Robert A. Hayden, DC, PhD
Jack came in the front door of the clinic in obvious agony, leaning forward and to his left. His low back pain radiated to the back of the right calf, severe and disabling, worsening with coughing and straining. He was supported by his petite wife, Shelly, who struggled valiantly under his size and weight.
Shelley's determination to hold Jack up was fueled not only by concern for her husband, but also by her anxiety about what was happening to him. Sometimes desperation gives us uncommon strength, and she was working beyond her predicted capability that day.
Jack worked in a career that involved long hours of stringing heavy electrical wires, dangling from a bucket on a boom high above the streets. He pulled, pushed, and twisted as part of his work every day for many years. The wear and tear had finally caught up with him.
Jack was also a victim of his own work ethic: he refused to leave his coworkers when he began having back pain because he did not want to leave them short handed. His team mentality and dedication to his job caused him to ignore very important signs of distress that his injured body sent to his brain in the form of intense pain.
It should also be said that Jack was also a victim of his own testosterone. Men are less likely to seek help with pain complaints than women, so when they finally present for care, often the condition has advanced. Also, men are socialized to play team sports as young boys. Sacrifices are made for the good of the team. These have always been factors in the higher mortality rates among men, for example, with heart disease.
Jack's presentation is a familiar sight in a chiropractic clinic. The initial impression is full of clues to the cause of the problem, raising the strong suspicion that this man had a bulge in the fifth lumbar disc that was protruding toward the back of the spine and off to the right side, pressurizing the first sacral nerve on the right side.
We have all heard someone say they have a bulging, degenerative, protruding, herniated, or ruptured disc. What does these terms mean?
The answer, as silly as this sounds, depends on who responds to the question. The terms have blurred in meaning and are frequently used interchangeably, making it easy to confuse them.
Discs are made of cartilage. When we are young, they are about 70% water. As we mature (a euphemism for "age"), the discs lose water. The loss of water means that the disc contracts, losing height and becoming more fragile. This is one of the reasons we lose height as we grow older.
Unfortunately, the discs also can tear with the kind of exertion that was Jack's daily routine. A tear allows the liquid center, or nucleus, of the disc to "leak" its fluid to the outer edges of the disc, causing the disc to bulge, protrude, or herniate (terms used interchangeably) at that point. If the nuclear fluid leaks from the bulge, the disc may be said to have ruptured or prolapsed. This leakage irritates the nerve that exits the spine at that level, radiating pain wherever that nerve goes. That is why a problem in the back may cause pain in a distant extremity.
Jack's history was obtained, and a physical exam was performed. The orthopedic and neurological exams were confirmatory of the initial impression of a fifth lumbar disc bulge. X-rays revealed the curve of the lumbar spine to the left, as he could not stand erect due to pain and muscle spasms. The bones themselves showed no pathology, save the normal wear and tear one would expect in a man his age.
Indeed, Jack's disc injury proved to be one of the worst in my experience as a chiropractor. Because his case was so involved, it ultimately became one of the most rewarding of my career thus far.
Jack's case presents several dilemmas which are truly emergencies for him. Let's look at some of the issues he faces, because they are common to most of us at one time or another.
First, there is the pain. With a disc bulge, the pain may be severe, or there may be numbness or tingling or all of these. Many times these sensations will radiate to an extremity. Knowledge of the anatomical areas served by a given nerve allows the doctor to trace the problem to its source and localize it. While pain is useful in the diagnosis, it must be controlled as soon a possible.
Second, Jack could not work until this problem is resolved. This would have had devastating financial consequences had Jack not worked for a company that allowed him leave to recuperate. Jack was fortunate, but many others are less fortunate. The length of the recovery period is thus crucial to the patient for several reasons, though not all of them are physical.
Another issue is anxiety, which was compounded by all of the above. Not only was Jack anxious about his condition, but also his wife was terrified. This injury threatened his ability to make a living, his role as a father, his role as a husband, and every other aspect of life. Jack's injury would be a family affair because it would affect all of them. In short, his life would be on hold until he could get back on his feet.
So, what can be done for Jack and his family?
The Agency for Health Care Policy and Research (AHCPR), a blue-ribbon panel of experts, looked at the literature for acute low back pain and concluded that the most effective and efficient way to treat the condition was the combination of spinal manipulation, early mobility (walking), and mild pain medication when needed. Spinal manipulation, of course, is what chiropractors do.
The most important goal for me on that first visit was to gain Jack's confidence as we established our doctor-patient relationship. I began this process by explaining the condition so that he understood what was happening to him. Jack needed also to understand that his condition was very treatable by conservative means. Only about 1 to 2% of these patients require a surgical consultation, and knowing this alleviated some anxiety.
It was just as large a task to help Shelley with her anxiety. One of my strategies was to include her in all the patient education that we did at the clinic. She was taught to help Jack exercise and stretch properly as part of his rehabilitation. Spouses often feel helpless to help mates in pain, but she felt better and more secure being part of his care.
The actual treatment of choice for this condition was disc decompression manipulation (flexion-distraction is the older term), which involved putting Jack on a specialized treatment table in a prone position. The table was gently and comfortably flexed, opening the injured joint and creating suction in the affected disc. This pulled the bulging disc material off the nerve so that the pain was alleviated. The disc healed and actually recovered some height with time and treatment.
Jack's pain was addressed with physiotherapy, including ice, trigger point massage, specialized electrotherapy, ultrasound, gentle stretches, and progressive exercise. Disc injury patients are mobilized early in accordance with AHCPR recommendations, as walking helps maintain mobility.
Jack began to respond to care. We began treating him twice daily to accelerate his recovery. Within a few days, his pain was significantly reduced. The second week, we dropped his treatment frequency to three times that week. As his condition improved, the treatment frequency was reduced accordingly. He stood completely erect and pain-free in three weeks. He went back to work full- time in his original position in the fifth week.
Some might ask why we did not obtain magnetic resonance imaging (MRI). The standard of care we follow is that if the patient is not at least 50% better by subjective criteria (how he/she feels) and objective criteria (based on the physical exam) within four weeks, the patient is referred for further diagnostic work, such as an MRI, or to another provider (a conservative orthopedist or neurologist) for co-management. In the vast majority of patients treated with disc decompression manipulation, however, the decision about MRI never comes up because they have recovered long before the four-week point.
MRIs also give about 40% false positive information regarding disc protrusions or bulges. The physical examination is a far more sensitive indicator of a patient's condition than this kind of imaging in the early phases of care. These expensive scans should always be reserved for when they are truly indicated.
Jack is still working today, and planning for a long and happy retirement soon. He still comes in for a "tune-up" when he feels his back getting sore or stiff with a hard day's work. He maintains himself with weight loss, exercise, and improved body mechanics. He also uses more realistic judgment about his physical limitations. Shelly, too, is a patient, as are the next two generations of that family.
Don't become another "Jack." If you don't take good care of your spine now, you may someday find yourself fighting a "battle of the bulge."