The Natural History Of A L4 Disc Protrusion Over A 12 Year ......L2-3 L3-4 L4-5 degenerated disc, 6.5 mm broad central/left paracentral extrusion, with inferior prolapse, left lateral

10/14/2015

1

The Natural History Of A L4 Disc Protrusion Over A 12 Year Period

SUBMITTED BY MICHAEL MCMURRAY D.C.,C.C.S.P.CAMPBELL, CA

PRESENTED AT COX SEMINAR IN LAS VEGAS NV.3/21/2015

Chief Complaint and History

The patient first presented for care on June 15, 2011. The patient appeared as a healthy 38 year old male who had a life

history of being very athletic. At his initial visit he complained of chronic sciatica in a L5 Dermatome

down the left leg. Weight lifted since 10 years old. He sleeps on his stomach 50% of the time. He has a PhD in Physics and has spent a great deal of his life sitting.

1Cox® Technic Case Report #149 published at www.CoxTechnic.com (sent 11/10/15)

10/14/2015

2

Past Athletic History

Dirt bike rider Road bikes 100 miles per week Ran cross country in college

Initial Onset

2003-2005 He experienced occasional occurrences of minor back pain related to running/squatting.

In 2006, he fell on his head onto the sand from a wave and heard a ‘strange’ noise in his neck.

10/2008 He felt an acute sharp pain when doing free squats and had burning in the lower spine shortly afterwards.

2008-2009 He saw various orthopedists & PT’s with no significant improvement. 8/29/09 He had an MRI done showing herniated discs at L4 and L5. 2009-2010 He saw a physiatrist for about a year who recommended a different set of

physical therapists.


10/14/2015

3

2009 MRI

MRI report 2009

L4-L5 Mild broad-based disc bulge with the posterior annular tear and minor facet arthropathy

L5-S1 Mild broad-based disc bulge with a left paracentral component and a posterior annular tear with narrowing of the left lateral recess and possible compression of the left S1 nerve root

Mild congenital narrowing of the pedicles


10/14/2015

4

2nd Event

Physical Therapy improved his lower back pain to the point he could sit

2/2011 Felt a back spasm while lifting his daughter out of her crib and was in pain and hobbled around for a week, Subsequent to this he started a program of 2 days a week going to Bikram Yoga. This cleared up the pain.

3rd Event

6/2011 He spent a four day period significantly increasing the amount of road biking without interspersing it with yoga and stretching. He started to feel back soreness and tightness in his upper hips.

Patient then went back to yoga which moved the pain into the left leg in a L5 dermatone.

Then over the next several days, sharp pain started shooting down the left leg (for the first time) which persisted for several weeks. Patient at this point researched the web and found stretches that alleviated the pain.


10/14/2015

5

Physical Examination

Patient stated he has a healthy diet of vegetables and lean meats.

Ht. 6’0 Wt. 180

All DTR testing and lower extremity motor function were normal

Scoliosis with apex at L3 to the Right

Active lumbar ROM was

Flexion 90 with L5 spasm

Extension 10 with L glute pain

Rotation R 20

Rotation L 30

R Lateral Flexion 30

L Lateral Flexion 30

Orthopedic Findings & Motor Exam

Pain on Palpation over L4 & L5 left, which also caused L glute pain

- Valsalva’s, has been positive in the past + Kemps on the L for L glute pain + Seated leg raise for L buttock pain + Straight leg raise for L glute pain at 60 degrees R Psoas Spasm and weaker than the L L hip extensor has slightly less “power” than the R


10/14/2015

6

Findings on 2012 MRI

Flexion


10/14/2015

7

Extension

Oblique


10/14/2015

8

MRI report 2012

Lumbar spondylosis, mild scoliosis. Annular bulges, L1-2 L2-3 L3-4

L4-5 degenerated disc, 6.5 mm broad central/left paracentral extrusion, with inferior prolapse, left lateral recess stenosis, effacement of proximal left L5 root

L5-S1 degenerated disc, central 2-3 mm protrusion, with central annular tear

Disc appeared stable with Flexion and Extension

Lateral 2015


10/14/2015

9

Axial 2015

MRI report 2015

There is a central L5-S1 osteophyte and disc protrusion complex. This is close to both S1 nerve roots. There is 10% spinal canal stenosis. There is no change from flexion to extension to recumbent positioning.

There is central to somewhat left sided L4-L5 disc extrusion. This extends inferiorly from the disc space level. There is 10% spinal canal stenosis. There signal intensity no change from flexion to extension to recumbent.

Pedicles appear shortened in general L1 through L5.


10/14/2015

10

Diagnosis

Left lateral L4 disc protrusion Left Grade 3 Sciatic radiculitis

Treatment Plan

Cox® Flexion Distraction Decompression using Disc Protocol I was begun on June 16, 2011.

The contact was made at the L4 spinous process. The table was put into 10 degrees right lateral flexion during the application of the treatment.

The patient was adjusted full spine using Activator Methods protocol. Active Release Technique was applied to the Left Piriformis, Bilateral Psoas

muscles, Gemelli Obturator internus complex and Iliolumbar ligament. Sacral Occipital Technique using Category 3 blocking. Medical Radiance MR4 Laser Disc Sciatica Protocol


10/14/2015

11

Home care Therapies

Ice: On his back on the floor with his legs up over a support (chair/couch/bed) for added relief he was told to use a chair and to pull the chair up so that his buttocks was under the chair and his knees approximated to his chest.

Exercises: Pelvic tilt, Single and Double knee to chest stretches, each is to be held for 1 to 2 seconds. The patient was also given neutral and lateral planks and told to work up to a minute to hold.

Basic Instructions for when he has to work: DO NOT sit on the edge of the chair at work; make sure knees are level with the hips (parallel); elbows and wrists must also be supported.

Sleep instructions: Told to sleep on his left side or his back in order to get relief while sleeping

Nutritional Therapies

Told to drink ½ his body weight in ounces of water Prescribed Discat Plus (to help the disc imbibe (absorb)

water). 4 in the morning and 4 night. inflammation reduction cartilage regeneration


10/14/2015

12

Clinical Outcome

The patient’s initial treatment plan was 3 times per week for 6 weeks. At his first re-evaluation, the patient had less sciatica and activities of daily

living were more comfortable. After the next 6 weeks of care, the patient had improved more than at his

previous re-evaluation. He was able to sleep through the night without left Piriformis pain and no longer had sciatica below the left buttock.

On his December 21 re-evaluation, the patient stated he could walk without a limp. He could sit at work for long periods without leg pain. He increased his aerobic exercise, he was riding his bike and swimming. He still had sporadic flare-ups of Left lower leg tingling and Left Piriformis pain. These symptoms were intermittent and were resolved with rest and stretching.

Summary of Treatment

He started his treatment on June 16, 2011. His treatment was as follows:

6 visits in June 2011 11 visits in July 2011 11 visits in August 2011 6 visits in Sept 2011 4 visits in November 2011 2 visits in December 2011


10/14/2015

13

Discussion

After 43 treatments between June of 2011 and December 2011 The patient had improve to the point he could sit longer and exercise without sever flare-ups of pain. He continued to have tingling in the left leg occasionally to the foot. His sleep was at times interrupted due to left sciatic pain,

He continued care at 2 times per week from January 2012 to March 2012.

From March 2012 to the present time (March 2015), he has been on monthly maintenance care.

He presently has occasional symptoms of tingling into the left leg (in L5 dermatome) and tightness in the lower back.


Documents

The Natural History Of A L4 Disc Protrusion Over A 12 Year ......L2-3 L3-4 L4-5 degenerated disc, 6.5 mm broad central/left paracentral extrusion, with inferior prolapse, left lateral