Posterior Open Wedge of the L5/S1 Disc Space: L5 or Sacral Subluxation?

A 47-year-old male presented to the office on November 7, 2005, with complaints of severe lower back pain. He stated that he also had right and left leg pain. The injury was a result of lifting a heavy object the previous day.

(From the December 2005 The “G”Note)

Relevant Physical Findings

Instrumentation analysis found a “break” at L5. On digital palpation, the L5 spinous was more painful than the S1 tubercle. Lumbar range of motion was painful and restricted, especially in forward flexion. The Achilles tendon reflex was diminished bilaterally. The patient was not antalgic but did have difficulty walking. He was able to arise from a chair without difficulty.

AP and Lateral Lumbar X-Ray Findings – 11/7/05

The lateral x-ray revealed an open wedge of the L5/S1 disc space to the posterior on a D3 disc. The AP showed a listing of L5 PRI-M and a sacrum P-L (8 mm). (photos #1 & #2)

Chiropractic Care

L5 was adjusted on the pelvic bench with a pull move. This was done on 11/7, 11/8, 11/9, and 11/11. On 11/13, the patient stated that he was feeling much better. A follow-up exam was conducted on 11/20. The patient was asymptomatic. Lumbar range of motion and other tests were normal. A lateral x-ray was taken at that time.

Lateral Lumbar Post-X-Ray Finding

The L5/S1 disc space now has an open wedge to the anterior. (photo #3)

In dealing with this condition, Dr. Gonstead stated that the subluxation is the most tender segment. On this patient, the L5 spinous process was much more painful upon palpation that the S1 tubercle.

Notes: Cold as a palliative for 20 minutes, 2-3 times daily is usually beneficial for acute low back pain. The side posture adjustment is recommended for acute low back pain.The prone adjustment may exacerbate the pain. An open wedge of the L4/L5 disc space to the posterior is usually indicative of an intersegmental subluxation subadjacent to it, L5/S1, if there are indications of subluxation in the lower lumbar spine.

Posterior Open-a-12-05

PRE-AP LUMBAR SPINE
Lumbar spine is PR. Sacrum is Posteriorly rotated on the left by 8 mm on an ASIn ilium.

Posterior Open-b-12-05

PRE-LATERAL LUMBAR SPINE
Note how the L5/S1 disc space has an open wedge to the posterior

Posterior Open-c-12-05

POST-LATERAL LUMBAR SPINE
Note how the L5/S1 disc space now has an open wedge to the anterior. Ed: the open wedge posterior in the first film might be due to disc swelling. The post-film has the pre-injury arrangement.