This month we take a close look at manipulation of the joints of the lumbar spine and the relationship to Lumbar disc protrusion. Often lumbar manipulation involves some degree of rotation. Lumbar spine manipulations that are primarily rotational in nature are often discouraged as it is assumed that such maneuvers are associated with an increased risk of injury to the annulus of the intervertebral disc. The traditional caution pertaining to such manipulations is based upon an understanding of the anatomy of the annulus. The collagen fibers that comprise the annulus of the disc are arranged in layers, and each layer is crossed in opposite directions. During disc rotational movements, half of the annular collagen fibers become tense, and the other half become lax. Consequently, it is argued that rotational stress applied to the annulus of the disc is resisted by only half of the annular collagen fibers, the half that become tense. In essence, it is argued that the disc is operating at only half strength during rotationally applied stress, increasing its vulnerability to injury.
Crossed Annular Fibers of the Intervertebral Disc
Despite these academic arguments, there is contrary evidence pertaining to the dangers of rotational manipulations of the lumbar spine. In fact, there is evidence that rotational manipulations are safe when applied by an appropriately trained provider. Additionally, there is evidence that lumbar spine rotational manipulations are effective in the treatment of low back pain, including the management of disc herniation.
In 1954, RH Ramsey, MD published a study titled:
Conservative Treatment of Intervertebral Disk Lesions
Dr. Ramsey’s study appeared in the Instructional Course Lectures of the American Academy of Orthopedic Surgeons. Dr. Ramsey states:
“The conservative management of lumbar disk lesions should be given careful consideration because no patient should be considered for surgical treatment without first having failed to respond to an adequate program of conservative treatment.”
“If after a fair trial of conservative treatment, the pain and disability continue and the symptoms are of sufficient gravity to warrant surgery, the patient is advised that he should be operated upon and the offending disk lesion should be removed.”
Dr. Ramsey advocated the following sequence of conservative treatment before considering a surgical option for patients with low back pain:
1) Varying degrees of rest:
Rest is most beneficial in acute cases and less beneficial in chronic cases.
It is important to curtail non-occupational activities such as athletics or more strenuous home hobbies. “Prolonged sitting, standing or walking should usually be stopped.”
2) Manipulation.
3) Local heat.
4) A firm bed:
“Most patients with low back pain on a mechanical basis rest much better on a bed which does not sag in the middle.”
5) A low back support:
“The patient is advised to wear the support during the day and also in the evening at anytime he or she is going to be up and more active.”
6) Instruction in the avoidance of strain:
“The patient should be advised to avoid all activities that aggravate his pain. He is especially warned about heavy lifting.”
Under some circumstances, it may be necessary for the patient to change his occupation.
“All strenuous athletic pursuits should be stopped temporarily.”
7) Postural exercises:
These should be both strengthening and stretching exercises.
8) Medication:
“Fairly large doses of the vitamin B Complex have proved beneficial to many patients.”
9) Weight control:
“Obesity definitely predisposes the patient to painful back conditions and such patients should be encouraged to reduce to a normal weight.”
10) Improvement in general health.
Pertaining to manipulation, Dr. Ramsey makes the following comments:
“From what is known about the pathology of lumbar disk lesions, it would seem that the ideal form of conservative treatment would theoretically be a manipulative closed reduction of the displaced disk material.”
“Many forms of manipulation are carried out by orthopaedic surgeons and by cultists and this form of treatment will probably always be a controversial one.”
“We limit the use of manipulation almost entirely to those patients who do not seem to be responding well to non-manipulative conservative treatment and who are anxious to have something else done short of operative intervention.”
“The method we use is relatively simple and can be done with or without anesthesia. It is more likely to be effective with anesthesia because the muscle relaxation permits greater motion by manipulation.”
“The patient lies on his side on the edge of the table facing the surgeon and the leg that is up is allowed to drop over the side of the table, tending to swing the up-side of the pelvis forward. The arm that is up is allowed to drop back behind the patient, tending to pull the shoulder back. The surgeon then places one hand on the patient’s shoulder and his opposite forearm on the patient’s iliac crest. Simultaneously, the shoulder is thrust suddenly back, rotating the torso in one direction while the iliac crest is thrust down and forward, rotating the pelvis in the opposite direction. This gives the lumbar spine a twist that frequently causes an audible and palpable crunch. This procedure is then repeated with the patient on his other side. The patient is then turned on his back and his hips and knees are hyperflexed sufficiently to forcibly flex the lumbar spine which tends to open up the disk spaces posteriorly.”
“The patient should be cautioned beforehand that forceful manipulation may possibly make his symptoms worse although many patients will get marked relief.”
Dr. Ramsey clearly defines the procedure as a lumbar spine manipulation. It is also clear the manipulation is rotational in nature, describing it using the term “twist.” Additionally he notes that the manipulation is “forceful” and associated with an “audible and palpable crunch.” Although he cautions that the manipulation may make the patient worse, “many patients will get marked relief.”
Fifteen years later (in 1969), physicians JA Mathews and DAH Yates from the Department of Physical Medicine, St. Thomas’ Hospital, London, published a study titled:
Reduction of Lumbar Disc Prolapse by Manipulation
This study by Drs. Mathews and Yates appeared in the September 20, 1969 issue of the British Medical Journal. These authors evaluated a number of patients that presented with an acute onset of low back and buttock pain who did not respond to rest. Diagnostic epidurography showed a clinically relevant small disc protrusion, along with antalgia and positive lumbar spine nerve stretch tests. These patients were then treated with long-lever rotation manipulations of the lumbar spine, using the shoulder and iliac crest as levers. These lumbar spine manipulations were clearly accompanied with a thrust maneuver. The manipulations were repeated until abnormal symptoms and signs had disappeared. Following the manipulations there was resolution of signs, symptoms, antalgia, and reduction in the size of the protrusions.
The following drawing and description of the rotation manipulation was included in their study:
REDUCTION OF LUMBAR DISC PROLAPSE BY MANIPULATION
The caption below this drawing said:
“A firm additional thrust completed the rotation manipulation.”
Important comments from Drs. Mathews and Yates from this study include:
“Manipulation of the lumbar spine has been used as an empirical treatment of low backache since antiquity. The persistence and popularity of this type of treatment was based on the clinical impression that it is beneficial.”
“The frequent accompaniment of acute onset low back pain by spinal deformity suggests a mechanical factor, and the accompanying abnormality of straight-leg raise or femoral stretch test suggests that the lesion impinges on the spinal dura matter of the dural nerve sheaths.”
“The lumbar spine was rotated away from the painful side to the limit of its range, the buttock or thigh of the painful side being used as a lever; a firm additional thrust was made in the same direction. This manoeuver was repeated until abnormal symptoms and signs had disappeared, progress being assessed by repeated examination.”
“Rotation manipulations apply torsion stress throughout the lumbar spine. If the posterior longitudinal ligament and the annulus fibrosus are intact, some of this torsion force would tend to exert a centripetal force, reducing prolapsed or bulging disc material.”
“The results of this study suggest that small disc protrusions were present in patients presenting with lumbago and that the protrusions were diminished in size when their symptoms had been relieved by manipulations.”
These authors concluded “it seems likely that the reduction effect [of the disc protrusion] is due to the manipulating thrust used.”
Once again, this article by Mathews and Yates clearly describe and draw the manipulations used, including the words “forceful,” “thrust,” and “rotation.” An interesting explanation for the successful treatment as well as the reduction in the size of the protrusion is uniquely linked to the rotational component of the manipulation: rotation tightens up intact aspects of the annular ring, pulling the nuclear protrusion towards the center and away from the nervous system.
In another study published in 1969, BC Edwards compared the effectiveness of heat/massage/exercise to spinal manipulation in the treatment of 184 patients that were grouped according to the presentation of back and leg pain, as follows:
Group
Treatment
Acceptable Outcome
Central Low Back Pain Only
heat/massage/exercise
83%
spinal manipulation
83%
Pain Radiation to Buttock
heat/massage/exercise
70%
spinal manipulation
78%