This is a 48 year old female patient who presented with acute low back pain. The pain began when she was making a bed (she works as a hotel maid). Upon presentation, the pain was non-radiating, midline lumbar pain. The patient denied previous episodes of lower back pain and did not have a history of back surgery. This was the first time the patient was seen at this office.
In the initial chiropractic examination, instrument reading was found at L5. Fixation and tenderness were noted upon palpation. Straight leg raiser was positive on the right side. Gait and movements were slow and cautious as is typical of one with acute lower back pain. Pain was exacerbated by forward flexion.
On the evaluation on September 19, 2001, lumbar range of motion was normalized and no pain was elicited upon forward flexion. There was slight tenderness at L5 to digital palpation.
On the initial visit (09/07/01), weight-bearing AP and lateral x-ray were taken. On the lateral film, intersegmental subluxation was found at L5 that was characterized by posterior-inferior misalignment. The L4 disc was narrow at the anterior and wide at the posterior. This was likely due to the misalignment at L5. There was a loss of the lumbar lordosis. On the AP film, L4 was visibly in compensation. The lumbar spine was antalgic to the right due to the L5 subluxation. (see photo #1 & #2)
On September 19, 2001, post-x-rays were taken. On the lateral view, L5 subluxation was reduced; L4 disc spacing was normal; and the lumbar lordosis was restored. On the AP film, L4 was no longer in a compensatory position and the antalgia was no longer present. (see photo #3 & #4)
Course of care
During the course of care, L5 PRS-M was adjusted side posture on the pelvic bench using the “Pull Move.”
September 7, 2001: Examination, x-ray, and L5 adjustment
September 8, 2001: Patient feels better; no adjustment given.
September 12, 2001: Patient complains of dull lower back pain; adjustment given.
September 19, 2001: Patient asymptomatic; no adjustment given; post-x-ray taken.
September 19, 2001: Patient released.
This patient who presented with acute lower back pain was first seen on September 7, 2001. Between the initial visit and release on September 19, 2001, the patient was checked four times and was adjusted twice. The correction was faster than was initially expected.
In acute lower back pain cases like the case presented, L5 is often misaligned markedly posterior-inferior on the lateral x-ray. The disc above, (L4/L5) may compensate by widening at the posterior and narrowing at the anterior. This results in reduction in the normal lumbar curve or lumbar lordosis as in the case presented. The patient is usually in extreme pain and pressure put on L4 will exacerbate their pain. Effective correction will often restore the normal lumbar curve. The side posture position is recommended due to the pain intensity. Prone adjustments may exacerbate their pain.
Lately, there are questions on which chiropractic findings are most important to determine if a subluxation is present and the level of subluxation. Most long-time Gonstead chiropractors state that instrumentation and digital palpation are the most important findings when determining if a subluxation is present and the vertebral level. Dr. Gonstead as well spoke of the importance of digital palpation over other findings.
Another question is what is most important to the doctor when determining whether to adjust or not. The response by Dr. Vance is pretty typical of very experienced, long-time Gonstead chiropractors. He, as do many Gonstead chiropractors (including myself) tend to weigh heavily on patient complaints (or lack of complaints) rather than exclusively on findings when determining whether to adjust or not during the course of care. He quotes Dr. Alex Cox: “When a patient says he feels better, check another segment (if you feel a subluxation is still present) and back off for a week.” When in doubt, leave the spine alone. Of course, it is not as simple as that, because there are cases where the findings may be more important. Oftentimes in these situations, you are adjusting a different segment. There are situations where a patient is quite symptomatic but findings indicate that you better back off. If a patient says he feels better, you better listen to him (and pat chiropractic on its back).
|Photos #1 & #2:|
Sept. 7, 2001
Lateral view: Note the open wedge of the L4/L5 disc space to the posterior. There is loss of the normal lumbar curve to a kyphotic state and osteophytic activity.
AP view: note the scoliosis caused by muscle guarding. Also seen is L4 and L5 lateral osteophytic activity and D4 discs.
|Photos #3 & #4: |
Sept. 19, 2001
Lateral view: Note restoration of the lumbar curve. L4/L5 disc space now shows slight open wedging to the anterior. L4/L5 disc space is D4 and L5/S1 is D5.
AP view: There is reduction of the lateral curve and leveling of L4 on L5. Although, partially cut off at the bottom, the obturators are vertically narrower than those on the initial x-ray.