The Treatment of an Older United States Military Veteran with Chronic Lumbar Spinal Stenosis Utilizing Flexion-Distraction Spinal Manipulative Therapy

Lumbar Spinal Stenosis (LSS) is a condition of the lower back resulting in a variety of pathological symptoms such as pain, weakness, and/or paresthesia [1]. LSS impacts over an estimated 100 million persons worldwide and results in approximately 600,000 surgical interventions in the United States annually [2]. Clinically, LSS is characterized by narrowing in any of the 3 anatomical vertebral sites: the central canal or either neural foramen. The spinal canal houses the spinal cord while the neural foramen are regions where the nerve roots exit to the peripheral body. There are various common causes of this narrowing including herniated or bulging spinal discs or a hypertrophic ligamentum flavum. Other causes include degenerative spondylosis, usually from aging, “wear-and-tear,” and/or trauma. Degenerative spondylosis often leads to joint arthropathy and osteophyte formation with an overgrowth of bone formation surrounding the facet joints that make up the neural foramen [1,3].

Spondylolisthesis, or movement of one vertebral body on another, is another cause of LSS seen often clinically [4]. Less commonly, spaceoccupying lesions such as synovial or neural cysts, neoplasms, or lipomas can be a cause of LSS [3] Among other symptoms, LSS may cause an event known as neurogenic claudication; a result of central canal narrowing potentially leading to aching, numbness, pain, or balance issues among other symptoms [5,6].

Several conservative treatment options are available for LSS including Physical Therapy (PT) and active care, Spinal Manipulative Therapy (SMT), and acupuncture. Pharmaceutical interventions generally include anti-inflammatories, over-thecounter pain medicine, prescription pain medicine, and antiinflammatory or numbness injections to the lumbar region. If conservative and pharmaceutical options have failed to manage the condition, surgical interventions are often performed. Some of these procedures include laminectomy’s, spinal fusions, or minimally invasive laser surgeries [2,6,7]. Unfortunately, surgical costs can be staggering. One recent study found a single lumbar fusion can costs upwards of $70,000 [8]. There are also risks involved in surgery such as prolonged or increased pain, inflection, bleeding, blood clots, revisions, or death [9,10]. Given these risks, it is understandable why some patients with LSS would choose to avoid the surgical route.

The following case report focuses on one of the conservation options mentioned above: SMT. There are a variety of case reports and reviews addressing SMT for the treatment of LSS, but gaps continue to exist [11]. Due to the structural changes within the spinal elements for many of those with LSS, an SMT approach known as Flexion-Distraction (FD) is utilized [12]. This technic generally has the patients in a prone (face-down) position and with the assistance of a specialized table, the practitioner can apply forward flexion and cephalic distraction resulting in reduced intradiscal pressure of up to a measured 192mmHg, increase intervertebral disc height, and increase the neural foraminal region [13,14]. Though no current study exists singularly addressing the safety of FD, many case reports and cohort studies report only mild adverse events such as temporary soreness to the region [15-17]. The purpose of this case report is to review the treatment of an older United States (US) military Veteran with LSS utilizing FD that led to reduced pain and paresthesia and, interestingly, resulted in increased mobility and deferred surgical intervention.

Presentation and PMHX

A 68-year-old male Veteran of the US military presented to the chiropractic clinic with several years of Lower Back Pain (LBP) that was worsening over the previous 2 months. The pain also was reported into the posterior of Lower Extremities (LE’s) and wrapped to the top of the feet. The pain was constant and fluctuated depending on activities and body position. The LBP was sharp while the pain into the LE’s was a dull ache. Prolonged stationary positions such as sitting and standing made the pains worse, as did prolonged walking. Leaning forward after walking relieved this pain. He also reported that stretching, heat, and some muscle relaxers were helpful in reducing the pain. He notes previous interventions with PT and nerve blocks in the lower back that had little to no benefit towards the symptoms. Past medical history included chronic pain throughout multiple body regions, hypertension, prediabetes, glaucoma, and coronary arty disease.

Physical examination

Patient entered with a forward lean antalgic posture. His gait demonstrated a shortened stride length. Patient was alert, attentive, oriented and cooperative. Speech was clear and fluent. He had a positive attitude and was excited about additional treatment options for his chronic pain. Table 1 outlines an extension review of the remainder of the physical exam at the consultation and findings on follow-up exam.

Table 1:Physical Exam Findings at Consult and Six Week Follow-up.

Diagnostic imaging

Prior to the consult the patient had extensive imagine done on his lumbar spine including radiographs and MRI. Findings are as follows in Table 2 and images are included in Figures 1-4.

Table 2:Radiographic Imaging.

Figure 1:AP Lumbar Spine Radiograph.

Figure 2:Lateral Lumbar Spine Radiograph.

Figure 3:MRI Lumbar Mid-sagittal View.

Figure 4:MRI L4-L5 Axial View.

Interventions

The patient began a trial of care that included Cox Technic Flexion-Distraction (CTFD) Protocol 1 that incorporated 3 sets of 5 flexion-distraction motions. Between sets the practitioner applied manual trigger point therapy to lumbar musculature with an analgesic gel. This treatment was performed 1 time per week for 6 weeks until follow-up.

Assessments and outcomes

Outcome assessments utilized included the Numeric Pain Rating Scale where the patient noted current pain, lowest pain, highest pain, and average pain over a 1-week period on a 0-10 scale. The University of Alabama at Birmingham Life Space Assessment (LSA) was also used to measure mobility. Mobility, in terms of LSA, can be defined by distance extending from the location where a person sleeps and dependency on assistance. Outcomes at consult and follow-up can be found in Table 3. At the end of the trial and on follow-up exams there were measurable objective and subjective findings. The patient overall felt improvement and had pain and symptoms in the LSP and LE as well as demonstrated increase mobility. He desired to continue this therapy in lieu of a surgical consult or further injections.

Table 3:Outcome Measures at Consult and 6-week Follow-up.

After thorough examination and review of imaging, the patient was diagnosed with LSS and was treated with CTFD and manual trigger point therapy. After 6 treatments there was a reduction in pain and symptoms as well as an increase in mobility, improved sensations, and improved functional movement. This is a case where conservative care was beneficial as an intervention and prevented surgical consultation or further injections to lumbar spine for a patient suffering with LSS. Further investigations such as a case series and cohort studies would be beneficial to measure the impact CTFD may have on this condition. Future studies would also be beneficial to assess the utility of the LSA in regard to manual therapy and mobility as limited studies using this assessment exists. This report may be a useful start for this type of investigation..

The author notes limitations of this report including subjective findings on exam and outcomes may not necessarily be clinically meaningful. The LSA has never had published study with chiropractic care and it is difficult to know if changes are clinically relevant to care without a baseline study, though future investigations may have interesting findings. The patient also was taking gabapentin which may or may not have influenced how he was feeling at the times of exam.

The use of FD for an older adult male US Veteran was beneficial in management of his LBP associated with LSS. He demonstrated functional improvements including mobility and also had improves symptoms of pain reduction and improved sensation. Though some level of pain persists, the patient notes managing well and increasing activities. This report may serve as a base for further investigation into the association of LSS, FD SMT, and mobility improvement as seen on the LSA.

The author acknowledges the Birmingham VHA Department of Physical Medicine and Rehabilitation clinic for the use of their facility for treatment in this case.

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