Chiropractic: Fragmented/Sequestered and Extruded Herniated Discs and Radicular Pain
Disc herniations are a common diagnostic entity in chiropractic practices with varied etiologies ranging from auto accidents to sports injuries to slips and falls and any other type of trauma that can cause the disc to tear. Treatment has varied from doing nothing to conservative care to opiates and the surgery and in the recent past, opiates and surgery have been the treatment of choice leaving a population of too many addicts and too often failed surgeries. This is not to suggest that all surgeries or opiates are unnecessary, but if drugs and/or surgery can be avoided it is an obvious choice. When considering disc issues, Fardone et. Al (2014) defined the nomenclature that has been widely accepted both in academia and clinically and should be adhered to, to ensure that reporting and visualizing pathology is consistent with the morphology visualized. In the past, this has been a significant issue as many have called a bulge a protrusion, a prolapse or herniation. In today’s literature Fardone’s document has resolved much of those problems.
Herniated Disc: “Herniated disc is the best general term to denote displacement of disc material. The term is appropriate to denote the general diagnostic category when referring to a specific disc and to be inclusive of various types of displacements when speaking of groups of discs. The term includes discs that may properly be characterized by more specific terms, such as ‘‘protruded disc’’ or ‘‘extruded disc.’’ The term ‘‘herniated disc,’’ as defined in this work, refers to localized displacement of nucleus, cartilage, fragmented apophyseal bone, or fragmented annular tissue beyond the intervertebral disc space. ‘‘Localized’’ is defined as less than 25% of the disc circumference. The disc space is defined, craniad and caudad, by the vertebral body end plates and, peripherally, by the edges of the vertebral ring apophyses, exclusive of the osteophyte formation. This definition was deemed more practical, especially for the interpretation of imaging studies, than a pathologic definition requiring identification of disc material forced out of normal position through an annular defect.” (page E1454)
Protruded Disc: “Disc protrusions are focal or localized abnormalities of the disc margin that involve less than 25% of the disc circumference. A disc is ‘‘protruded’’ if the greatest dimension between the edges of the disc material presenting beyond the disc space is less than the distance between the edges of the base of that disc material that extends outside the disc space. The base is defined as the width of the disc material at the outer margin of the disc space of origin, where disc material displaced beyond the disc space is continuous with the disc material within the disc space. The term ‘‘protrusion’’ is only appropriate in describing herniated disc material, as discussed previously.” (page E1455)
Extruded Disc: “The term ‘‘extruded’’ is consistent with the lay language meaning of material forced from one domain to another through an aperture and with reference to a disc, the test of extrusion is the judgment that, in at least one plane, any one distance between the edges of the disc material beyond the disc space is greater than the distance between the edges of the base measured in the same plane or when no continuity exists between the disc material beyond the disc space and that within the disc space.” (page E1455)
Extruded Sequestered, Fragmented Disc or Migrated Disc: “Extruded disc material that has no continuity with the disc of origin may be characterized as ‘‘sequestrated.” A sequestrated disc is a subtype of ‘‘extruded disc’’ but, by definition, can never be a ‘‘protruded disc.’’ Extruded disc material that is displaced away from the site of extrusion, regardless of continuity with the disc, may be called ‘‘migrated,’’ a term that is useful for the interpretation of imaging studies because it is often impossible from images to know if continuity exists. (page E1455)
Bulging Disc: “The terms ‘‘bulge’’ or ‘‘bulging’’ refer to a generalized extension of disc tissue beyond the edges of the apophyses. Such bulging involves greater than 25% of the circumference of the disc and typically extends a relatively short distance, usually less than 3 mm, beyond the edges of the apophyses. ‘‘Bulge’’ or ‘‘bulging’’ describes a morphologic characteristic of various possible causes. Bulging is sometimes a normal variant (usually at L5–S1), can result from an advanced disc degeneration or from a vertebral body remodeling (as consequent to osteoporosis, trauma, or adjacent structure deformity), can occur with ligamentous laxity in response to loading or angular motion, can be an illusion caused by posterior central subligamentous disc protrusion, or can be an illusion from volume averaging (particularly with CT axial images).” (page E1455)
It was reported by McMorland, Suter, Casha, du Plessis, and Hurlbertin (2010) that over 250,000 patients a year undergo elective lumbar discectomy (spinal surgery) for the treatment of low back disc issues in the United States. The researchers did a comparative randomized clinical study comparing spinal microdiscectomy (surgery) performed by neurosurgeons to non-operative manipulative treatments (chiropractic adjustments) performed by chiropractors. They compared quality of life and disabilities of the patients in the study.
The study was limited to patients with distinct one-sided lumbar disc herniations as diagnosed via MRI and had associated radicular (nerve root) symptoms. Based upon the authors’ review of available MRI studies, the patients participating in the study were all initially considered surgical candidates. Both the surgical and chiropractic groups reported no new neurological problems and had only minor post-treatment soreness. 60% of the patients who underwent chiropractic care reported a successful outcome while 40% required surgery and of those 40%, all reported successful outcomes. This study concluded that 60% of the potential surgical candidates had positive outcomes utilizing chiropractic as the alternative to surgery.
Although the previous report concluded that a chiropractic spinal adjustment is an effective treatment modality for herniated disc a more recent study (Lehman ET. Al. (2014), further clarifies the improvement with chiropractic care. This study considered both herniated discs and radiculopathy or pain radiating down into the leg as a baseline for analysis. The study also considered acute and chronic lumbar herniated disc pain patients.
In this study the acute onset patient (the pain just started) reported 80% improvement at 2 weeks, 85% improvement at 1 month, and a 95% improvement at 3 months. The study went on to conclude that the patient stabilized at both the six month and one-year mark after the onset of the original complaint. Although one might argue that the patient would have gotten better with no treatment it was reported that after two weeks of no treatment only 36% of the patients felt better and at 12 weeks up to 73% felt better. This study clearly indicates that chiropractic is a far superior solution to doing nothing and at the same time helps the patient return to their normal life without pain, drugs or surgery.
Chiropractic Care and Herniated Discs with Leg Pain
2 Week Improvement 1 Month Improvement 3 Month Improvement
80.6% 84.6% 94.5%
In a prospective outcome study, Ehrler et. Al. (2016) studied outcomes of chiropractic care on both extruded and sequestered disc patients. They reported “The purpose of this study was to evaluate whether specific MRI features, specifically axial location and type (bulge, protrusion, extrusion, sequestration) of a herniated disc, are associated with the short and long term outcomes of patients treated with high-velocity, low-amplitude SMT specifically to the level of the symptomatic, MRI confirmed, herniation. This is the first study to address this question. Studies searching for predictors of improvement after treatment in previous low back pain patients did not target type and axial location of the herniated discs.Additionally, patients with disc sequestration were not excluded from this study.” (Page 196)
Ehrler et. Al. continued “Over 77% of patients with disc sequestration reported clinically relevant “improvement” compared to 66.7% of patients with extrusion. Although not statistically significant, 100% of patients with sequestration reported clinically relevant improvement at the 3-month data collection time point and at all data collection time points a higher proportion of patients with sequestration reported clinically relevant improvement. There were no significant differences for disc herniation location either by spinal level or in the axial plane for any of the data collection time points. This now calls into question the traditional thinking that disc sequestrations are more dangerous than herniations that remain attached to the parent disc and are more likely to require surgery. However, the studies reporting this did not consider chiropractic spinal manipulative therapy as a treatment option.” (page 197)
I would like to leave you with a last and seemingly unrelated statement. I felt it was important to add this at the end since many of our critics negatively portray the safety of chiropractic care. This statement shall put that to rest leaving only personal biases left standing. Whedon, Mackenzie, Phillips, and Lurie (2015) based their study on 6,669,603 subjects and after the unqualified subjects had been removed from the study, the total patient number accounted for 24,068,808 office visits. They concluded, “No mechanism by which SM [spinal manipulation] induces injury into normal healthy tissues has been identified” (5). This study supersedes all the rhetoric about chiropractic and stroke and renders an outcome assessment to help guide the triage pattern of mechanical spine patients.
Fardon, D. F., Williams, A. L., Dohring, E. J., Murtagh, F. R., Gabriel Rothman, S. L., & Sze, G. K. (2014). Lumbar disc nomenclature: Version 2.0. Recommendations of the combined task forces of the North American Spine Society, American Society of Spine Radiology, and American Society of Neuroradiology. Spine, 39(24), E1448-E1465.
Leeman S., Peterson C., Schmid C., Anklin B., Humphryes B., (2014) Outcomes of Acute and Chronic Patients with Magnetic Resonance Imaging-Confirmed Symptomatic Lumbar Disc Herniations Receiving High-Velocity, Low Amplitude, Spinal Manipulative Therapy: A Prospective Observational Cohort Study With One-Year Follow Up, Journal of Manipulative and Physiological Therapeutics, 37 (3) 155-163
McMorland, G., Suter, E., Casha, S., du Plessis, S. J., & Hurlbert, R. J. (2010). Manipulation or microdiscectomy for sciatica? A prospective randomized clinical study. Journal of Manipulative and Physiological Therapeutics, 33 (8) 576-584
Ehrler M., Peterson C., Leeman S., Schmid C., Anklin B., Humphreys B. K., (2016) Symptomatic, MRI Confirmed, Lumbar Disc Herniations: A Comparison of Outcomes Depending on the Type and Anatomical Axial Location of the Hernia in Patients Treated with High-Velocity, Low-Amplitude Spinal Manipulation, Journal of Manipulative and Physiological Therapeutics, 39 (3) 192-199
Whedon, J. M., Mackenzie, T. A., Phillips, R. B., & Lurie, J. D. (2015). Risk of traumatic injury associated with chiropractic spinal manipulation in Medicare Part B beneficiaries aged 66-69 years. Spine, 40(4), 264-270
6. Studin M., Owens W. (2016) Chiropractic Outcomes on Fragmented/Sequestered and Extruded Discs and Radicular Pain, American Chiropractor, 34 (11) 26, 28, 30, 32-33