Case Correlations

Case Report

History• On 10/24/2005 a 77 year old white female

presented to the Palmer Rock Island Clinic with left Sacroiliac pain.

• She stated that 10 days ago she slipped and fell, landing on her left gluteal region.

• Since, she has been self treating heat and ice packs.

• Her pain is intermittent and passes across her left buttocks, down her lateral thigh to her left lateral ankle.

History

• Her pain is exacerbated by different movements or positions.

• Sitting makes it better

• The pain severely limits her motion

• Pain is listed as 9/10

Past History• 2003 She had chiropractic care in the

Palmer clinics for low back pain involving the right sacroiliac region and down her anterior and posterior thigh.

• 1993 Laminectomy of L3-4

• Pain MVA in 2000

• Currently on 3 hypertension medications and 1 antidepressant

Other History

• Retired Seamstress

• Nothing else remarkable

Review of systems• Review of Systems:• Skin, Hair, and Nails: Dry scaly skin

noted on lower extremity otherwise no abnormalities detected.

• Head and Neck: No abnormalities detected

• Respiratory System: No abnormalities detected.– Cardiovascular System: History of

hypertension, current BP 138/70.

Provide your Differential Diagnosis

• Minimum of 2

• Examinations for DDx – What examinations would you

perform on your patient?

Examination Results• 5’1”, 190lbs., BP 140/70• Posture – Right hip, shoulder and head tilt• Reflexes – normal• Muscles testing – normal (5)• ROM - All lumbar motion caused pain

Flexion 40/70 Pain

Extension 20/35 Pain

Lt. Lat. Flex. 15/20 Pain

Rt. Lat. Flex 20/20 Pain

Examination Results• Supported Adams – Negative

• Kemp’s – Left circumduction with extension caused pain in the left SI joint

• Bechterew’s – Low Back tightness on leg extension

• SLR – back and leg pain at 45o bilaterally

• Nauchlas – pain in back at 30o

What do the test results mean?

• Positive tests?

• Negative tests?

• What else should we test?

Spinographic Exanimation

A-P Lumbopelvic• Narrowing of the hip joints

is seen bilaterally

• A generalized decrease in bone density consistent with osteoporosis is noted.

• A number of discrete radiodensities are viewed with in the upper right abdomen likely reflective of granulomata with in the liver.

Lateral Lumbopelvic• fusion of the L3 to L4 level

with marked loss of disc height and calcification within this disc

• Advanced degenerative disc disease is seen throughout the lower thoracic and lumbar spine with marked loss of disc height, osteophytic change and the presence of vacuum cleft signs at all visible disc levels

Lateral Lumbopelvic

• Pronounced anterolateral osteophyte formation is seen at the L4 and L5 disc level. This is also noted LI, L2 and L3 with posterior osteophyte formation viewed

• The combination of these findings may contribute to possible stenosis

Eisenstein’s Measurement • Articular Line• Posterior body Margin• A measurement below

15mm may indicate spinal stenosis

• This patient measured 8-13mm

IMPRESSIONS:

1. Post surgical fusion L3 - L4

2. Advanced degenerative disc disease with posterior osteophyte formation and possible canal stenosis

3. Advanced degenerative joint disease iliofemoral joints

What else should we test?Lumbar spinal stenosis should be

suspected especially in the elderly patient who presents complaining of chronic back pain with radicular symptoms and with intermittent neurogenic claudication.

The patient's history usually reveals the need for frequent rest periods after walking a short distance.

Furthermore, a change in posture, such as leaning forward (e.g., supporting oneself over the cart when shopping) or assuming a sitting position, is necessary to bring about some relief.

Dvorak et al. Musculoskeletal Manual Medicine. 2008: Thieme Publishing Stuttgart, Germany

What else should we test?To demonstrate possible deep tendon reflex

changes, alteration in sensation, as well as muscle weakness, it is often necessary to have the patient move until the state of claudication is reproduced.

Electro-diagnostic studies may provide additional information, especially when the presentation is relatively "classic" but the neurologic examination is rather unremarkable. MR! or CT have become the mainstay tools in the diagnostic work-up, in addition to a thorough history and physical examination.

neurologic claudication (cramp-like pain and weakness in the legs, due to nerve root irritation, particularly with activity.

Dvorak et al. Musculoskeletal Manual Medicine. 2008: Thieme Publishing Stuttgart, Germany

DDX: Spinal Stenosis vs. Herniated Disc:

Spinal Stenosis Herniated Disc

Pain neurologic claudication(cramp-like pain and weakness in the legs, due to nerve root irritation, particularly with activity)

pain along the course of a nerve or it's roots into the lower extremity, accompanied by numbness, tingling, weakness, tenderness and loss of sensation

Relief rest/bending forward variable, extension, lying down

Locale often bilateral; radiates to buttocks, groins, thighs and down legs

usually unilateral; radiates down leg to foot

Numbness may be relieved by change in body position

unrelieved by change in body position

Motor Weakness often absent; heaviness' of both legs with use

possible motor weakness and loss of reflex(es)

Neural Tension Signs none Positive (straight leg raise, tripod and bowstring signs)

http://www.wcb.ab.ca/providers/medref02.asp

Oh, by the way• Patient did have an MRI in October of

2003 which showed “severe spinal stenosis at the L2-3 and L3-4 levels”.

• Previous chiropractic care had helped with symptoms

Final Dx

• 721.42 Lumbar region Spondylogenic compression of lumbar spinal cord

• 722.52 Lumbar or lumbosacral intervertebral disc

• 724.02 Spinal Stenosis Lumbar region• 739.3 Lumbar Spinal

subluxation/segmental dysfunction• 739.4 Sacral region Sacrococcygeal

region Sacroiliac region subluxation/segmental dysfunction

Literature Review• A non-surgical approach that attempts to target the

unique pathophysiology of LSS may be best able to rapidly improve pain and function in these patients.

• Such a treatment strategy would attempt to mobilize the segment(s) involved, decompress the involved nerve root(s) and mobilize the involved nerve root(s) to break up periradicular adhesion, thus releasing nerve root entrapment, and restoring vascular function.

• It would appear that maintaining intersegmental and nerve root mobility would then be important in order to maximize the long term benefit of treatment

Murphy, Hurwitz, Gregory, Clary. A non-surgical approach to the management of lumbar spinal stenosis: A prospective observational cohort study. BMC Musculoskeletal Disorders 2006, 7:16 doi:10.1186/1471-2474-7-16

Literature Review• A prospective consecutive case series with long

term follow up of fifty-seven consecutive patients who were diagnosed with Lumbar Spinal Stenosis (LLS).

• The mean patient-rated percentage improvement from baseline to long term fallow up (16.5 months) was 75.6%.

• Conclusion: A treatment approach focusing on distraction manipulation and neural mobilization (cat/camel & nerve flossing) may be useful in bringing about clinically meaningful improvement in disability in patients with LSS.

Murphy, Hurwitz, Gregory, Clary. A non-surgical approach to the management of lumbar spinal stenosis: A prospective observational cohort study. BMC Musculoskeletal Disorders 2006, 7:16 doi:10.1186/1471-2474-7-16

Literature Review• Intervention and Outcome: Flexion-distraction

manipulation of the lumbar spine was performed. • Incremental increases in traction forces were

applied as the patient responded positively to care. • He experienced a decrease in the frequency and

intensity of his leg symptoms and a resolution of his low back pain.

• These improvements were maintained at a 5-month follow-up visit.

• CONCLUSION: Successful management of symptoms either caused by or complicated by lumbar spinal stenosis is presented. Manipulation of the spine shows promise for relief of symptoms through improving spinal biomechanics.

Snow GJ. Chiropractic management of a patient with lumbar spinal stenosis. J Manipulative Physiol Ther. 2001 May;24(4):300-4.

Literature Review• Chiropractic manipulation for patients with lumbar stenosis

has been shown to be most effective when the symptoms are posture-dependent, there is no evidence of segmental instability, and the patient has the cognitive and physical abilities to participate in the treatment.

• In a case report of multilevel stenosis, flexion-distraction manipulation decreased the intensity and frequency of leg pain and even led to the resolution of back pain.

• It has been speculated that spinal manipulation exerts a powerful placebo effect that produces a specific but short-term benefit.

• Others believe that manipulative therapy reduces local ischemia and mechanical compression of chronically irritated nerve roots.

• Although we do not recommend chiropractic treatment to all of our patients, if it is sought by a patient, we caution against extension manipulation.

YUAN, ALBERT.Nonsurgical and Surgical Management of Lumbar Spinal Stenosis. THE JOURNAL OF BONE & JOINT SURGERY. JBJS.ORG VOLUME 86-A · NUMBER 10 · OCTOBER 2004

Literature Review• North American Spine Society (NASS).

Diagnosis and treatment of degenerative lumbar spinal stenosis. Burr Ridge (IL): North American Spine Society (NASS); 2007 Jan. 262 p. [394 references]

• Diagnosis and treatment of degenerative lumbar spinal stenosis.

• http://www.guideline.gov/summary/summary.aspx?doc_id=11306

• What is the role of manipulation in the treatment of spinal stenosis?

• (Insufficient Evidence)

ManagementChiropractic Management Plan

• Patient to be seen 3 times per week for 4 weeks to improve function and range of motion in lumbar spine and decrease pain levels.

• No outcome measure was used

• Technique used – Palmer Package (Drops and Flexion/Distraction with some activator when indicated)

Dailey SOAPs10/24 – 1st adjustment.

• Pain level is 9/10,

• SAC P-L, Drop

• Rt. Ilium PI, Drop

• Flexion/Distraction at L4-5

• Post adjustment notation – Patient walking better and says she is feeling less pain

Dailey SOAPs10/25 – Patient reports she is feeling better (7/10)

Sleep has improved walking easier, still pain over SI joints but leg pain has decreases.

• Adjust Rt. Ilium, SAC, T6

10/27 – Left SI pain still present and pain level staying at 7/10. Pain is worse at night, and aggravated when moving from a seated to a standing position

• Adjusted Lt. Ilium (AS-supine) and T6 no F/D due to prone position irritated patient

Dailey SOAPs10/28 Patient reports doing well after the last

adjustment. Pain came back after sleeping. Pain lasted 45 minutes, then went away. The pain is 7/10 normal but 9/10 during flare up.

• Adjust Lt. Ilium and T611/1 Patient did well after the adjustment. Her

pain is down to 5/10. She did have a flare up 2 days after the last correction. Pain was sharp and started when she lays down. 9/10 pain with flare up. The pain is only in her Left SI, no pain down the leg.

• Adjust Lt. SI (AS- Supine Drop )

Dailey SOAPs11/3 She had another Flare up about 1 hour before

visit. Pain was mostly in the leg with little back pain (7/10) and lasted 15 minutes (adjusted Lt. Ilium – AS)

11/7 Patient states she responded well to care. However, she did have a flare up this morning where the pain went to 9/10. (adjusted Lt. Ilium – AS)

11/10 Patient states she responded well to care, She is sleeping better. Pain is 5/10 in the Lt. SI and hurts more when she pushes and pokes at it. She reported her Left knee Locked on her today. (Adjust Lt. Ilium and Lt tibia (lat) with Act.)

Dailey SOAPs

11/15 Patient reports she is better after the last adjustment. She is sleeping through the night and the pain is a dull ache (3/10) with no aggravation with movement or laying down. (SAC – P-L)

11/17 Patient states she continues to do well, she is sleeping through the night. She does have an ache (2/10) in the left SI and calves after walking. The pain decreases 5 minutes with rest. (SAC – P-L)

Re-Evaluation• ROM - All lumbar motion caused pain

Flexion 60/70 (40) No PainExtension 30/35 (20) PainLt. Lat. Flex. 20/20 (15) No PainRt. Lat. Flex 20/20 (20) No Pain

• Kemp’s – Left circumduction with extension caused tightness in the left SI joint

• Bechterew’s – Negative• SLR – back tightness at 60o bilaterally • Nauchlas – pain in back at 50o bilaterally

Questions Comments Concerns?