LATERAL DISC HERNIATION

aka FAR LATERAL DISC PROTRUSION

LATERAL DISC HERNIATIONs are an enigma that often baffles the chiropractor. Why?

Please accept that this may be a bit of neuroanatomy that is probably beyond the average patient, but what is important is that the herniation is one level higher than that expected.

Why is that important? Because, with 29 years of examining patients with lower lumbar back pain, I can tell you that is often not clear whether the herniation is a L4 Lumbar Spine lateral disc protrusion, or L5. Or L3. Double hernias are not uncommon too just to add to the confusion.

And, because it is far beyond the usual cut of the MRI, it is often missed by the radiologist, and a 'normal' report is sent to baffle your chiropractor and your doctor.

What is it?

This is a (far) lateral disc herniation.

Chronic disabling Low Back Pain

How can you know if this attack of lower lumbar back pain is going to go away, or become a nightmare?

A 2009 study from the University of Washington of 1885 workers with lumbar disc protrusion injuries, has come with some interesting facts:

Predictors of chronic disability

1. The first and most important predicator is the patient's own report of how disabling and limiting the injury is.

2. The second most important predicator was the patient's first health provider. If it was a chiropractor, the chances of the condition becoming chronic and disabling one year later was 5%. If it was a medical doctor, the chances were more than double - 12%.

3. Number of pain sites.

4. A 'very hectic' job.

5. No offer of light work for a period.

6. A previous injury with a month or longer off work.

   Reported: Spine vol 33: Early Predicators of Chronic Work Disability af a Back Injury by Turner et al.

FROM THE COAL FACE

Sitting and standing became very painful, and he walked with a limp because of the weakness that developed progressively in his foot. He tripped several times, aggrevating the condition further, because his toe didn't lift normally in the swing phase of his gait.

By the time Mr Hanisch consulted me four months later, he had difficulty raising his great toe off the ground and the side of his lower leg and the top of foot felt numb - using a pinwheel, he said the prickle was 40% less. And the Medial Hamstring reflex was noticably diminished.

So far nothing unusual. This describes very typically an L4-L5 disc herniation. But the MRI was negative, and eventually he was sent back to work by the company doctor. Up to point I can understand that: there is strong research showing that a man off work for more than six months is most unlikely ever to return. So, he was sent back to work. Only, he couldn't do his work as a plumber.

I admit to a hesitation. Often, one isn't absolutely sure which vertebra to manipulate. Either several are fixated, or none, or several are painful, and you are not absolutely sure. I wasn't sure: L5 was fixated, whereas it should have been L4.

For two weeks I made the wrong decision, following my neurology rather than the clinical examination. A mistake, and he didn't progress.

"To hell with it! The jammed up joint is L5, Mr Hanisch, I'm changing the treatment."

After the first adjustment of L5, he felt a slight bit of relief, and I could raise his leg a little higher at the next consultation.

It was several months before the pain and weakness in his leg returned to normal, but after the rehab exercise program, he was able to return to work. A little wiser, he now gets help with heavy lifting.

An unexpected benefit was that he agreed to quit smoking. His doctor had often tried to persuade him with grave announcements about lung cancer and heart attacks, all of which he ignored. But when I told him his back was unlikely to heal with my treatment, and he would end up in surgery if he didn't quit, he made the noble decision.

How do I know he had a (Far) lateral disc herniation? Frankly I don't. The MRI's of these Far Laterals are usually negative, and the only way to confirm it with is with a myelogram or surgery, both of which can have nasty side-effects.

Can chiropractic have nasty side-effects? Yes, indeed, though research consistently reveals that it is much less frequent, and the chance of going on to chronic disabiling pain with a condition like a Lateral Disc Herniation is 5/12 less likely that if you start with a medical doctor.

Have a moment of sympathy for your Chiropractor who is dealing with Lateral disc herniation. Surgeons too need a streak of stubborn boldness to get on with what needs to be done with the patient in severe pain, though his patients are under deep anaesthesia.

"Boldness be my friend."

- William Shakespeare

PREVENTION

IMPORTANT CONSIDERATIONS if you have pain and tingling in the feet and legs.