Cervical and Lumbar Disc Disease: Conservative and Surgical Management Copyright, 2002 © Joseph S. Ferezy, D.C. UCERF & NWCC By Joseph S. Ferezy, D.C.

Cervical and Lumbar Cervical and Lumbar Disc Disease: Disc Disease:

Conservative and Conservative and Surgical ManagementSurgical Management

Copyright, 2002 © Joseph S. Ferezy, D.C.

UCERF &NWCC

•By Joseph S. Ferezy, D.C.

•Sponsored By:

IntroductionIntroductionFrequently, doctors of chiropractic face the challenge of Frequently, doctors of chiropractic face the challenge of delivering health care to patients with serious spinal disorders. delivering health care to patients with serious spinal disorders. These conditions often require co-management which These conditions often require co-management which includes medical and surgical options. One such disorder is includes medical and surgical options. One such disorder is herniation of the nucleus pulposis of the intervertebral disc. herniation of the nucleus pulposis of the intervertebral disc. You can meet the challenge of knowing when to treat and You can meet the challenge of knowing when to treat and when to refer by utilizing some logical guidelines.when to refer by utilizing some logical guidelines.

Steps in Proper Disc Steps in Proper Disc ManagementManagement

Proper diagnosis (exam, imaging, etc.).Proper diagnosis (exam, imaging, etc.).

Conservative management.Conservative management.

Referral for medical/surgical options.Referral for medical/surgical options.

Long term care and follow-up.Long term care and follow-up.

Diagnosis of HNPDiagnosis of HNPH&P.H&P. Symptoms of neurological involvement.Symptoms of neurological involvement. Signs of neurological involvement (myelopathy, Signs of neurological involvement (myelopathy,

radiculopathy, cauda equina).radiculopathy, cauda equina).

Imaging.Imaging. Plain film.Plain film. Advanced (CT, MRI, discography).Advanced (CT, MRI, discography). Pitfalls.Pitfalls.

Other lab.Other lab.

Pitfalls of DiagnosisPitfalls of Diagnosis

Do Not Rely on Imaging Alone!Do Not Rely on Imaging Alone!

1984 Volvo Award in Clinical 1984 Volvo Award in Clinical Sciences: A Study of Computer- Sciences: A Study of Computer-

AssistedAssisted Tomography: The Tomography: The Incidence of Positive Cat Scans in Incidence of Positive Cat Scans in

an Asymptomatic Group of Patientsan Asymptomatic Group of Patients Sam W. Wiesel MD, Nicholas Tsourmas, Sam W. Wiesel MD, Nicholas Tsourmas,

MD, Henry L. Feffer, MD, Charles M. MD, Henry L. Feffer, MD, Charles M. CITRIN, MD, and N. PATRONAS, MDCITRIN, MD, and N. PATRONAS, MD

Spine Vol. 9; #6 1984Spine Vol. 9; #6 1984

Positive CAT Scans Positive CAT Scans

In Order to Study the Type and Number of In Order to Study the Type and Number of CAT Scan CAT Scan AAbnormalities of the Lumbar bnormalities of the Lumbar Spine That Occur In Asymptomatic Spine That Occur In Asymptomatic People, 52 Studies From a Control People, 52 Studies From a Control Population With No History of Back Population With No History of Back Trouble Were Mixed Randomly With Six Trouble Were Mixed Randomly With Six Scans From Patients With Surgically Scans From Patients With Surgically Proven Spinal Disease, and All Were Proven Spinal Disease, and All Were Interpreted by Three Neuroradiologists In Interpreted by Three Neuroradiologists In aa B Blinded Fashion.linded Fashion.

Positive Cat ScansPositive Cat ScansIrrespective of Age, 35.4% (26.6%, 51.0%, and 31.3%) Irrespective of Age, 35.4% (26.6%, 51.0%, and 31.3%) Were Found to Be Abnormal.Were Found to Be Abnormal.Spinal Disease Was Identified in an Average of 19.5% Spinal Disease Was Identified in an Average of 19.5% (23.8%, 22.7%, and 12.5%)(23.8%, 22.7%, and 12.5%)Of the Under 40-year-olds, It Was a Herniated Nucleus Of the Under 40-year-olds, It Was a Herniated Nucleus Pulposus In Every Instance.Pulposus In Every Instance.In the Over 40-year-old Age Group,there Was an In the Over 40-year-old Age Group,there Was an Average of 50% (29.2%, 81.5%, and 48.1%) Abnormal Average of 50% (29.2%, 81.5%, and 48.1%) Abnormal Findings, With Diagnoses of Findings, With Diagnoses of HHerniated Disc, Facet erniated Disc, Facet Degeneration, and Stenosis Occurring Most Frequently.Degeneration, and Stenosis Occurring Most Frequently.[Key Words: Positive Cat Scans, Asymptomatic Patients, [Key Words: Positive Cat Scans, Asymptomatic Patients, HNP and Disc, Facet Degeneration, Stenosis]HNP and Disc, Facet Degeneration, Stenosis]

Abnormal Magnetic Resonance Abnormal Magnetic Resonance Scans of the Lumbar Spine in Scans of the Lumbar Spine in

Asymptomatic SubjectsAsymptomatic Subjects

SD Boden, MD, DO Davis, MD, T Dina, SD Boden, MD, DO Davis, MD, T Dina, MD, NJ Patronas, MD, SW Wiesel, MDMD, NJ Patronas, MD, SW Wiesel, MD

J Bn Jt Surg Vol. 72-A, No. 3 March J Bn Jt Surg Vol. 72-A, No. 3 March 19901990

Abnormal Magnetic Resonance Abnormal Magnetic Resonance ScansScans

67 Patients Who Never Had LBP, Sciatica 67 Patients Who Never Had LBP, Sciatica or Neurogenic Claudication.or Neurogenic Claudication.

Interpreted by 3 Independent Interpreted by 3 Independent Neuroradiologists.Neuroradiologists.

1/3 had Substantial Abnormality.1/3 had Substantial Abnormality.

< 60 Years Old< 60 Years Old 20 % HNP20 % HNP 0% Spinal Stenosis0% Spinal Stenosis

Abnormal Magnetic Resonance Abnormal Magnetic Resonance ScansScans

> 60 Years Old.> 60 Years Old. 57% Abnormal.57% Abnormal. 36% HNP.36% HNP. 21% Spinal Stenosis.21% Spinal Stenosis.

Degenerated or Bulging Disc at Least One Degenerated or Bulging Disc at Least One Level.Level. 35% Between 20-39 Years Old.35% Between 20-39 Years Old. All But One of 60-80 Year Olds.All But One of 60-80 Year Olds.

Concluded MRI Must Be Correlated To Clinical Concluded MRI Must Be Correlated To Clinical Presentation and Age.Presentation and Age.

Non-Surgical Treatment Non-Surgical Treatment OutcomesOutcomes

What if I Do Not Refer for What if I Do Not Refer for Surgery?Surgery?

Nonoperative Treatment of Nonoperative Treatment of Herniated Lumbar Herniated Lumbar Intervertebral Disk With Intervertebral Disk With Radiculopathy: An Radiculopathy: An Outcome StudyOutcome Study

Jeffrey A. SAAL, MD, and JOEL S. Jeffrey A. SAAL, MD, and JOEL S. Saal, MDSaal, MD

Spine Vol. 14; #4 1989Spine Vol. 14; #4 1989

Nonoperative TreatmentNonoperative TreatmentThe Functional Outcome of Patients With Lumbar HNP The Functional Outcome of Patients With Lumbar HNP Without Significant Stenosis Was Analyzed in a Without Significant Stenosis Was Analyzed in a Retrospective Cohort Study.Retrospective Cohort Study.Inclusion Criteria:Inclusion Criteria:

1.1. A Chief Complaint of Leg Pain, Primarily.A Chief Complaint of Leg Pain, Primarily.2.2. A Positive Straight Leg Raising (SLR) at Less Than 60 Degrees - A Positive Straight Leg Raising (SLR) at Less Than 60 Degrees -

Reproducing the Leg Pain.Reproducing the Leg Pain.3.3. A Computed Tomography (Ct) Scan Demonstrating HNP Without A Computed Tomography (Ct) Scan Demonstrating HNP Without

Significant Stenosis by a Radiologist's Reading, Also Confirmed by Significant Stenosis by a Radiologist's Reading, Also Confirmed by Authors.Authors.

4.4. A Positive Electromyogram (EMG) Demonstrating Evidence of A Positive Electromyogram (EMG) Demonstrating Evidence of Radiculopathy.Radiculopathy.

5.5. Response to a Follow-up Response to a Follow-up Questionnaire.Questionnaire.

Nonoperative TreatmentNonoperative TreatmentAll Patients Had Undergone Aggressive Physical All Patients Had Undergone Aggressive Physical RehabilitationRehabilitation Back School.Back School. Stabilization Exercise Training.Stabilization Exercise Training.

A Total of 347 Consecutively Identified Patients.A Total of 347 Consecutively Identified Patients. 64 Patients With Average Follow-up Time of 31.1 Months Met 64 Patients With Average Follow-up Time of 31.1 Months Met

InclusionInclusionCriteria.Criteria.

Sent Questionnaires That Inquired About:Sent Questionnaires That Inquired About:Activity LevelActivity LevelPain LevelPain LevelWork StatusWork StatusFurther Medical Care.Further Medical Care.

Nonoperative TreatmentNonoperative Treatment

Patients With Neurologic Loss, Extruded Patients With Neurologic Loss, Extruded Discs, and Those Seeking a Second Discs, and Those Seeking a Second Opinion Regarding Surgery Were Opinion Regarding Surgery Were Identified and Subgrouped.Identified and Subgrouped.

Results for the Total Group Included 90% Results for the Total Group Included 90% Good or Excellent Outcome With a 92% Good or Excellent Outcome With a 92% Return to Work Rate. Return to Work Rate.


Subgroups With Extruded Discs and Second OpinionsSubgroups With Extruded Discs and Second Opinions 87% and 83% Had Good or Excellent Outcomes, Respectively87% and 83% Had Good or Excellent Outcomes, Respectively All (100%) Returned to Work.All (100%) Returned to Work.

Sick Leave Time for These SubgroupsSick Leave Time for These Subgroups 2.9 Months (+/-1.4 Months) and 3.4 Months (+/- 1.7 Months) 2.9 Months (+/-1.4 Months) and 3.4 Months (+/- 1.7 Months)

Respectively.Respectively.

Compared Favorably With Previously Published Surgical Compared Favorably With Previously Published Surgical Studies.Studies.Four of Six Patients Who Required Surgery Were Found Four of Six Patients Who Required Surgery Were Found to Have Stenosis at Operation.to Have Stenosis at Operation.


No Statistically Significant Difference in No Statistically Significant Difference in Outcome In Patients With Neurologic Outcome In Patients With Neurologic Weakness or Extruded Discs From Study Weakness or Extruded Discs From Study Population.Population.

Demonstrates That Lumbar HNP With Demonstrates That Lumbar HNP With Radiculopathy Can Be Treated Very Radiculopathy Can Be Treated Very Successfully Without Operation.Successfully Without Operation.


Surgery Should Be Reserved for Surgery Should Be Reserved for Patients Where Function Cannot Be Patients Where Function Cannot Be Satisfactorily Improved by Physical Satisfactorily Improved by Physical Program.Program.Failure to Respond to Nonoperative Care Failure to Respond to Nonoperative Care Suggests Presence of Stenosis. Suggests Presence of Stenosis. [Key Words: Lumbar Herniated Disc, [Key Words: Lumbar Herniated Disc, Nonoperative Treatment, Clinical Course]Nonoperative Treatment, Clinical Course]

The Natural History of Lumbar The Natural History of Lumbar Intervertebral DiscIntervertebral Disc EExtrusions xtrusions

Treated Nonoperatively Treated Nonoperatively

JEFFREY A. Saal, MD, Joel S. JEFFREY A. Saal, MD, Joel S. SAAL, MD, and RICHARD J. SAAL, MD, and RICHARD J.

Herzog, MDHerzog, MD

Spine 15 (7) 1990 (P 683)Spine 15 (7) 1990 (P 683)

Natural History Natural History

Purpose Was to Evaluate the Natural Purpose Was to Evaluate the Natural History of Morphologic Changes Within the History of Morphologic Changes Within the Lumbar Spine In Patients Who Sustained Lumbar Spine In Patients Who Sustained Lumbar Disc Extrusions.Lumbar Disc Extrusions.

All Patients in This Study Were Treated All Patients in This Study Were Treated Nonoperatively for Radicular Pain and Nonoperatively for Radicular Pain and Neurologic Loss.Neurologic Loss.

Natural HistoryNatural History

The Following Questions Were The Following Questions Were Addressed:Addressed:

1.1. Does Perithecal or Perineural Fibrosis Result Does Perithecal or Perineural Fibrosis Result When Extrusions Are Not Removed When Extrusions Are Not Removed SurgicallySurgically

2.2. Do Disc Extrusions Spontaneously Resolve, Do Disc Extrusions Spontaneously Resolve, And, If So, How Rapidly?And, If So, How Rapidly?


Study Population Consisted of 11 Patients With Study Population Consisted of 11 Patients With Extrusions and Radiculopathy. Extrusions and Radiculopathy. All Patients Were Successfully Treated All Patients Were Successfully Treated Nonoperatively. Nonoperatively. All Had a Primary Complaint of Leg PainAll Had a Primary Complaint of Leg PainAll Had Positive Straight Leg Raising All Had Positive Straight Leg Raising Reproducing Their Leg Pain at Less Than or Reproducing Their Leg Pain at Less Than or Equal to 60 DegreesEqual to 60 Degrees87% Had Muscle Weakness on a Neurologic 87% Had Muscle Weakness on a Neurologic Basis in a Root Level Distribution Corresponding Basis in a Root Level Distribution Corresponding to the Site of Disc Pathology.to the Site of Disc Pathology.


(CT) Examinations Were Obtained on All (CT) Examinations Were Obtained on All Patients at the Inception of Treatment.Patients at the Inception of Treatment.These Studies Were Compared With Follow-up These Studies Were Compared With Follow-up MRI Studies. MRI Studies. The Initial Ct Scans Were Evaluated for the The Initial Ct Scans Were Evaluated for the Following Criteria:Following Criteria: Disc Size and PositionDisc Size and Position Thecal Sac EffacementThecal Sac Effacement Nerve Root Enlargement or DisplacementNerve Root Enlargement or Displacement Evidence of Central or Intervertebral Canal Stenosis.Evidence of Central or Intervertebral Canal Stenosis.


In Addition to the Pathomorphology In Addition to the Pathomorphology Evaluated on Ct Scans, Follow-up MRI Evaluated on Ct Scans, Follow-up MRI Studies Also Evaluated:Studies Also Evaluated: Disc Hydration at the Herniated and Disc Hydration at the Herniated and

Contiguous LevelsContiguous Levels The Presence of Perithecal or Perineural The Presence of Perithecal or Perineural

Fibrosis.Fibrosis.


The Following Grading System Was Used to The Following Grading System Was Used to Evaluate Change in Fragment Size on the Follow-up Evaluate Change in Fragment Size on the Follow-up Studies:Studies: Grade 1 - 0 to 50% Decrease in Size.Grade 1 - 0 to 50% Decrease in Size. Grade 2 - 50 to 75% Decrease in SizeGrade 2 - 50 to 75% Decrease in Size Grade 3 - 75 to 100% Decrease in Size.Grade 3 - 75 to 100% Decrease in Size.

Results on Follow-up MRI Examinations Were As Results on Follow-up MRI Examinations Were As Follows:Follows: 11% of the Patients Had Grade 1 - 2 Residual Fragments.11% of the Patients Had Grade 1 - 2 Residual Fragments. 36% Had Grade 2 - 4 Fragments36% Had Grade 2 - 4 Fragments 46% Had Grade 3 - 5 Fragments.46% Had Grade 3 - 5 Fragments.


Associated Morphologic Changes Were As Follows:Associated Morphologic Changes Were As Follows: No Patients Had Perithecal or Perineural Fibrosis.No Patients Had Perithecal or Perineural Fibrosis. 1 Patient Had a Progression of Stenosis.1 Patient Had a Progression of Stenosis. All Patients Had Disc Desiccation at the Level of Disc Herniation With All Patients Had Disc Desiccation at the Level of Disc Herniation With

Contiguous Levels Being Normally Hydrated.Contiguous Levels Being Normally Hydrated. All Patients Had a Decrease in Neural Impingement.All Patients Had a Decrease in Neural Impingement.

The Interval Between the Initial Presentation and Follow-up The Interval Between the Initial Presentation and Follow-up Was a Median of 25 Months With a Range of 8 to 77 Was a Median of 25 Months With a Range of 8 to 77 Months.Months.[Key Words: Lumbar Disc Herniation, Nonoperative [Key Words: Lumbar Disc Herniation, Nonoperative Treatment]Treatment]

Dynamic Muscular Dynamic Muscular Stabilization in the Stabilization in the

Nonoperative Treatment of Nonoperative Treatment of Lumbar Pain Syndromes.Lumbar Pain Syndromes.

Saal J A, Orthop Rev, 19: 691-Saal J A, Orthop Rev, 19: 691-700 Aug 1990 700 Aug 1990

Dynamic Muscular Dynamic Muscular StabilizationStabilization

The Results of a Three-year Study of Patients The Results of a Three-year Study of Patients With Herniated Nucleus Pulposus and With Herniated Nucleus Pulposus and Radiculopathy Are Presented. Radiculopathy Are Presented.

NonoperativeNonoperative TreatmentTreatment Options for These Options for These Lumbar Disorders.Lumbar Disorders. An Aggressive Physical Rehabilitation ProgramAn Aggressive Physical Rehabilitation Program Pain Control MethodsPain Control Methods Exercise Training Designed to Eliminate Repetitive Exercise Training Designed to Eliminate Repetitive

Intervertebral Disc or Facet Joint InjuryIntervertebral Disc or Facet Joint Injury Dynamic Muscular Lumbar Stabilization TechniquesDynamic Muscular Lumbar Stabilization Techniques

Dynamic Muscular Dynamic Muscular Stabilization Stabilization

Successful Outcomes Were Achieved in Successful Outcomes Were Achieved in 50 of the 52 (96%) 50 of the 52 (96%) NonoperativelyNonoperatively Treated Patients. Treated Patients.

A Subcategory of Patients With Extruded A Subcategory of Patients With Extruded Nuclear Fragments Had an 87% Success Nuclear Fragments Had an 87% Success Rate. Ninety-two Percent of the Overall Rate. Ninety-two Percent of the Overall Study Population Was Able to Return to Study Population Was Able to Return to Work.Work.

Side Posture Manipulation for Side Posture Manipulation for Lumbar Intervertebral Disk Lumbar Intervertebral Disk

HerniationHerniation J. David Cassidy, D.C., Haymo W. Thiel, D.C., J. David Cassidy, D.C., Haymo W. Thiel, D.C., And William H. Kirkaldy-Willis, M.D., F.R.C.S. And William H. Kirkaldy-Willis, M.D., F.R.C.S.

(E & C), F.A.C.S.(E & C), F.A.C.S.

J Manipulative Physiol Ther 1993: 16:96-103J Manipulative Physiol Ther 1993: 16:96-103

Key Indexing Terms: Lumbar Vertebrae, Spine, Key Indexing Terms: Lumbar Vertebrae, Spine,Intervertebral Disk, Low Back Pain, Chiropractic.Intervertebral Disk, Low Back Pain, Chiropractic.

Side PostureSide PostureAbstractAbstract The Objective of This Article Is to Review the Status The Objective of This Article Is to Review the Status

of Side Posture Manipulation for Lumbar of Side Posture Manipulation for Lumbar Intervertebral Disk Herniation.Intervertebral Disk Herniation.

The Data Presented in This Article Are From the Back The Data Presented in This Article Are From the Back Pain Clinic at the Royal University Hospital and the Pain Clinic at the Royal University Hospital and the Articles Cited Are Those Which We Feel Are Articles Cited Are Those Which We Feel Are Important in Reviewing This Subject.Important in Reviewing This Subject.

Conclusions: The Treatment of Lumbar HNP by Side Conclusions: The Treatment of Lumbar HNP by Side Posture Manipulation Is Both Safe and Effective. Posture Manipulation Is Both Safe and Effective. Further Research Is Required to Understand More Further Research Is Required to Understand More Fully the Effects of This Treatment on the Fully the Effects of This Treatment on the Intervertebral Disk.Intervertebral Disk.

Lumbar Intervertebral Disc Lumbar Intervertebral Disc Herniation: Treatment by Herniation: Treatment by Rotational ManipulationRotational Manipulation

Jeffrey A. Quon, D.C., J. David Cassidy, Jeffrey A. Quon, D.C., J. David Cassidy, D.C., Sandra M. O'Connor, D.C., And D.C., Sandra M. O'Connor, D.C., And

William H. Kirkaldy-Willis, M.D.William H. Kirkaldy-Willis, M.D.

J Manipulative Physiol Ther 1989: J Manipulative Physiol Ther 1989: 12:220-22712:220-227

Herniation: TreatmentHerniation: Treatment

We Describe the Case of a Patient With a We Describe the Case of a Patient With a Lumbar Disc Herniation Who Underwent a Lumbar Disc Herniation Who Underwent a Course or Side Posture Manipulation, Despite Course or Side Posture Manipulation, Despite the Appearance of an Enormous Central the Appearance of an Enormous Central Herniation on the CT Scan.Herniation on the CT Scan.

The Patient Improved Considerably During Only The Patient Improved Considerably During Only 2 Wk of Treatment.2 Wk of Treatment.

The Disparity Which So Commonly Exists The Disparity Which So Commonly Exists Between Radiological and Clinical Findings Is Between Radiological and Clinical Findings Is Depicted in This Case.Depicted in This Case.

Herniation: TreatmentHerniation: Treatment

Further, It Is Emphasized That Manipulation Has Further, It Is Emphasized That Manipulation Has Been Shown to Be an Effective Treatment of Been Shown to Be an Effective Treatment of Some Patients With Lumbar Disc Herniation.Some Patients With Lumbar Disc Herniation.

While Complications of This Form of Treatment While Complications of This Form of Treatment Have Been Reported in the Literature, Such Have Been Reported in the Literature, Such Incidents an Rare.Incidents an Rare.

Key Indexing Terms: Lumbar Disc Herniation, Key Indexing Terms: Lumbar Disc Herniation, Manipulation, Cauda Equina Syndrome, Manipulation, Cauda Equina Syndrome, Computed Tomography.Computed Tomography.

How Many Days Of Bed How Many Days Of Bed Rest For Acute Low Back Rest For Acute Low Back

Pain? A Randomized Pain? A Randomized Clinical Trial Clinical Trial

RICHARD A. Deyo, M.D., M.P.H., Andrew K. RICHARD A. Deyo, M.D., M.P.H., Andrew K. Diehl, M.D., M.Sc.,Diehl, M.D., M.Sc.,

And MARC ROSENTHAL, DR.P.H.And MARC ROSENTHAL, DR.P.H.

N Engl J Med 1986; 315:1064-70.N Engl J Med 1986; 315:1064-70.

Bed Rest Bed Rest

Bed Rest Is Usually Recommended for Acute Bed Rest Is Usually Recommended for Acute Low Back Pain.Low Back Pain.

Although the Optimal Duration of Bed Rest Is Although the Optimal Duration of Bed Rest Is Uncertain, a Given Prescription May Directly Uncertain, a Given Prescription May Directly Affect the Number of Days Lost From Work or Affect the Number of Days Lost From Work or Other Activities. Other Activities.

In a Randomized Trial, We Compared the In a Randomized Trial, We Compared the Consequences of Recommending Two Days of Consequences of Recommending Two Days of Bed Rest (Group I) With Those of Bed Rest (Group I) With Those of Recommending Seven Days (Group Ii).Recommending Seven Days (Group Ii).

Bed Rest Bed Rest The Subjects Were 203 Walk-in Patients With Mechanical The Subjects Were 203 Walk-in Patients With Mechanical Low Back PainLow Back Pain78 Percent Had Acute Pain (< 30 Days), and None Had 78 Percent Had Acute Pain (< 30 Days), and None Had Marked Neurologic Deficits.Marked Neurologic Deficits.Follow-up Data Were Obtained at Three Weeks (93 Percent) Follow-up Data Were Obtained at Three Weeks (93 Percent) and Three Months (88 Percent).and Three Months (88 Percent).Although Compliance With the Recommendation of Bed Rest Although Compliance With the Recommendation of Bed Rest Was Variable, Patients Randomly Assigned to Group I Missed Was Variable, Patients Randomly Assigned to Group I Missed 45 Percent Fewer Days of Work Then Those Assigned to 45 Percent Fewer Days of Work Then Those Assigned to Group II (3.1 Vs. 5.6 Days) and No Differences Were Group II (3.1 Vs. 5.6 Days) and No Differences Were Observed in Other Functional, Physiologic, or Perceived Observed in Other Functional, Physiologic, or Perceived Outcomes.Outcomes.

Bed Rest Bed Rest

For Many Patients Without Neuromotor Deficits, For Many Patients Without Neuromotor Deficits, Physicians May Be Able to Recommend Two Physicians May Be Able to Recommend Two Days of Bed Rest Rather Than Longer Periods, Days of Bed Rest Rather Than Longer Periods, Without Any Perceptible Difference in Clinical Without Any Perceptible Difference in Clinical Outcome.Outcome.

If Widely Applied, This Policy Might Substantially If Widely Applied, This Policy Might Substantially Reduce Absenteeism From Work and the Reduce Absenteeism From Work and the Resulting Indirect Costs of Low Back Pain for Resulting Indirect Costs of Low Back Pain for Both Patients and Employers.Both Patients and Employers.

Bed RestBed Rest

Consensus Summary of Consensus Summary of the Diagnosis and the Diagnosis and

Treatment of Lumbar Disc Treatment of Lumbar Disc Herniation.Herniation.

Anderson GGB Brown MD, Dvorak Anderson GGB Brown MD, Dvorak J, J, Herzog Herzog Rj, Kambin P, Malter A, McCulloch JA, Saal JA, Rj, Kambin P, Malter A, McCulloch JA, Saal JA,

Spratt KF, Weinstein JN, Spratt KF, Weinstein JN,

Spine:21, 1996; 75S Through 78S Spine:21, 1996; 75S Through 78S

Consensus Consensus

Clinicians Must Not Simply Decide That a Clinicians Must Not Simply Decide That a Patient With Symptoms and a Positive Patient With Symptoms and a Positive Diagnostic Test Has a Reason for a Specific Diagnostic Test Has a Reason for a Specific TreatmentTreatmentClinicians Must Not Decide That a Patient With Clinicians Must Not Decide That a Patient With Symptoms and a Negative Test Does Not Have Symptoms and a Negative Test Does Not Have a Clinically Important Problem.a Clinically Important Problem.Must Also Consider the Sensitivity, Specificity Must Also Consider the Sensitivity, Specificity and Predictive Value of the Diagnostic Test and and Predictive Value of the Diagnostic Test and the Individual Characteristics of the Patient.the Individual Characteristics of the Patient.

ConsensusConsensus

Treatment Outcome Depends on Many Treatment Outcome Depends on Many Factors. Factors. Point of Service Decisions Vs Population Point of Service Decisions Vs Population Based Decisions Are Obviously Different.Based Decisions Are Obviously Different.Each Patient Presents to the Treating Each Patient Presents to the Treating Practitioner on a Given Day, at a Given Practitioner on a Given Day, at a Given Time, and It Is This Picture Upon Which a Time, and It Is This Picture Upon Which a Plan of Care Is Formulated.Plan of Care Is Formulated.

Decisions in Conservative Decisions in Conservative Management of HNPManagement of HNP

Pain level and impairment.Pain level and impairment.

Neurological symptomatology.Neurological symptomatology.

Neurological deficit.Neurological deficit.

Flavor of the case.Flavor of the case.

Selection of technique.Selection of technique.

Doctor comfort level.Doctor comfort level.

Referral TypesReferral Types

Testing only.Testing only.

Second opinion only.Second opinion only.

Co-managementCo-management

Complete transfer.Complete transfer.

Unrelated health problem detected.Unrelated health problem detected.

Decision to Refer for Decision to Refer for Neurosurgical ConsultationNeurosurgical Consultation

Patient is overly concerned.Patient is overly concerned.

Pain control - severe, intractable pain - initial Pain control - severe, intractable pain - initial failure of conservative care.failure of conservative care.

Profound or progressive neurological deficit.Profound or progressive neurological deficit.

Bowel or bladder involvement.Bowel or bladder involvement.

Myelopathy.Myelopathy.

Cauda equina syndrome.Cauda equina syndrome.

Choosing a NeurosurgeonChoosing a NeurosurgeonReputation - experience.Reputation - experience.

Familiar with chiropractic treatment.Familiar with chiropractic treatment. Patient or refers patients.Patient or refers patients. Endorsement by other dc’s/ will co-Endorsement by other dc’s/ will co-

manage.manage. Speaks or writes for DC publications.Speaks or writes for DC publications.

Familiar with manipulation literature - Familiar with manipulation literature - open-minded.open-minded.

Location, ease of scheduling, Location, ease of scheduling, reporting.reporting.

Spend a day at office/surgery.Spend a day at office/surgery.

Long Term Care & Follow-upLong Term Care & Follow-up

Occupational and recreational considerations.Occupational and recreational considerations.

Education of patient.Education of patient. Lifting, bending, standing, sitting, driving, sleeping, etc.Lifting, bending, standing, sitting, driving, sleeping, etc.

Interval outcome assessment.Interval outcome assessment.

Follow-up any neurological deficit.Follow-up any neurological deficit.

Home care/lifestyle.Home care/lifestyle. Acute.Acute. Ongoing.Ongoing.

Cervical and Lumbar Disc Cervical and Lumbar Disc Disease: Conservative and Disease: Conservative and

Surgical ManagementSurgical ManagementMust diagnose.Must diagnose.

Decision to conservatively manage.Decision to conservatively manage.

Decision to refer to neurosurgeon.Decision to refer to neurosurgeon.

Selecting a neurosurgeon.Selecting a neurosurgeon.

Long term treatment and follow-up.Long term treatment and follow-up.

Cervical and Lumbar Disc Disease: Conservative and Surgical Management Copyright, 2002 © Joseph S. Ferezy, D.C. UCERF & NWCC By Joseph S. Ferezy, D.C.

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