Chiropractic Care & Risk for Acute Lumbar Disc Herniation
- RRS Education
Lumbar disc herniation (LDH) is considered one of the most recognizable and clinically challenging sources of low back pain (LBP). The diagnosis of LDH is usually based on a clinician observing a set of signs and symptoms that point to compression or irritation of a lumbar spinal nerve root, such as:
- lumbosacral radiculopathy (radicular leg pain or ‘sciatica’);
- nerve root tension signs (e.g. positive straight leg raise or nerve tension tests);
- neurologic deficits (e.g. muscle weakness, reflex changes, sensory deficits); and
- advanced imaging (e.g. MRI or CT) findings that correlate with the clinical syndrome.
The clinical picture of LDH in the early stages (i.e. the prodromal phase), in which LBP progresses to radicular leg pain and possible neurologic signs, is often uncertain and can be a confusing time for both patients and clinicians. Thus, making a diagnosis of LDH during the early course of symptoms is often very difficult. People with LDH may consult a healthcare provider at different points in time along this course before radiculopathy or neurologic deficit has manifested, in which case the treatment itself might be mistakenly blamed for causing the LDH (which, in theory, was going to happen anyway). This type of error is called protopathic bias, wherein reverse-causality bias is present that is related to processes that occur before an outcome has been measured or diagnosed.
When LBP patients receive chiropractic care while in the prodromal phase of LDH and then later experience acute herniation, the observed association between the intervention and outcome may not be causal. Also, many LBP patients seek care from primary care physicians (PCPs) whose interventions are not likely to cause LDH, so any observed association between intervention and outcome could be attributed to care seeking for the initial symptoms of LDH (i.e. protopathic bias). Several randomized clinical trials have reported on the effectiveness of spinal manipulation in the management of LDH with radiculopathy; however, the safety of this treatment has not been adequately investigated. No valid epidemiologic studies have assessed the risk for acute disc herniation following chiropractic treatment; only case reports and small case series (lowest level of scientific evidence) have linked lumbar spine manipulation to LDH.
The objective of this study (e-published ahead of print in the European Sine Journal) was to compare the associations between PCP and chiropractic care in relation to acute LDH with early surgery. The study's hypothesis was that chiropractic care could only be thought to increase the risk for acute LDH if the measured association between chiropractic visits and acute LDH exceeded the association between PCP visits and acute LDH…LOG IN OR SUBSCRIBE TO ACCESS THIS REVIEW!