SpineUniverse Case Study Library

Conservative Treatment of Rapidly Reducible Disc Pathology and Nerve Root Adherence

History

The patient is a 16-year-old high school student and football/cross-country athlete. He was referred to Physical Therapy by his primary care physician, upon the suggestion of the patient's mother.

The patient presents with a 2-month history of intermittent left buttock and thigh pain that was caused by a rather rough tackle in spring football practice. He reports no change in his symptoms since onset. He previously consulted with an orthopaedic surgeon who performed MRI of his hip and knee, but no spinal imaging.

He is in otherwise excellent health. The patient's functional difficulty is inability to sit, rise from sit, or lift without pain. Walking and lying down provides some relief.

Examination

The patient had a poor habitual sitting posture; correction of this posture by manually increasing his lordotic curve reportedly decreased the severity of his buttock and thigh pain.

Neurological Testing

  • Motor deficit: no apparent deficits L2-S1 myotome
  • Sensory deficit: no apparent deficits L2-S1 dermatome
  • Dural Signs: positive left straight leg raise at 45-degrees, positive slump test, and positive well-leg raise
  • Reflexes: not assessed

Lumbar Movement Loss

 
Maj
Mod
Min
Nil
Pain/Deviations
Flexion in standing
X
 
 
 
Deviates from sagittal plane left, produced left thigh pain
Extension in standing
 
 
 
X
 
Slide-gliding right
 
 
 
X
 
Side-gliding left
 
 
 
X
 

 

Lumbar Repeated Movement Testing
(ERP=end range pain; PDM=pain during movement; LBP=low back pain; NE=no effect)

Pretest symptoms standing: none

Movement Test Symptoms during Testing Symptoms after Testing Mechanical Response
Flexion in standing Produced ERP, left thigh No worse No effect
Rep. flexion in standing Increases left thigh No worse No effect
Extension in standing No effect No effect No effect
Rep. extension in standing No effect No effect No effect

Pretest symptoms lying: none

Movement Test Symptoms during Testing Symptoms after Testing Mechanical Response
Flexion in lying No effect No effect No effect
Rep. flexion in lying No effect No effect No effect
Extension in lying Produced ERP, left LBP No worse No effect
Rep. extension in lying Decreases Better Better

 

Prior Treatment

None

Imaging

Pre-treatment imaging not available

Diagnosis

Based on the rapid reduction in pain with sitting posture correction and repeated unloaded extension, the patient was classified as suffering from mechanical back pain due to reducible internal derangement of the intertvertebral joint complex in the lower segments of the lumbar spine. The patient also had significant signs of dural tension believed to be caused from a secondary diagnosis of nerve root adherence, which was the result of the healing process following this traumatic injury.

Initial Treatment

Treatment initially was directed at the derangement; mechanical therapy to remodel the nerve root adherence was placed on hold until the derangement was deemed reduced and stable through mechanical testing.

The initial treatment chosen was unloaded end range lumbar extension exercises (press ups). This was prescribed 10 times every 2 hours. In addition to the extension exercises, the patient was educated in sitting posture and given a lumbar support roll to maintain his lordotic curve while seated. He was also discouraged from activity that required bending or spinal flexion. He was scheduled for follow up in 24 hours to monitor his progress.

Upon follow up, he reported he had performed his home program 4 to 5 times and felt a little better. Using the lumbar pillow improved his sitting tolerance and it was easier to move around, but he was still quite restricted in his ability to bend or extend his knee while seated. He was encouraged to continue the exercises more frequently and postural advice/ restrictions on flexion were reviewed. He was sent home to continue for another 72 hours before his next follow up.

At the third visit, he reported further improvement of sitting tolerance and ability to rise from sitting. He was now able to perform his press up exercise to end range without production of back pain. His straight leg raises was still unchanged, as was his ability to bend or extend his knee in sitting. His home program was modified by adding lumbar extension in standing, as well as lying, to be performed every 3 to 4 hours. Postural restrictions of no slouching or bending were reinforced. He was scheduled for follow up in 10 days.

At the fourth visit, 10 days later, the patient reported no pain with sitting up to 2 hours, no pain with rising from sitting, and improved tolerance for lifting. He still had thigh pain with extension of his knee while seated and when attempting to bend with the knee extended. The patient's response to mechanical testing was as follows:

Neurological Testing

  • Motor deficit: no apparent deficits L2-S1 myotome
  • Sensory deficit: no apparent deficits L2-S1 dermatome
  • Dural Signs: positive left straight leg raise at 55-degrees, positive slump test, and positive well-leg raise
  • Reflexes: not assessed

Lumbar Movement Loss

 
Maj
Mod
Min
Nil
Pain/Deviations
Flexion in standing
X
 
 
 
Deviates from sagittal plane left, produced left thigh pain
Extension in standing
 
 
 
X
 
Slide-gliding Right
 
 
 
X
 
Side-gliding Left
 
 
 
X
 

Lumbar Repeated Movement Testing
(ERP=end range pain; PDM=pain during movement; LBP=low back pain; NE=no effect)

Pretest symptoms standing: none

Movement Test Symptoms during Testing Symptoms after Testing Mechanical Response
Flexion in standing Produced ERP, left thigh No worse No effect
Rep. flexion in standing Increases left thigh No worse No effect
Extension in standing No effect No effect No effect
Rep. extension in standing No effect No effect No effect

Pretest symptoms lying: none

Movement Test Symptoms During Testing Symptoms after Testing Mechanical Response
Flexion in lying No effect No effect No effect
Rep. flexion in lying No effect No effect No effect
Extension in lying No effect No effect No effect
Rep. extension in lying No effect No effect No effect

Suggest Treatment

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Selected Treatment

Patient Video
Clinical testing 2-weeks post-treatment

The derangement was deemed reduced and stable and treatment was then directed at remodeling of his nerve root adherence. This was to be accomplished by performing end-range flexion exercises with the nerve root on stretch (flexion in standing) and other stretching maneuvers that place tension on the adherent neural structures causing the limited knee extension, restricted lumbar flexion, and thigh pain. The flexion exercises were prescribed every 4 hours and were to be followed by the extension exercises previously prescribed as a safety check to avoid recurrent derangement. He was encouraged to gradually start to resume his normal activity to include general exercise and sports (running).

Because the adherence of the neural tissue was unlikely to rapidly change, the patient was sent home to perform his exercises as prescribed and follow up for re-assessment every 2 weeks until full function is restored. Full restoration of function or ability to extend knee or bend without pain was estimated to take weeks or months.

Outcome

The patient continued the prescribed treatment and presented for follow up every 2 weeks, then eventually monthly for a period of one-year (20 visits). At this time he was experiencing no thigh pain, was able to fully extend his knee, and bend without pain.

He resumed cross-country running for distances up to 6 miles in less than one hour without pain. He felt he was fully recovered and no longer required my services. He was given long-term advice to continue the extension exercises 1 to 2 times each day to prevent derangement and flexion exercises a few days per week to maintain nerve root mobility.

The patient's final mechanical assessment was as follows:

Neurological Testing

  • Motor deficit: no apparent deficits L2-S1 myotome
  • Sensory deficit: no apparent deficits L2-S1 dermatome
  • Dural Signs: negative left straight leg raise at 80-degrees, positive slump test, and negative well-leg raise
  • Reflexes: not assessed

Lumbar Movement Loss

 
Maj
Mod
Min
Nil
Pain/Deviations
Flexion in standing
 
 
 
X
 
Extension in standing
 
 
 
X
 
Slide-gliding right
 
 
 
X
 
Side-gliding left
 
 
 
X
 

Lumbar Repeated Movement Testing
(ERP=end range pain; PDM=pain during movement; LBP=low back pain; NE=no effect)

Pretest symptoms standing: none

Movement Test Symptoms during Testing Symptoms after Testing Mechanical Response
Flexion in standing No effect No effect No effect
Rep. flexion in standing No effect No effect No effect
Extension in standing No effect No effect No effect
Rep. extension in standing No effect No effect No effect

Pretest symptoms lying: none

Movement Test Symptoms during Testing Symptoms after Testing Mechanical Response
Flexion in lying No effect No effect No effect
Rep. flexion in lying No effect No effect No effect
Extension in lying No effect No effect No effect
Rep. extension in lying No effect No effect No effect



Video: Clinical testing; one-year post-treatment

Case Discussion

Mr. Stover presents an interesting case with a clinical presentation that is not uncommon for practitioners who treat patients with spinal pathology. The history of this patient reveals some important clues which, combined with the physical examination of the patient, clearly points towards Mr. Stover's clinical hypothesis and diagnosis.

McKenzie and May1 describe the symptoms and mechanical presentation of a derangement syndrome (page 547) as well as the clinical presentation of an adherent nerve root (page 673). This patient, following the Mechanical Diagnosis and Therapy examination and treatment method, is clearly an excellent candidate for conservative spinal management.

Mr. Stover's clinical reasoning to address the derangement first is most important and his focus on return to function is clearly demonstrated. Another hallmark of the Mechanical Diagnosis and Therapy treatment method is highlighted in this case, which is the focus on education and home treatment so the patient is able to treat himself. Especially at the end of the treatment, when the focus is on remodeling of tissue, which will take substantial time, formal physical therapy visit frequency should be reduced as Mr. Stover's case clearly demonstrates. This also highlights the problem many practitioners experience with third-party payers who limit the amount of days patients can receive physical therapy to 60 or 90 days following the start of an episode of care.

At the discharge visit, this patient's function has been fully restored and he receives important information to avoid recurrence of his symptoms. Overall, this is an interesting case that demonstrates good clinical reasoning and a full return to function of this patient using Mechanical Diagnosis and Therapy examination and treatment.

Reference
1. McKenzie R, May S. The Lumbar Spine. Mechanical Diagnosis & Therapy. 2nd ed. Waikanae, New Zealand: Spinal Publications; 2003: 547, 673.

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