Sacralization of L5 CaseFile

Sacralization of L5 casefile sometimes creates a dilemma for the DC.

Sacralization of L5

This page was last updated by Dr Barrie Lewis on 1 January, 2019.

Lumbarisation or sacralization?

Mrs D, a 39 year old woman first consulted me two years ago. Over the previous three years she had three severe, acute attacks of LBP, without referral to the lower limbs. Whilst the acute phase passed, she continued to have nagging backache every day.

Her mother and sister also have episodic lumbar problems. This is a strongly hereditary condition.

What finally prompted her to consult a chiropractor was two episodes, one six weeks and the second just a few days before her first consult.

Despite physiotherapy treatments spanning every week for a whole year, and an orthopaedic consult, the condition was clearly going downhill. Sneezing caused extreme pain in the small of the back; that's often a symptom of a disc injury.

Sacralizations and lumbarisations are not uncommon at the chiropractic coalface. They have a higher incidence of lower back and leg pain.

We call the zone between the sacrum, a solid but slightly movable bone, and the lumbar spine which is highly flexible, a transition zone. Sometimes the last vertebra can't make up its mind whether it is belongs to the lumbar spine, or the sacrum. The result is six or four movable lumbar segments, instead of the regulation five.

They are but two sides of the same coin.

Skullduggery is the word. The search engines have no interest in the word lumbarisation so I've called this page sacralization of L5 but in fact this sacralization of L5 casefile is a lumbarisation; six vertebrae instead of five.

Xrays are particularly helpful in these cases which is why, if there is a strong family history of lower back pain, further examination is advisable. Even a scan if you have the money, particularly if there is any leg pain.  They are expensive. The big advantage with MRI is that to date there are no known side effects, as there are with xray and CT; ionizing radiation is dangerous.

Sacralization of L5 lateral view

Sacralization of L5 CaseFile

Sacralization of L5 spot view

On examination

A slim, but strongly built woman, she obviously stood with a pelvis distinctly low on the left side. This led to a mild scoliosis.

Forward bending was strongly painful in the low back. Extension and sideways bending to the left was mildly uncomfortable in the left SIJ; or was it at L5 in that pseudo joint?

On motion palpation, L5 was strongly fixated, due no doubt to the lumbarisation or sacralisation of the lowermost vertebra, which would normally be the fifth lumbar. There was no sacroiliac fixation on motion palpation, despite the tenderness in the joint. Surprising, as it usually gets tight along with bottom back bone.

On orthopedic testing, the slump test was positive with a crossed sign; raising the left leg provoked right lower back pain. All four sacroiliac joint anatomy tests were positive. Yet no sacroiliac fixation on motion palpation; odd.

A heel lift for the short leg.

A 5mm heel lift under her left heel provided instant relief when bending. Simply catering for the leg length inequality is often half the battle in dealing with chronic lower back pain in which a leg length inequality is a complicating factor.

Progress at this leg length inequality case file

Whilst for most chiropractors, myself included, Chiropractic Help would include adjusting the low back and pelvis manually most of the time, Mrs D responded immediately to the Thompson drop protocol in the pelvis, and the heel lift, so that I've never actually manipulated her back. Within a week the pain was gone.

However she went faithfully through the rehabilitation protocol, another 4 to 5 treatments, making it 12 in total. She also had some neck pain.

She had one slight setback about three months later, which passed with one of the six weekly control treatments. That was eighteen months ago. Since then she has had no pain at all.

Mrs D wears her heel lift faithfully, does her exercises with passion and enthusiasm; they only last one and a half minutes every morning and every evening in bed, before arising and taking to dreamland, and comes now every ten weeks for a control treatment, as we call it in the Netherlands.

She reported this morning that she has had absolutely no problems. Long may it continue. No treatment, no charge.

Here's the discussion of sacralization of L5 casefile. Lumbarisations, creating six lumbar vertebrae instead of the standard five, and sacralisations, creating four lumbar vertebrae, can sometimes be very troublesome. Each case is unique and one has to work out a protocol that brings relief of pain and disability.

These oddities at the lumbo sacral junction are often associated with other anomalies, in Mrs D's case a short leg, and a pronated foot.

Addressing all the above is what brings success in the treatment of lower back pain; the foot, a subluxated cuboid bone, the short leg, a heel lift, and the pelvis in this case. I still haven't adjusted her lumbar spine. The problem was in the pelvis, but oddly with no palpatable fixation in the sacroiliac joint.

Each back brings its surprises, and peculiarities. Hence the challenge to your chiropractor. Can she or he puzzle it out? With your honest feedback and positive contribution by faithfully doing your exercises, for example, I'm sure!


» Sacralization of L5 casefile

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Interesting challenges of the day

1. Mr S is a 76 year old man with neck pain of some 9 months duration. Luckily, most of the discomfort is upper cervical which is only rarely arthritic; his lower cervical spine is a degenerative mess that I've left alone. After seven treatments his pain and stiffness is 50 percent better, and he's happy in the circumstances. He can sleep through the night now and that makes a huge difference.

2. Mr P is 32 year old man with very severe lower back pain radiating to the big toe which is 30 percent numb. He had an episode three weeks ago, took anti inflammatories and was soon better as is typical of the medial disc herniation. But before it healed, after a trivia it came roaring back, much worse. The characteristic crossed sign was evident; sitting in a chair, straightening the right leg provoked severe left back pain and tingling in the leg. He's doing well.

3. Severe lower back pain is scary; just ask Mrs P. Just watching her get out of the car I she was in trouble; she had a slipped disc at L4 making her lean towards the opposite side; luckily she had no pain in the leg. Despite family pressure that this was far too severe for a chiropractor, she persevered. Within five days she was standing upright, and after two weeks almost painfree. 

Despite a hectic job, she wisely took my advice and stayed home for what I call exercising bed rest.

4. Mr S has had lower back, groin and back of thigh and calf pain for fourth months.

He has a pincer deformity in the hip causing the stabs in the groin, and a degenerative facet causing the sciatica. Both are responding well to chiropractic and he's well pleased; sixty five percent better after three treatments.

5. Mr T is a wise man; he's taken a warning TIA seriously and has lost 15 pounds, and has at least as much again to lose. A change to a low starch diet and half hour daily walk has made the difference; but the walking is making his foot and back miserable. The expensive orthotic is hopeless; luckily his hips and back are fine, but he needs a simple heel lift.

6. I too have had serious lower back issues, luckily fixed by my own chiropractor; so I too have to do my exercises, take care when lifting supers full of honey, gardening and using the chainsaw. Regaining the function of your spine is just as important as the pain.

7. My own granddaughter, only 7 is hypermobile giving her pelvic, knee and ankle issues. Xrays show a mildly dysplastic hip. Years ago we would have called it growing pains. She too regularly needs chiropractic care and luckily responds well. Increased range of motion is more difficult than too stiff in my opinion. Our care is for kids too.

8. This 65 year old lady is a serious gardener; every day she is bending, lifting and digging for 2 to 3 hours a day. It regularly catches her in the sacroiliac joint, so she has a treatment once a month that sorts it out. She does her lower back exercises faithfully.

9. This 88 year old lady is an inspiration; every day she is busy in the community. With a nasty scoliosis she manages very well with a chiropractic adjustment every six weeks and exercises faithfully done.  

10. Mr X is a 71 year old retired man who wants to continue with maintenance care every six to eight weeks; he had suffered from two years of lower back pain when he first came a year ago. He has no discomfort now after 8 chiropractic treatments, but is aware that danger lurks.

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. Mr D is a 38 old year man with chronic shoulder pain after a rotator cuff tear playing cricket. It responded well to treatment, but he knows he must do his exercises every day; for two years he couldn't sleep on that shoulder.

13. Mr D, a 71 year old man, has a severe ache in the shoulder and midback since working above his head. Trapped nerve tests are negative but he has advanced degenerative joints of Luschka; after just two treatments he is 50 percent better. Can we reach 90?

And so the day goes; chiropractors shouldn't be treating the elderly most medical sites state but that's so much bunkum.

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