In the late 19th century, a Wells Fargo station agent name Lester Moore was confronted by an angry patron whose package was damaged in transit. In the course of the argument, the patron, Hank Dunstan, pulled his gun, as did Lester Moore. Both died in the ensuing gunfight. Mr. Moore's epitaph on the grave marker is famous: "Here lies Lester Moore, four slugs from a .44, no Les, no more." The "less is more" principal is the focus of this discussion.
Cory is a healthy-looking, slender, athletic 22-year young man who presented with an unusual problem. It is unusual for both the magnitude of the condition and apparent lack of provocation for it. His story is relevant for us because it illustrates the impact of the choices of treatment options available to us.
The athletic appearance is something he worked to achieve. At 6' and about 180 pounds, he has low body fat and enviable muscle mass, the result of many hours of workouts. He stays busy at work, too, as he has a business in Macon that he started while in high school, and he is going to school to further secure his future in another field of endeavor. He is a remarkable and admirable guy.
His back pain began a few weeks ago without any particular injury, though, and it worsened. Eventually, he had significant pain radiating to the right posterior calf and the left lateral calf. It began to interfere with work, ability to sit and study for school, drive, and even walk. Making him even more miserable was the inability to sleep or rest due to the pain.
This is interesting because the pain is most likely due to two disc bulges. Why would an otherwise healthy 22-year old bulge two lumbar discs without an injury? This is a good question. It does happen. There is some research evidence that some people have a genetic error in the sequencing of some amino acids that synthesize cartilage. There is usually a family history of disc, knee, and other soft tissue injuries in these cases.
Cory had an MRI that supported the physical findings. Two lumbar disc bulges were giving him increasing back and leg pain bilaterally. It was interfering with his daily activities increasingly, and he needed help.
He went to an orthopedist who recommended epidural injections, then surgery. It is likely that the surgeon would have done a microdiscectomy, a procedure that trims the bulging disc away from the nerve. Some research suggests that the majority of these will have leg pain returning within ten years. In any event, the prospect of major back surgery on a 22-year old is frightening.
Surgery should always be a last resort short of a dire emergency. In a case like Cory's, appropriate conservative care should be tried for at least four to eight weeks. I was startled to hear that conservative care was neither tried nor recommended. In fact, the surgeon told him to avoid chiropractic care. The irony here is that Cory is precisely the patient scenario that should be in conservative care first before surgery is ever considered. The potential risk of anesthesia, side effects of surgery, and the unknown outcomes of surgery create imponderables for a 22-year old that are not pleasant.
When Cory came to the clinic, I repeated the exam to confirm his condition. We began a flexion distraction treatment regimen to reduce the disc bulges. This involves gentle decompression of the discs in a soothing stretching motion, and it is highly effective with Cory's condition. After two treatments, he was experiencing 80% relief (subjectively) and standing erect (objectively). We added some mechanical decompression on the third visit with good results, stretching his lumbar spine to reduce the disc bulges.
As of now, he is mending quite well. He is able to walk, sit, bend, and drive his car. Leg pain is receding, and his back pain is fading as well. A very important indicator of improvement is that he is resting at night, sleeping comfortably, which will accelerate his healing. He will likely continue to do well, resuming his business and his studies to prepare him for a promising entrepreneurial future.
There are some lessons for us in Cory's case. The one that I want to stress is that conservative care is always the first approach. Drug therapy and surgical intervention should only be considered if conservative care does not reverse the condition.
My rule of thumb is to treat a condition like Cory's for four to eight weeks, looking for at least 50% improvement in how he feels (subjective) and how he looks on examination (objective). If we do not achieve those benchmarks, we consider imaging, co-management, or referral for further care in consultation with the patient, who is the decision maker. We frequently utilize the imaging center, a surgeon, a pain management specialist (anesthesiologist), a neuromuscular therapist, a physical therapist, or other professional when indicated.
So, although a little trite, "Less is more--" again.