Chiropractic Management of Low Back and Neck Pain with
Bilateral Radiculopathy Caused by Spinal Stenosis: A Case Study
ABSTRACT
Objective: To determine if chiropractic care can provide relief of low back and neck
pain with bilateral radiculopathy caused by spinal stenosis.
Clinical Features: An 89-year-old retired engineer had low back pain and neck
pain, both with bilateral radiculopathy, and previous diagnoses of lumbar stenosis
and osteoarthritis throughout the entire spine. Exacerbation of leg pain and arm
pain occurred spontaneously and was most closely associated with lumbar / hip
extension and cervical extension and lateral flexion, respectively. Palpation
revealed decreases in all ranges of motion throughout the spine and a severely
fixated posterior-inferior right ileum. Hypertonicity and reduced range of motion
was evident in the hamstrings and iliopsoas muscles. The patient brought with him
two radiographic studies completed three months prior to beginning care and these
studies, a 7-view cervical series and a 5-view lumbar series, were reinterpreted at
Logan. Film findings confirmed the lumbar stenosis and advanced osteoarthritis
diagnoses and identified the presence off diffuse idiopathic skeletal hyperostosis
(DISH) with anterior longitudinal ligament calcification and calcific bridging of the
vertebral bodies at most levels throughout the spine.
Intervention and Outcome: Light mobilization was used in side posture to treat
the fixated sacroiliac joint, and the lumbar and thoracic spine were mobilized in the
prone position with light pressure from posterior to anterior. Passive ranges of
motion were used to mobilize the cervical spine. Post-isometric relaxation
techniques were used to stretch the hamstrings and iliopsoas muscles while
avoiding pain provocation with excessive lumbar extension. The patient was also
given core stabilizing home exercises. After two treatments the patient reported
relief regarding his muscle hypertonicity but no change in his intermittent radicular
pain. The patient also reported joint soreness one and two days following each
treatment. The soreness did not interfere with his daily exercise regimen of walking
around the parking lot at his senior living center. After two more weeks of
treatment the patient reported a 30% improvement in low back and leg pain, a 15%
improvement in neck and arm pain, and a 15% improvement in balance.
Conclusion: Chiropractic care consisting of diversified and flexion distraction
adjusting, light mobilization, manual distraction, post-isometric relaxation
stretching and core stabilization exercises can provide some benefit in symptom
relief to patients suffering from spinal stenosis with radiculopathy. Decompression
surgery, while often effective in treating spinal stenosis, should be performed only
on appropriate candidates whom have failed to achieve relief via a trial of
conservative care.
Key Words: lumbar stenosis, diffuse idiopathic skeletal hyperostosis, osteoarthritis,
low back pain with radiculopathy, neck pain with radiculopathy, chiropractic
adjustment, soft tissue manipulation
Introduction:
This is a case presentation of an 89year-old retired engineer with low
back and sacroiliac pain with
intermittent radiation into both legs
and neck pain with intermittent
radiation into both arms. The patient
had previous diagnoses of lumbar
stenosis and advanced osteoarthritis
throughout the spine, which were
documented in lumbar and cervical
radiographic studies taken prior to the
patient’s arrival at Montgomery
Health Center. The patient was
seeking chiropractic care as a means
of pain relief.
Case Report:
An 89-year-old retired engineer
reported a six month history of low
back and hip pain that was worse on
the right side and occasionally
produced shooting pain down one or
both legs, especially with lumbar and
hip extension and when going from a
seated to a standing position or
following long periods of walking. The
patient also reported neck pain and
stiffness with occasional radiation into
one or both arms with no consistent
pattern. The pain from both
complaints was rated on the visual
Analog Scale as a 9 out of 10 during
bouts of radiation and as a 1-2 out of
10 throughout most of the day. The
constant pain was described as a dull
ache while the radicular pain was
characterized as sharp and shooting.
The patient had presented with these
symptoms to his primary care
provider three months prior to
entering Montgomery Health Center,
and five-view lumbar and seven-view
cervical series were ordered by his
primary care provider and revealed
lumbar canal stenosis that was most
pronounced at the lumbosacral
junction and advanced spinal
osteoarthritis with neural foraminal
encroachment in the lower cervical
spine. The patient had sought
chiropractic care from a chiropractor
who made weekly visits to his senior
living center, and the patient had
experienced some pain relief from
treatment with an unspecified
orthopedic stimulation device.
However, the chiropractor changed
locations and quit visiting the senior
living center, and this prompted the
patient to seek further care at
Montgomery Health Center.
Social history revealed that the patient
is a widower who lives alone in an
independent living center for senior
citizens. He is a retired engineer as
well as a World War II veteran who
served in the infantry in the United
States’ European campaign.
Accompanying the patient was his
geriatric care manager, a licensed
physical therapist specializing in
geriatric management, who informed
the intern after the initial visit that the
patient struggles with feelings of
loneliness, low self-worth and fear of
death in his day-to-day life. The
patient deals with these emotional
difficulties by staying busy with
consulting work and various meetings
and clubs, which also makes it difficult
to get the patient in for care twice a
week as desired. His chief complaints
impact his social life by limiting his
ability to walk and exercise because
his symptoms are increased with
prolonged activity. The patient also
experiences apprehension and anxiety
regarding the somewhat
unpredictable flare-ups of his
symptoms, especially because he has
fallen twice, luckily without significant
injury, upon standing up as the pain
shot down his legs in an almost
paralytic manner.
Health history reveals hypertension
and peripheral vascular disease with
intermittent dizziness and two
transient ischemic attacks in 2006.
The patient also suffers from benign
prostate hypertrophy and underwent
a trans-urethral resection of the
prostate in 1970. He also experiences
mild renal insufficiency and dysuria
and has had two benign colon polyps
removed and undergone three
hemorrhoid banding procedures. The
patient has bilateral macular
degeneration and has had cataract
removal and lens implants in both
eyes. Also included in the health
history is sleep apnea, inguinal hernia
with surgical repair in 2005, right
shoulder surgery in 1982,
osteoarthritis of the small joint of both
hands (Rf negative), and tenosynovitis
of the left small finger flexors.
Dermatological history includes
seborrheic dermatitis, seborrheic
keratoses, seborrheic eczema,
nummular eczema, cherry
hemangiomas, and a basal cell
carcinoma on the left ear and
melanoma on the back that were both
surgically removed. The patient takes
over a dozen medications to help
control his hypertension,
hypercholesterolemia, skin conditions,
constipation, macular degeneration,
and BPH. The patient reports regular
exercise in the form of walking around
his senior living center on most days
until his symptoms flare. Previous
chiropractic history included
approximately six weeks of care with
an orthopedic stimulation device
called an OrthoStim, which the patient
reported to provide some pain relief.
Chiropractic care was discontinued
when the patient’s chiropractor
relocated, and this prompted the
patient to seek care at Montgomery
Health Center.
The hip examination revealed limited
extension accompanied by hypertonic
psoas, hamstrings and tensor fascia
lata muscles bilaterally but more
pronounced on the right. Patrick
FABERE test produced mild right
sacroiliac pain and pain and tightness
in the adductors and hamstrings. The
lumbar examination revealed low
back and buttock pain most
pronounced around the right
sacroiliac joint. This pain was
aggravated by right lumbar lateral
flexion, Milgram’s test, and prone
extension tests including Yeoman’s,
Hibb’s, Nachlas’ and Ely’s tests, but
radiculopathy was never reproduced
during the examination. Marked
hypertonicity was noted in the lumbar
erector spinae bilaterally and all
lumbar ranges of motion, both active
and passive, were reduced. The
thoracic spine also exhibited a global
decrease in ranges of motion, but no
specific maneuvers provoked pain in
the thoracic spine. Scapular
approximation, however, did
reproduce the lower cervical pain for
which the patient is seeking
treatment. Examination of the
cervical spine again revealed global
loss of motion with severe anterior
head carriage and hypertonic upper
trapezius, levator scapulae,
sternocleidomastoid and sub-occipital
muscles bilaterally. Jackson’s
Compression and Maximal Foraminal
Compression tests reproduced the
chief complaint of neck pain but failed
to produce radiculopathy. The
physical exam revealed no abnormal
vascular, lymphatic, or neural deficits.
Upper and lower extremity deep
tendon reflexes were +1 bilaterally,
Hoffman and Babinski were negative,
myotomes all 5/5 and the patient
could heel and toe walk without
assistance. The Oswestry Low Back
Pain Questionnaire revealed a 56%
disability rating, while the Neck
Disability Index Questionnaire
showed a 32% disability rating.
As previously mentioned, the patient
had 5-view lumbar and 7-view
cervical radiographic studies
performed three months prior to
beginning care and Logan, and these
studies were reinterpreted by the
Logan Radiology Department. The
presence of lumbar stenosis and full
spine advanced osteoarthritis with
osteophytosis and neural foraminal
encroachment were confirmed, and
the diagnosis of diffuse idiopathic
skeletal hyperostosis (DISH) was
added with calcification of the
anterior longitudinal ligament and
calcific bridging of the anterior centra
at most levels throughout the spine.
No absolute contraindications to
conservative care were identified.
Intervention and Outcome
The patient was treated with side
posture and prone drop-piece
adjusting of the sacroiliac joints,
flexion-distraction of the lumbar
spine, light prone mobilization of the
thoracic spine, manual cervical
distraction and passive ranges of
motion of the cervical spine, soft
tissue massage and core stabilization
exercises. The patient reported a 30%
improvement in his low back and leg
pain, a 15% improvement in his neck
and arm pain, and a 15%
improvement in his balance after one
month of treatment with no ill effects
from the treatment.
Discussion
Degenerative spinal stenosis typically
occurs in older individuals following
osteoarthritis of the spine. As one
ages, joints that are frequently
subjected to significant pressures may
exhibit degeneration of the articular
cartilage within the joints. As the
cartilage is eroded away the joint
space decreases and this brings the
articulating surfaces of the bones
closer together and can lead to
complete approximation of the bony
surfaces with damage and sclerosis
over time. When this occurs in the
spine it often consists of a loss of
intervertebral disc space heights
following years of sustained axial
compression. As disc space height is
lost the apophyseal joints are forced
to bear more axial compression and
this stimulates bony hypertrophy in
these areas to help bear the increased
load and stabilize the spine. This is
the typical progression of the common
form of spinal osteoarthritis termed
discogenic spondylosis1.
The increased loading of the
apophyseal joints that occurs in
discogenic spondylosis can lead to
various patterns of bony hypertrophy
and ossification. Facet hypertrophy
can eventually lead to neural
foraminal encroachment and
dermatomal pain and loss of
sensation. Bony hypertrophy can also
invade the spinal canal and lead to
spinal stenosis, which can produce a
variety of pain patterns and neural
deficits depending on both the levels
of the spine involved and the
geographic area of the spinal cord that
is being encroached upon. Typical
symptoms of lumbar stenosis may
include low back and buttock pain and
possibly bowel and/or bladder
dysfunction, whereas cervical stenosis
would likely produce neck, shoulder
and arm pain and possibly associated
deficits1.
In addition to hypertrophy of bone,
degenerated spinal joints may also
exhibit calcification of the
surrounding soft tissues. When this
calcification occurs within multiple
levels along the anterior longitudinal
ligament with anterior bridging of the
vertebral bodies the condition is
referred to as diffuse idiopathic
skeletal hyperostosis, or DISH. DISH
can be another attempt by the body to
stabilize the spine following disc and
joint degeneration, and the anterior
calcific bridging can greatly reduce
spinal motion and contribute
significantly to back pain1.
Conservative care including
chiropractic management has long
been used in cases of spinal
osteoarthritis. However, spinal
stenosis has traditionally been treated
via one of several variations of
decompression surgery. The first
variation is the traditional
laminectomy, in which the lamina and
spinous process are removed from the
affected level in efforts to open up the
spinal canal. While often successful in
decompressing the spinal cord,
laminectomy leaves that area of the
spine weakened and that area of the
spinal cord relatively unprotected
from the posterior side. Newer
surgical approaches attempt to
achieve cord decompression without
removal of so much material from the
sine and surrounding musculature.
Some of these new surgical
approaches include the chimney sub
laminar decompression2, the
interlaminar decompression3, and the
spinous process-splitting
laminectomy4.
Several studies have been conducted
to assess the outcomes of the various
decompression surgeries performed
in cases of spinal stenosis. Gunzburg
et al5 assessed forty post-surgical
patients after a minimum one year
follow-up (mean of 1.7 years) in terms
of pain, functional status, pain while
walking and leg pain overall. The
study found that based on these
criteria only 55% of the patients who
underwent surgery had a successful
outcome one year later. Hee and
Wong6 conducted a similar study of 68
patients aged 60 and older and found
somewhat more favorable results.
Their follow-up data was obtained on
average eight years following
decompression surgery and consisted
of 68% successful outcomes, 22% fair
and 10% poor. Back pain was relieved
in 91% of patients, leg pain in 76% of
patients, and 7% underwent repeat
surgeries. In another retrospective
study, Jonsson et al7 assessed the
outcomes of 105 patients who
underwent decompression surgery for
lumbar stenosis. Their study used
similar self-reporting measures to
evaluate surgical success, and
produced four-month follow up
success rates of 63% and five-year
success rates of 52%. The study also
reported that 18% of the patients
underwent a follow-up surgery either
to make repairs due to surgical
complications, repeat the
decompression following repeated
stenosis, or to fuse the affected levels
in an attempt to treat increasing
lumbar pain.
Conservative management of spinal
stenosis is somewhat lacking in
controlled studies, but some research
has been done to assess the
effectiveness of different approaches
in symptom relief8. A case study by
Snow9 found that flexion-distraction
adjusting of the lumbar spine in a 78year-old male patient with lumbar
stenosis with back pain and bilateral
radiculopathy resulted in elimination
of his back pain and reductions in
both the frequency and intensity of his
leg pain that were maintained after
five months of follow-up. In a similar
study by DuPriest10, a 76-year-old
male patient with lumbar stenosis and
back and leg pain was treated twelve
times with a combination of flexiondistraction adjusting, deep tissue
massage, ultrasound, therapeutic
exercise, a heel lift and modification of
activities of daily living. Results from
this study were the complete
elimination of all symptoms after only
three weeks of treatment. In a cohort
study by Murphy et al11, fifty-seven
patients who received flexiondistraction adjusting for lumbar
stenosis were assessed for long-term
outcomes of care. The results
included a 75.6% mean improvement
following care and also a 73.2%
improvement in disability.
Conclusion:
This case report consists of an 89year-old male patient diagnosed with
advanced discogenic spondylosis with
neural foraminal encroachment of the
cervical spine, lumbar stenosis and
diffuse idiopathic skeletal
hyperostosis. The patient was treated
with diversified and flexiondistraction adjusting, manual traction
and passive motion of the cervical
spine, soft tissue massage and core
stability exercises. Outcomes included
a 30% reduction in low back and leg
pain, 15% reduction in neck and arm
pain and a 15% improvement in
balance. The literature most strongly
supports flexion-distraction adjusting
in the conservative management of
spinal stenosis, and long-term followups of decompression surgery reveal
success rates of only 52-55%5, 6, 7, 12.
Much more research is needed in the
area of conservative management of
spinal stenosis.
References:
1. Simon RP, Greenberg DA, Aminoff MJ. Clinical Neurology. 7th Ed. McGraw-Hill,
2009.
2. Lin SM, Tseng SH, Yang JC, Tu CC. Chimney sublaminar decompression for
degenerative lumbar spinal stenosis. J. Neurosurg. Spine. May 2006, 4(5):
359-364.
3. Hatta Y, Shiraishi T, Sakamoto A, Yato Y, Harada T, Mikami Y, Hase H, Kubo T.
Muscle-preserving interlaminar decompression for the lumbar spine: a
minimally invasive new procedure for lumbar spinal canal stenosis.
Spine. Apr 2009, 34(8): E276-280.
4. Lee DY, Lee SH. Spinous process splitting laminectomy for lumbar canal
stenosis: a critical appraisal. Minim. Invasive Neurosurg. Aug 2008, 51(4):
204-207.
5. Gunzberg R, Keller TS, Szpalski M, Vandeputte K, Spratt KF. A prospective
study on CT scan outcomes after conservative decompression surgery for
lumbar spinal stenosis. J. Spinal Diord. Tech., Jun 2003, 16(3): 261-267.
6. Hee HT, Wong HK. The long-term results of surgical treatment for spinal
stenosis in the elderly. Singapore Med. J. Apr. 2003, 44(4): 175-180.
7. Jonsson B, Annertz M, Sjoberg C, Stromqvist B. A prospective and consecutive
study of surgically treated lumbar spinal stenosis. Part II: Five-year
follow-up by an independent observer. Spine. Dec 1997, 22(24): 29382944.
8. Stuber K, Sajko S, Kristmanson K. Chiropractic treatment of lumbar spinal
stenosis: a review of the literature. J. Chiro. Med., Jun 2009, 8(2): 77-85.
9. Snow GJ. Chiropractic management of a patient with lumbar spinal stenosis. J.
Manip. Physiol. Ther., May 2001, 24(4): 300-304.
10. DuPriest CM. Nonoperative management of lumbar spinal stenosis. J. Manip.
Physiol. Ther., Jul-Aug 1993, 16(6): 411-414.
11. Murphy DR. Hurwitz EL, Gregory AA, Clary R. A non-surgical approach to the
management of lumbar spinal stenosis: a prospective observational
cohort study. BMC Muscoloskel. Disord., Feb 2006, 7:16.
12. Hsu CJ, Chou WY, Chang WN, Wong CY. Clinical follow up after
instrumentation-augmented lumbar spinal surgery in patients with
unsatisfactory outcomes. J. Neurosurg. Spine. Oct 2006, 5(4): 281-286.