LUMBAR SPONDYLOSIS CaseFile


(Keywords: LUMBAR SPONDYLOSIS CaseFile, Chiropractic Help, Femero Acetabular Impingement Syndrome Pincer deformity, hip pain, groin pain, anterior thigh pain )

The word "spondylosis" means basically wear-and-tear in the joints of the spine. The term describes the osteophytes, or bony outgrowths that emerge from the vertebral bodies of the spine. Thus to an extent, in the older person, it is a not unexpected or an unusual finding. They are usually asymptomatic, but give an indication of a spine that has been under stress. They grow to stabilise the back.

Only in some people, for one reason or another, it is greatly advanced causing gross changes sometimes affecting the nerves as they exit between the spinal joints, especially when they grow out from the posterior margin of the vertebral body. These are stock photos, not from the Lumbar spondylosis casefile below.



CASE HISTORY @ LUMBAR SPONDYLOSIS CaseFile

A sixty-two year old woman has had lower back pain for five years. Two years ago pain began on the side of the hip. Within a few months she started to experience groin pain, with a radiating pain down the front of the right thigh towards the knee. Walking became difficult and painful, both dawdling as when shopping, and when trying to go for a walk. She was unable to garden, her favourite hobby.

Anti inflammatory drugs brought temporary relief. Treatment by another chiropractor and by a physiotherapist helped only marginally. Exercises aggravated the groin pain.

LUMBAR SPONDYLOSIS CaseFile: Physical examination

On observation, she clearly had a marked scoliosis (spinal curvature) but no obvious short leg.

Forward bending caused mild-to-moderate low back pain, and no pain in the leg. Exension of the spine was rather more painful, but neither caused leg pain.

The Sciatic nerve (which comes from the LOWER lumbar spine) stretch test was negative, but the Femoral nerve (UPPER lumbar spine) stretch test was strongly positive with pain in the front of the thigh. There were no abnormal sensory or muscle weakness signs. The achilles reflex (S1) was zero. Sacro-iliac orthopaedic tests were negative.

Flexion of the right hip caused groin pain, but internal and external rotation were relatively normal.

She failed the Ten Second Step Test ...


LUMBAR SPONDYLOSIS CaseFile: X-RAYS

LUMBAR SPONDYLOSIS CaseFile:

CHIROPRACTIC EXAMINATION

No Sacro-iliac joint fixations were found (probably because of the previous chiropractic treatment).

Marked L1 and L5 fixations on motion palpation.

Flexion fixation of the right hip.

Active trigger points in the Quadratus Lumborum, Pectineus and Adductor Magnus muscles.

3mm heel lift in her left shoe markedly improved the spinal proprioception test.


DISCUSSION

Solving a back problem is in some ways like a game of Su Doku. Having gone thoroughly through all the basics, one has to start looking for polygons and triplets and uniques. Often they are obscure and there may be diversions that only lead down a cul-de-sac.

One such cul-de-sac was the lumbar spondylosis seen at L3. The joint looks horrid on the X-ray, but clinically proved irrelevant. Clearly this was an acquired condition, whereas the Pincer deformity is congenital. But they correspond neurologically, both to the Femoral nerve. It's my opinion, that a hip condition, either neurologically, abnormal muscle tension, altered gait can actually cause the lumbar spondylosis, but this actually chiropractic heresy. Is it vice versa?


Other significant findings:

  • Positive Femoral nerve Stretch test (think upper lumbar problem)
  • Limited right hip flexion with pain in the groin (think hip problem. Arthritis? FAIS?)
  • Active trigger points (think muscular problem)
  •  Fixations at L5 and L1 (think chiropractic lumbar facet syndrome ...)
  • Slightly short left leg (too small to be detected by simple observation but seen on X-ray (think leg length inequality ...).


Significant X-ray findings:

  1. Pincer deformity: Femoro Acetabular Impingement syndrome.
  2.  Short left leg.
  3. Left convex scoliosis.
  4.  Lumbar spondylosis. Actually an irrelevant finding.


TREATMENT of LUMBAR SPONDYLOSIS CaseFile

  1. Chiropractic adjustments of L1 and L5.
  2. Mobilisation of the right hip.
  3. Active release technique on the active trigger points and the hip joint capsule.
  4. 3mm heel lift in left shoe.
  5. Vigorous appropriate rehabilitation exercises.



PROGRESS @ LUMBAR SPONDYLOSIS CaseFile

Some conditions are bastards and take weeks and even months of struggle on the part of both patient and chiropractor before there is significant improvement. This lady unexpectedly responded positively within the first two weeks.

Now, after six weeks, she has almost no pain, and can walk normally.

The key point in her case were to grasp that it was a multi-factorial case. As we say in Chiropractic education: "Remember the patient can have two diseases."

  • Radiating nerve pain from a high lumbar subluxation (called Maigne's syndrome).
  • Appreciating that we were dealing with a latent Femoro Acetabular Impingement Syndrome FAIS.
  • What completed the picture was the heel lift. Because the leg length deficiency was so marginal, I refrained from providing a heel lift in the first few weeks. But the correction of the short leg, reducing the scoliosis and balancing the pelvis, brought even better positive results.

All in all a most satisfactory outcome. She now comes in every six weeks for maintenance. If possible I hope to extend that to eight or ten weeks.

She does her exercises faithfully.

Confession: These are very small lumbar spondylosis osteophytes, and the name of this page could perhaps be better Maignes syndrome or Femoro Acetabular Impingement Syndrome Pincer, or even a good page for Leg Length Inequality research ...

USEFUL LINKS @ LUMBAR SPONDYLOSIS CaseFile


CAUSES OF OSTEOPOROSIS



For a woman of 62-years not to be able to walk easily and freely, is not only painful and disabling. By failing the TEN SECOND STEP TEST her life expectancy was also being cut short. Why? Many reasons but one obvious one is that, not being able to enjoy all the walking benefits, she was failing in one of the prime causes of osteoporosis. Lack of exercise.This however was not a neurological abnormality, but an inability to easily flex the hip. After treatment she could perform the test quite normally. 


QUESTIONS

  • The Pincer deformity is just as evident in the left hip. Why only right thigh and groin pain? It's hard to be sure, but I feel the irritated high lumbar nerve, and the short leg are probably behind it. Only a dedicated research programme can sort out these mysteries.
  • Why the loss of the S1 (lower lumbar) reflex? Probably an old injury, reflexes often do not return. This was not an S1 sciatica, but the subluxation at L5 was (in addition to L1) an important part of the overall treatment.
  • Many medical people believe that a short leg less than 10-15mm is not significant. I heartily disagree, but that too needs to be researched. 


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Interesting challenges of the day

1. Mrs D, a 78 year old woman has very severe sacroiliac joint pain, and even more severe cramps in her right leg. There are two problems; she is on two diuretics but no slow K. Taking her temporarily off one diuretic and adjusting the SIJ brought 50 percent relief within four days. 

2. Mr S, a 48 year old man, has right low back pain, groin pain and a numb feeling in his lower leg when he sports. For six months he's been off football. He too has two problems; a very treatable lumbar facet syndrome and a very serious blocked artery in the groin; it's called intermittent claudication. Smokers beware.  

3. Mr S looks like the leaning tower of Pisa; he has a slipped disc at L5 making him lean towards the opposite side. It's called the postero lateral disc hernia; we'll fix it, but he has to stop for a week or two. Antalgias are serious so take them seriously. 

4. Mrs V too has  two conditions; a chronic low grade sciatica giving her an ache in the right leg, and a threatening Morton's neuroma. She's glad I'm back in Holland; chiropractic fixed it before, and we'll fix it again. 

5. Mrs W is one of the lucky ones, says her doctor. I agree. He says only 40% of patients with lumbar stenosis have a successful operation. We fixed a nasty slipped disc three years ago, but it came back two years later; the surgeon did a fine job but she has a weak ankle now giving her subtalar joint pain; it's routine stuff. 

6. I myself had an acute exacerbation of a femoral nerve lesion last year. One immediate treatment of the new strain 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?


LOW BACK and LEG PAIN


Falls

Bending and twisting


Sitting

Short leg?


Lower back and leg pain


Lumbar facet syndrome


Slipped disc


Sacro-Iliac Joint


Spondylolysthesis


Examination

Interesting questions from visitors

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