Confessions of a Quackbuster

This blog deals with healthcare consumer protection, and is therefore about quackery, healthfraud, chiropractic, and other forms of so-Called "Alternative" Medicine (sCAM).

Sunday, January 09, 2005

Chiropractic injury, spinal stenosis, cauda equina syndrome

> To Whom It May Concern,
> I am looking for any information on Cauda Equina Syndrome and
> how it is conected with and or caused by chiropractic
> manipulation (rotational thrust). Any information would be
> greatly appreciated.
> ---------------------------------------------------------------------

It's unlikely, though not impossible. The lower end of the spinal cord, the cauda equina (horse's tail), below L1-2, is rather forgiving towards herniated discs. Since the nerves are now individual (there no longer being a solid, massive spinal cord, as above L1), they can be pushed aside easier, rather than being compressed. But it can happen. If the herniation is large enough and central enough, the whole works can get compressed, resulting in serious problems that need to be tackled ASAP. A quick trip straight to the ER is imperative. Let a real doctor (MD!) examine you. A couple hours too long and some very important bodily functions can be gone or handicapped forever! Better safe than sorry.

If this sounds like I'm trying to scare you, well....., I'm just trying to make sure that no one thinks they can wait till the next day. Then it really can be too late.....:-((( But, as in many things medical, how soon surgical intervention is called for is controversial. Check out the links below.

Now I've gone and assumed that you are familiar with the symptoms. Here's a list:

"Cauda equina syndrome (CES) has been defined as low back pain, unilateral or usually bilateral sciatica, saddle sensory disturbances, bladder and bowel dysfunction, and variable lower extremity motor and sensory loss."

"Complications: Residual weakness, incontinence, impotence, and/or sensory abnormalities are potential problems if therapy is delayed."

A manipulation is contraindicated whenever there is the least suspicion of a possible herniated disc. This is the MD & PT viewpoint. Why chiropractors don't seem to respect this is a question you'll need to ask them. There is no proof that a manipulation can reduce a herniated disc, but there is plenty of risk for making it larger. So, while unlikely, it is certainly not impossible. The risk of it happening with chiropractors is in direct proportion to their generally strong tendency to use manipulation in every imaginable and unimaginable situation, regardless of what MDs & PTs might consider contraindications.

The Cauda Equina Syndrome is a form of spinal stenosis - Lumbosacral Stenosis. Whether the hole is too small, or the contents become too large, the result is the same.

Here's a case history from my own practice:

Spinal Stenosis after HVLA (High Velocity Low Amplitude thrust)

Immediately after getting a referral from his doctor, a young (23 yrs.) man ("Jack"), phoned my clinic a Friday noon in 1995 to make an appointment, ASAP. He had never been to a PT (or chiropractor) before. He was in pain, but I just couldn't squeeze him in and gave him a time on Monday afternoon. When "Jack" showed up on Monday, I could see in his face that something was terribly wrong. When he opened his mouth, I could have finished his sentence and said "You've been to a chiropractor, haven't you?". But I resisted the temptation. I'd experienced the situation enough times before.

He said: "I've done something wrong. You mustn't tell my doctor."

I reassured him that I had a duty to respect the confidentiality between therapist and patient. He seemed to relax a little, and told me his story.

That very morning, at work, he had pulled very hard and quickly on a handle that was stuck. He immediately felt a sharp pain and a snap/pop sound from an area between his right shoulder blade and spine (approximately in the T1-T3 area). The pain continued, so he left work and went directly to his GP, who examined him, gave him a prescription for a mild painkiller, and wrote a referral to a PT, whereafter Jack phoned me, and got the appointment for Monday.

He still had so much pain (still in the same area, nowhere else) Saturday morning, that his family and friends urged him to go to a chiropractor they knew, who was on call during the weekend. (The local chiros take turns holding open during weekends.) He drove to the one that was open, about 12 miles away.

The chiro examined him, told him that his vertebra was "out of joint", and needed to be "put back in place". He was "adjusted" manually in the neck and the upper-/midthoracic vertebral region. Jack said that he immediately felt a far worse pain there where he already had pain, as well as in the midline of his back where he'd been adjusted upper-/midthoracic, plus he immediately began to feel tingling in both hands and both feet.

When he described these symptoms, I could feel the hair rise on my neck and head, and goosebumps forming!! This combination of symptoms is rare and a very bad omen.

I examined him carefully to hopefully exclude my worst fears of a vertebral fracture. My examination was inconclusive in the absence of an x-ray, and in fact it's not even certain that an x-ray taken so soon would have revealed a hairline fracture, if there had been one. Therefore I would consider an HVLA, acute, as contraindicated.

I did a neurologic exam. I'd never seen these symptoms in both upper- and lower extremities at the same time before. His sense of touch, on the palms of his hands and the soles of his feet, was reduced. He had a lot of palpatory soreness in his right rhomboids and right levator scapula muscles, and was stiff in the area between his shoulderblades. A real case of muscle guarding. His neck was a little stiff as well. He complained about his gait: his sensation was disturbed enough that the floor felt "wrong" when he walked. But his balance was otherwise OK.

After getting his permission, I immediately phoned his doctor, explained his symptoms and recommended an x-ray, and if possible an MRI scanning. The doctor didn't need to see him since he trusted my judgement. He phoned the hospital immediately and ordered it for the next day. His doctor phoned me three days later, since he felt I deserved to hear the result as soon as possible.

The x-ray revealed no fracture, but the MRI showed massive swelling of the spinal cord (causing a spinal stenosis) in the upper thoracic area and a hematoma, possibly with blood (x) in the spinal fluid ((x) - I'm not sure I remember correctly here). Jack was given a sick-leave and received no more treatments from me. Time would hopefully take care of the problem.

About seven months later, I literally bumped into Jack as I came out the door of my bank. Fortunately neither of us got hurt! I asked him how he was doing. He was still on sick-leave, or more precisely, it resulted in him getting fired from his job (there is a 120 sick-day rule in Denmark, after which you can, but not necessarily, get fired). He had a little less pain, but the sensation on the palms of his hands and the soles of his feet felt like "cotton wool". A sad outcome with a nearly unchanged scenario.

--End of story--

We use different glasses

This experience tells me something about one of the most significant differences between the PT and chiropractic profession's ways of approaching things. And most definitely the chiropractor mentioned above. We are educated to see the neuromusculoskeletal system through different glasses. Our perceptions/assumptions are often fundamentally different. PTs and MDs have basically the same glasses on. Chiros have a very different set on.

The chiro above started with the assumption that there was a subluxation, and adjusted it. The problem was seen primarily as a joint problem. Ergo, Fix it! In my eyes a very "apparat/fejl" (Danish for "apparatus/defect") viewpoint. Ironically, this is exactly what alternative medicine practitioners accuse the established health care system of doing: treating people like machines.

I would also have started with an assumption. I would assume, with few, rare exceptions, that vertebra don't get out of joint. (I've lived and worked in Greenland, where about 30% of all Eskimos have a congenital spondylolisthesis. There my assumption allowed for more exceptions!! And HVLA would certainly not be considered as a treatment.)

In Jack's case, I would have suspected the pain and sound to be from a pulled muscle (rhomboids, levator scapulae), probably with some torn fibers, resulting in massive muscle cramping/spasm, causing fixed movement segments in the thoracic vertebral column. Pain would come from torn muscle fibers, cramped muscles, compressed intervertebral joints, etc..

Even if the major cause of pain were from a joint, a distinct possibility, I would start with the muscles in the area as the factor sustaining the joint in an unfortunate condition, whether relating to joint position or mobility/stability. (So the old "hen or egg first" argument would often be irrelevant for me.) My initial treatment would be local cooling during the first 24-48 hrs. Thereafter a progression including moist heat, massage, stretching, joint mobilizing (no HVLA), McKenzie and strength excercises. The progression being from treatment of pain, then, as pain lessens, treatment of impairment leading to full, normal, pain-free function. The ultimate goal of instruction and treatment would be self-reliance and lack of dependence on me as a therapist.

If it were possible to locate a small area with so intense pain that manual treatment would be too uncomfortable, representing the torn fibers, I might use ultrasound there (1 MHz, 3 watts, pulsating, for 4-7 minutes (depending on the size of the area), the patient's sensation of pain acting as a guide: The patient must feel no discomfort from the ultrasound).

I, too, would treat "defects in the apparatus" (they do exist....;-), but would look more broadly at it, treating first that which is under the patient's active control and capable of reaction to conscious and subconscious factors - the muscles. (I would treat the joint as a passive factor.) After the muscles are warmed up, stretched and less tense, the joint would be prepared for careful joint mobilization. After this, it's almost impossible to do a HVLA and get a "pop" sound.

The causative factor in a fixed joint is gone, ergo, the fixation often disappears by itself. I don't need to use "violent measures" on a joint that is held in a vice-like grip by tense, cramped muscles. They just need to be gently persuaded to let go. The joint will then return to its natural, neutral position. And that position is not something for me to determine. The joint just might happen to be naturally - genetically or pathologically - crooked. So I just let it find its timeworn natural position.