Lumbar disc problems usually involve a disc protruding beyond it’s normal limits, which may cause or contribute to compression on the nerves exiting through the spine and can result in neurological signs in the legs. The protruding disk may also compromise other local soft tissue structures which may contribute to the pain. Fluid pressure caused by inflammation may also increase compression of the spinal nerves. The back pain often reduces with the onset of leg pain. Pain is often aggravated by bending and increasing abdominal pressure such as with bowel movements, coughing or sneezing. There is often a severe lean in the posture to one side and if a nerve is compressed there may be numbness, tingling or pain running down the leg to the foot.

Herniation or extrusion is a more serious stage which suggests some of the disk material has torn and there may be a free fragment of the disk. Complications of severe disk problems may include cauda equine syndrome (compression of the nervous system resulting in bladder and bowel dysfunction), which is a surgical emergency.

Diagnosis

Diagnosis of lumbar disk problem is derived from the patient’s history and no indicators of potentially serious pathology. Imaging is only indicated in patients with a positive neurological exam or presence of a “red flag” [64-67].

As regulated health professionals specialising in the diagnosis, treatment and management of musculoskeletal disorders, chiropractors are educated and qualified to diagnose and treat intervertebral disc disorders, which may include sciatic symptoms of pain, sensory change and muscle weakness. Chiropractors perform a thorough history of complaint and examination (orthopaedic, neurological and chiropractic testing). Diagnostic imaging such as X-Rays or MRI scans may also be requested.

Evidence Base

A review of the evidence in 2017  supported chiropractic management strategies as helpful for sciatica and low back pain with radicular pain [162-163]. One included a meta-analysis which showed manipulation to be superior to inactive control, conventional care and intradiscal injections in terms of global effect. The evidence did not show strong support for the effectiveness of manipulation in terms of pain intensity and we therefore we cannot make specific claims that imply such an effect for manipulation alone.

A randomised double blind controlled trial looking at the chiropractic treatment of back pain and disk problems by Santilli et al. 2006 concluded that active manipulations have more effect than simulated manipulations on pain relief for acute back pain and sciatica with disc protrusion. (Santilli V, Beghi E, Finucci S. Chiropractic manipulation in the treatment of acute back pain and sciatica with disc protrusion: a randomized double-blind clinical trial of active and simulated spinal manipulations. Spine J. 2006 Mar-Apr;6(2):131-7. Epub 2006 Feb 3.). This has been reported as a moderate level of evidence for manipulation and suggested that it demonstrates manipulation to be superior to sham manipulation for sciatica/radiating leg pain in the short and long term.

A randomised controlled study by Dr. Gordon McMorland, and others published in 2010 found manipulation compared favourably with microdiskectomy for the treatment of sciatica (Dr G McMorland et al. Manipulation or Microdiskectomy for Sciatica? A Prospective Randomized Clinical Study. JMPT. 2010 Vol33, Issue8, P 576-584.) All patients had previously failed other nonoperative management including treatment with analgesics, lifestyle modification, physiotherapy, massage therapy, and/or acupuncture.

Sixty percent of patients with sciatica who had failed other medical management benefited from spinal manipulation to the same degree as if they underwent surgical intervention. Of 40% left unsatisfied, subsequent surgical intervention confers excellent outcome. Patients with symptomatic LDH failing medical management should consider spinal manipulation followed by surgery if warranted.

There is also other research evidence (though not of the same quality as randomised double blinded controlled trials) to support the chiropractic approach (of manipulation, mobilisation and exercise) as a safe and effective treatment intervention for mild-moderate disc lesions [72-78]. For references please see home page/ chiropractic/ research evidence.

Back-in-Action Clinical Comment

The chiropractic approach to rehabilitation of spinal disc problems is to proceed to active forms of exercise as quickly as possible to avoid dependency on passive treatment. Usually shorter duration of signs and symptoms may signal a quicker response to manipulation. The number of prior episodes may increase the number of treatments required to restore pain-free range of motion.

Chiropractors utilise a range of treatment and management interventions for intervertebral disc disorders including manipulative therapy, mobilisation, massage, flexion-distraction, acupuncture techniques, exercise prescription (individually tailored self mobilisation, stretching and strengthening), therapeutic advice, patient education strategies and onward referral where indicated. Our approach often incorporates muscle release techniques, cranial work, diet and nutritional advice, functional neurological exercises, breathing techniques, acupuncture, cryotherapy (heat and/or ice), postural improvements, foot orthotics, ergonomic advice and relaxation counselling.

The treatments used depend upon the severity of the condition and any associated neurological symptoms. Chiropractors are educated and qualified to assess patients using orthopaedic, neurological, palpation and other physical assessment tools. Assessment may also include the use of diagnostic imaging including x-ray and MRI.

Chiropractors frequently work with orthopaedic and neurosurgical colleagues in managing disc injuries and may refer back to the general practitioner for appropriate pain relief prescriptions. Chiropractors recognise that not all disc injuries are suitable for spinal manipulation and, although rare, adverse events have been described in the literature. However, there is evidence to support this approach as a safe and effective treatment intervention for mild-moderate disc lesions.

We also find that to get the best results with people we not only need to free the mechanically restricted areas but help deal with the underlying causes – i.e. helping reduce the stress on that area of the body.