Case Report: Conservative Management of Low Back pain with Radicular Pain and Numbness in the Right Leg and Foot
Background: Disc herniation is one of the most common causes of low back pain with radicular pain. The aim of presenting this case is to demonstrate the benefits of Chiropractic care including Spinal Manipulation and Mobilization Therapy (SMMT) and Exercise Therapy (ET) in the treatment of disc herniation.
Case Report: A 38-year old female patient came to my office with moderate to severe Right S1 Radiculopathy (VAS=8/10) with tingling and numbness following the S1 nerve root distribution on right leg and foot. The pre-treatment MRI demonstrated the Chronic Dehydrates Right Paracentral L5-S1 Protrusion with compromised right lateral recess at the same level. The patient problem started a year ago following performing barbell back squat exercise under supervision of a trainer. Since the onset of injury she experiences pain whenever put stress on her back. Prior referring to my office, this patient received about some sessions of physical and massage therapy which they did not alleviate the problem. She has been prescribed Diclofenac, Gabapentin and Tizanidine which apparently they did not resolve the patient’s discomfort. Recently the patient was visited by a neurosurgeon and a PM&R pain specialist who had recommended her the surgical procedure and Ozone therapy respectively. She also has dextroscoliosis at thoracolumbar junction with mild degenerative changes at this level.
Discussion: In such cases, it is highly recommended to perform a comprehensive neurological exam to rule out any ongoing neurological deficits. The EMG/NCV result showed no axonal degeneration. I recommended the patient to stop taking the above medications. The Naproxen (250mg bd) was recommended at the beginning of treatment if the pain got worse or intolerable. Patient was treated by 15 sessions of Chiropractic care including gentle precise flex/distraction with joint mobilization at L1-L4 and SI joint. After session 10, exercises such as pool therapy and Mild intensity stretching and strengthening exercises for pelvic and lower extremities were also added.
Results: Although the injury was old but the pain and activity of daily living improved significantly. The response to treatment after 15 sessions of Chiropractic care are as follows:
- Pain alleviated to VAS=1-2/10 without any tingling and numbness.
- Post treatment MRI scan demonstrated a few noticeable changes as follows:
- Increased T2 relaxation time on post-treatment MRI demonstrates rehydration of the disc.
- The herniated portion got smaller in size possibly due to reduction and the lateral recess got patent. Although the aforementioned changes are small but it seems such changes to the disc morphology had good impacts on the patient’s pain and the activity of daily living.
I think the size of the IVD herniation is not an indication for applying the surgical procedures or spinal injections including nerve blocks. The Presence of degenerative changes and dextroscoliosis at thoracolumbar junction should get noticed when prescribing exercise and apply SMMT because they can directly affect the short and long term response to treatment.
Babak Alagha M.D., D.C., DAME