Only 2 Wk of Treatment.
The Disparity Which So Commonly Exists Between Radiological and Clinical Findings Is Depicted in This Case.

35. Herniation: Treatment
Further, It Is Emphasized That Manipulation Has Been Shown to Be an Effective Treatment of Some Patients With Lumbar Disc Herniation.
While Complications of This Form of Treatment Have Been Reported in the Literature, Such Incidents an Rare.
Key Indexing Terms: Lumbar Disc Herniation, Manipulation, Cauda Equina Syndrome, Computed Tomography.

36. How Many Days Of Bed Rest For Acute Low Back Pain
How Many Days Of Bed Rest For Acute Low Back Pain? A Randomized Clinical Trial
RICHARD A. Deyo, M.D., M.P.H., Andrew K. Diehl, M.D., M.Sc., And MARC ROSENTHAL, DR.P.H.
N Engl J Med 1986; 315:

37. Bed Rest Bed Rest Is Usually Recommended for Acute Low Back Pain.
Although the Optimal Duration of Bed Rest Is Uncertain, a Given Prescription May Directly Affect the Number of Days Lost From Work or Other Activities.
In a Randomized Trial, We Compared the Consequences of Recommending Two Days of Bed Rest (Group I) With Those of Recommending Seven Days (Group Ii).

38. Bed Rest
The Subjects Were 203 Walk-in Patients With Mechanical Low Back Pain
78 Percent Had Acute Pain (< 30 Days), and None Had Marked Neurologic Deficits.
Follow-up Data Were Obtained at Three Weeks (93 Percent) and Three Months (88 Percent).
Although Compliance With the Recommendation of Bed Rest Was Variable, Patients Randomly Assigned to Group I Missed 45 Percent Fewer Days of Work Then Those Assigned to Group II (3.1 Vs. 5.6 Days) and No Differences Were Observed in Other Functional, Physiologic, or Perceived Outcomes.

39. Bed Rest
For Many Patients Without Neuromotor Deficits, Physicians May Be Able to Recommend Two Days of Bed Rest Rather Than Longer Periods, Without Any Perceptible Difference in Clinical Outcome.
If Widely Applied, This Policy Might Substantially Reduce Absenteeism From Work and the Resulting Indirect Costs of Low Back Pain for Both Patients and Employers.

40. Bed Rest

42. Consensus Summary of the Diagnosis and Treatment of Lumbar Disc Herniation.
Anderson GGB Brown MD, Dvorak J, Herzog Rj, Kambin P, Malter A, McCulloch JA, Saal JA, Spratt KF, Weinstein JN,
Spine:21, 1996; 75S Through 78S

43. Consensus
Clinicians Must Not Simply Decide That a Patient With Symptoms and a Positive Diagnostic Test Has a Reason for a Specific Treatment
Clinicians Must Not Decide That a Patient With Symptoms and a Negative Test Does Not Have a Clinically Important Problem.
Must Also Consider the Sensitivity, Specificity and Predictive Value of the Diagnostic Test and the Individual Characteristics of the Patient.

44. Consensus Treatment Outcome Depends on Many Factors.
Point of Service Decisions Vs Population Based Decisions Are Obviously Different.
Each Patient Presents to the Treating Practitioner on a Given Day, at a Given Time, and It Is This Picture Upon Which a Plan of Care Is Formulated.

45. Decisions in Conservative Management of HNP
Pain level and impairment.
Neurological symptomatology.
Neurological deficit.
Flavor of the case.
Selection of technique.
Doctor comfort level.

46. Referral Types Testing only. Second opinion only. Co-management
Complete transfer.
Unrelated health problem detected.

47. Decision to Refer for Neurosurgical Consultation
Patient is overly concerned.
Pain control - severe, intractable pain - initial failure of conservative care.
Profound or progressive neurological deficit.
Bowel or bladder involvement.
Myelopathy.
Cauda equina syndrome.

48. Choosing a Neurosurgeon
Reputation - experience.
Familiar with chiropractic treatment.
Patient or refers patients.
Endorsement by other dc’s/ will co-manage.
Speaks or writes for DC publications.
Familiar with manipulation literature - open-minded.
Location, ease of scheduling, reporting.
Spend a day at office/surgery.

49. Long Term Care & Follow-up
Occupational and recreational considerations.
Education of patient.
Lifting, bending, standing, sitting, driving, sleeping, etc.
Interval outcome assessment.
Follow-up any neurological deficit.
Home care/lifestyle.
Acute.
Ongoing.

50. Cervical and Lumbar Disc Disease: Conservative and Surgical Management
Must diagnose.
Decision to conservatively manage.
Decision to refer to neurosurgeon.
Selecting a neurosurgeon.
Long term treatment and follow-up.