Cervical Disk Herniation

WHAT EVIDENCE EXISTS REGARDING AUDIBLERELEASE SMT AT A CONFIRMED CERVICAL DISK PROTRUSION SITE? A 50-year-old male patient seeks care for neck and arm pain. Cervical orthopedic tests are negative except for localized pain. Sensory testing reveals no abnormal changes. Although he reports arm pain, you cannot pinpoint any specifi c dermatome levels. Muscle strength testing shows no weakness. He has a confi rmed cervical disk protrusion at C5-C6 on an MRI from his medical physician. You’ve seen this presentation frequently in your practice and proceed routinely. You recommend a structured regimen of highvelocity, low-amplitude (HVLA) adjustments and home exercises. But because your skeptical patient’s wife talked him into visiting your offi ce, he needs research, reassurance and reasoning. EVIDENCE-BASED CONSIDERATION: is era calls for evidence-informed clinical practice even though chiropractic expertise traditionally involves treating patients with neck and arm pain, with and without confi rmed cervical disk protrusion. How common is this condition according to the literature? e annual incidence (i.e., number of new cases per year) of cervical radiculopathy is 83 per 100,000 individuals, while the prevalence (the amount of cases in the population at/over a given time) is 3.5 per 1,000 individuals. Cervical disk protrusion occurs more commonly in patients ages 50 to 60. It demonstrates a variety of related physical fi ndings. In less than one-fourth of cases, the intervertebral disk is the sole causative agent. More than half of such cases are caused by both discogenic and spondylotic issues.1 Notably, the prevalence of cervical disk protrusions ranges between 8 percent and 70 percent among asymptomatic individuals.2 ,3 Inconclusive evidence exists to draw fi rm conclusions regarding spinal manipulative treatment (SMT).4 Some consider it contraindicated, although many perform SMT at adjacent sites. e natural history appears favorable.5 However, here is a recent study: Peterson C, Schmid C, Leeman S, Anklin B, and Humphreys BK. Outcomes from magnetic resonance imaging — confi rmed symptomatic cervical disk protrusion patients treated with high-velocity, low-amplitude spinal manipulative therapy: a prospective cohort study with 3-month follow-up. J Manipulative Physiol er 2013;36(8):461-7. OBJECTIVE: e authors asked, “How do patients with cervical disk protrusion and radiculopathy respond to osseous SMT?” METHODS: Fifty patients were recruited from a Swiss chiropractic practice. Aged between 18 and 65, they had neck pain and moderate-to-severe arm pain in a dermatomal pattern; sensory, motor or refl ex changes corresponding to the involved nerve root; and no contraindications to cervical SMT. At least one positive orthopedic test for radiculopathy was required. Exclusion criteria included spinal myelopathy, spinal stenosis and previous spinal surgery. Outcome measures included the Numeric Rating Scale (0-10), the Neck Disability Index (NDI) and the patients’ global impressions of change (PGIC). Patients were assessed at two weeks, one month and three months. Treatment occurred three to fi ves times per week for two to four weeks, and then one to three times per week until the patient was asymptomatic. Patients were allowed OTC pain medications. OF NOTE: SMT was performed “at the spinal level clinically assessed to correspond with the MRI fi ndings.” HVLA was applied “with the goal of moving the affected segment and producing an audible release.” If audible release was not achieved during the fi rst thrust, the DC could try twice more. RESULTS: Fifty patients provided data at baseline and three months. e average patient was 44 years old. About a third were male. After the initial two weeks of treatment, 55.3 percent were signifi cantly improved. None reported being worse. e percentage of improved patients continually rose during treatment. One patient was slightly worse at one month but reported improvement after Evidence in Action: Cervical Disk Herniation