Keywords: Lateral Disc Herniation, chiropractic help, femoral nerve damage, help for sciatica pain
Far lateral prolapses and extrusions are an enigma that often baffles the chiropractor and medical doctor alike. Why?
Please accept that this may be a bit of neuroanatomy that may be beyond the interest of the average patient, but what is important is that the herniation is one level lower than that expected.
Why is that important? Because, with 33 years of examining patients with lower lumbar back pain, I can tell you that is often not clear whether the herniation is a L4-L5 Lumbar Spine lateral disc protrusion, or L5... Or L3. Double hernias are not uncommon too just to add to the confusion.
Usually when there's sufficient wear and tear at a particular level to rupture the disc, there's also degenerative change at several other levels, each of which will be contributing to the mayhem.
Take this scan for example (see Femoral nerve damage ... for more details, if interested): Only seen on the axial views is that there is a very large extrusion from the L3-L4 disc, part of which has sequestered posteriorally into the spnal canal, but just look at the L4-L5 disc. Both discs would be painful.
And, because the "far lateral" 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?
Most herniations occur into the spinal canal (usually contained behind the Posterior Longitudinal Ligament) or into the inter-vertebral foramen (IVF) where the nerve exits. However the (Far) Lateral Disc Herniation ruptures beyond the foramen, and traps a higher nerve than expected.
Because the Lateral Disc Herniation is less common it will have your chiropractor scratching his/her head. You see, the pain pattern in your leg with a the lateral disc doesn't correspond to either his findings, or what may or may not be seen on the X-rays and scans. It just ain't following the proper radiating pain that it ought!
This is a (far) lateral disc herniation.
This next diagram shows the more usual pattern of a Postero-Lateral disc herniation, not to be confused with the the above (Far) Lateral disk protrusion. See how it gets a quite different nerve?
Pain and tingling in the leg, numbness and weakness. The Slump Test for sciatica can be done at home to test for a pinched nerve.
Chronic disabling Low Back Pain
Low back pain is the most common and costly work related injury. The huge costs involved come from the relatively small number of people (but still a very large number of workers) who go on from an acute episode to chronic disability.
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
Reported: Spine vol 33: Early Predicators of Chronic Work Disability af a Back Injury by Turner et al.
CHIROPRACTIC HELP FROM THE COAL FACE
Mr Hanisch is a 45 year-old plumber who lifted a heavy washing machine
up a narrow staircase. He felt something give in his back and the next
morning had severe lower lumbar back pain. Turning in bed was extremely
painful, he couldn't put his socks on, and a good smoker's
morning cough gave him a vicious stab of pain in the back. Within a few
days he felt pain radiating down the side of the leg and towards the great
toe. (4 sites of pain: Lower back > side of thigh + side of calf + great toe)
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, aggravating 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 a 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, and adjusted L4. 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, when I did Slump Test.
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. Stop Smoking Permanently ...
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. However, adjusting the level below that expected is what reduced the prolapsed disc...
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 of LATERAL DISC HERNIATION
aka Lateral disc protrusion
Each time you have an attack of acute low back pain, if it's associated with pain when you cough, sneeze or bear down on the toilet, you have likely lost some of the gel in the disc. This is even more so, if you go into the "leaning tower of Pisa" posture, or have pain in the leg. You are well on your way to having a 'flat tyre'.
like back exercises every morning, and some common sense when faced
with heavy lifting if you want to avoid lateral disc herniation and the
threat of lumbar spinal surgery. The 50 percent less pain rule is vital ...
"Walking is man's best medicine."
-Hippocrates, the Father of Medicine* (460-377 BC)
If you have pain and tingling in the feet and legs...
LOWER BACK EXERCISES
Leg Length Inequality
Or in normal jargon, could you have a short leg? Leg length inequality research confirms that it causes not only hip and knee arthritis, but also lower lumbar back pain. It probably untimately is also one of the causes of lumbar stenosis, and probably lateral disc herniation, though is unresearhed. Leg length inequality and low back pain are now confirmed to be strongly associated. Not responding to Chiropractic? Has your Chiropractor considered a short leg?
Here is a leg length inequality CaseFile that might interest you.
Did you find this page useful? Then perhaps forward it to a suffering friend. Better still, Tweet or Face Book it.
Interesting challenges of the day
1. Mr D has very severe midback back. He bent and twisted, feeding his son, and then laughed. Every breath is a nightmare. A sprung rib is every chiropractor's delight. He or she has golden hands. 30 percent better after one treatment.
2. Mrs C has a long history of severe, disabling migraine headaches since having her wisdom teeth removed. She clenches her teeth at night. After six treatments she has no migraines but some jaw joint discomfort remains; a bite plate is in the offing.
3. Mrs U has the trophy for the worst back this year. After major surgery with plates and screws two years later she still had paresis in the lower leg and severe disabling back pain. She's doing far better than expected, in no little part due to a lift in her shoe for a very short leg.
4. Mr V is 86 years old and hurt his back helping his wife into the car. Just one treatment of the sacroiliac joint and he's eighty percent better. It's not always like that.
5. Mr W lay on his back knocking down a pillar. Turning his head causes severe vertigo. He needs the Epley exercises, not pills, research shows. Update, he's fine.
6. I myself had an acute exacerbation of a femoral nerve lesion last year. One immediate treatment by my colleague has fixed the pain in the lower back, but there's some residual numbness in the lower leg; no soaring tomorrow alas.
7. This lady is a 86 year old woman with a 63 scoliosis. Chronic lower back has been her lot in life but she's well pleased with chiropractic and comes for chiropractic help once a month; some conditions you can never cure.
8. She is an 78 year old woman, is doing remarkably well with a bad sciatica. But over 200 pounds she is not losing weight; in fact, gaining despite my suggestions. She's high risk for a stroke. I have referred her to a dietician to crack the whip.
9. A 61 year old man with upper cervical pain yesterday; it's not severe but also not getting better of its own accord. He's afraid it may turn very acute as when I treated him three years ago. Since then it's been fine.
10. A 64 year old woman has had scheuermanns disease; it's left her with a spinal kyphosis and chronic middorsal pain. She responds well to chiropractic treatment provides she come every six weeks or so for maintenance treatment.
11. Mrs C has been having severe headaches, and taking a lot of analgesics. It's a non complicated upper cervical facet syndrome, and she's doing well.
12. Mrs D, a middle aged woman with hip pain of one year duration, despite other treatment. Xrays reveal an impingement syndrome and early hip arthritis. There's much to be done.
13. Mrs B has had one of the nastiest of conditions; vertigo caused by a disturbance in the inner ear. Falling repeatedly and vomiting she consulted her doctor but medication didn't help. After two sessions of the Epley manoeuvres she was 50 percent better. After two weeks 75 percent improved. No longer vomiting all falling. She's not enjoying the Brandt Daroff home exercises.
And so the day goes; chiropractors shouldn't be treating the elderly most medical sites state but that's so much bunkum.
Have a problem that's not getting better? Looking for a different slant on your pain? Want to pose a question?
Greetings, Dr B.
You helped me quite some time back with a soothing and professional response which turned out to be exactly correct. I now consult a local chiropractor. You write a superb newsletter, too.
Your own unresolved problem. Pose a question
Knowing that up to 70% of the time the correct diagnosis is made with no examination, no special tests, no xrays, but just from the history, there's a fair chance I can add some insight to your unresolved problem. But at least 30% of the time, I may be quite wrong! Give plenty of detail if you want a sensible reply.
You visited this chiropractic help site no doubt because you have a problem that is not resolving and want to know more about what chiropractors do.
The quickest and most interesting way is to read one of my ebooks of anecdotes. Described by a reader as gems, both funny and healthful, from the life and work of a chiropractor, you'll love them. Priced right at $2.99, though Kindle fiddles the price without telling me.