ABSTRACT INTRODUCTION Objective: Todiscuss a caseof subacute lumbar disc herniation successfully treated witha DRX-9000 spinal decomnression unit. Theintervertebral disctendsto degenerate in everyone as partof theagingprocess. Although thisdoesnotinevitably cause backpainit isprobably themostcommon siteof spinepain;accounting for upto 85%of cases.l Relentless research hasbeenapplied to determine theexactmechanismfordiscpain,andalthough theexactpathophysiology of thishasnotyetbeendetermined, several hypotheses exist.Themostlikelymechanism begins withaberrant mechanical forces causing an inflammatory response andthus stimulating thenocioceptive receptors withinthedisc.l ClinicalFeatures: A 50-year-old malepresented witha chiefcomplaint of severe lowerbackpainandleftsided persisting sciatica for two months.Mostorthopedic testing procedures couldnotbeperformed dueto theseverity of painat thetimeof presentation. Standard radiographs of thelumbar spinerevealed onlysomemoderate discspace narrowing at L5/S1.Howeveq thepatient didpresent a magnetic perresonance image(MRl)reportwithimages formedoneweekprior.ThelumbarMRimages obtained (weight-bearing) werescanned position in a neutral seated usinganupright unit.Theimaging report waswrittenby a chiropractic radiologist andrevealed an L5/S1 leftpara(extrusion) posterolateral central discherniation causing displacement of theleft51nerveroot. Intervention and Outcomes: Thepatientwasprovided spinaldecompression treatments following thewritten protocols for theDRX-9000 unit. Carewasprovided by various doctors andlocations. Relief of symptoms began following thefirsttreatment, andeightweeksof follow-up careprovided 100%reduction of symptoms. Neutral seated(weight-bearing) MRimages wererepeated approximately 7.5months following initiation of treatment, These images revealed complete reduction of thepreviously visualized L5/51 discal herniation. Thediscitselfismadeupof two majorcomponents, an pulposus. outerannulus fibrosus andaninnernucleus The annulus fibrosus iscomposed of a fibrocartilaginous series of concentric ringswithcollagen arranged at a 65degree plane,2 anglefromthevertical Eachringabutsanother, withadjacent fiberorientation in theopposite direction, andthus,it hasbeenfoundto betheprimary load-bearing pulposus structure of thedisc.Thenucleus isthegelatinouscenter of thedisc.lt isavascular andnurtured only froma process knownasimbibition. Activity duringthe dayandrestat nightiscrucial forthepumping of nutrient richfluidthrough thevertebral endplate andintothedisc,2 Whiletheouteronethirdof theannulus fibrosis isproprioceptively andnocioceptively innervated, theinnertwopainis thirdsof thediscisnot.2Purediscogenic pulposis theoretically notpossible untilthenucleus disruptstheouterannular fibers.Thisphenomenon occurs withpathological bulging or herniation of thedisc(Fig,1). Conclusion: DRX-9000 spinaldecompression therapy is Three factors areinvolved in theevolution of discogenic believed to provide bothbiochemical andbiomechanical pain.These include structural disruption of thedisc,inalterations to thedisc.Theaffects of axialsoinaldecomflammatory infiltration to thesiteof disruption andnociopression therapy onthispatient's casecouldbeobjectively ceptive sensitization at thelevelof thedisc's innervation. quantified pre-therapy through andpost-therapy MRimag- 0f thesethreefactors, thebiomechanical factorisperhaps ing. Spinal decompression applied bymeans of theDRX9000protocol Fig.1 isan effective resource for treatingpatients passing through various clinicians withoutsignificant inter-operator or examiner variability. painisderived Fig.1:Discogenic fronnuclear migration causing tearingof theouterannularfibers.Pathological disc bulges(A)generally cause linitedcanalintrusion, whileherniations(B)focallyprogress intotheconfines of thespinal canal. ffi This specialadvertisingfeatureis sponsoredby participating advertisers. The editorialmaterialwas providedand did not involvethe reportingor editingstaffof ChiropracticEconomics.O 2007 ChiropracticEconomics 2 C H r R o P R Acr lcEco No M lcs E ouc,q.rronal A uvsnronrar V ol 53: Is s uE 2 withinthe mostrelevant in thisstudy, aswithoutthisfactor; the 51nerveroot.Anareaof brightsignalintensity tear.There was chemical andnociocentive factorswouldnothaveexisted.3 discherniation represents an annular approximately 50%lossof discheightat thesamelevel CASE REPORT degenerative lossof signalintensity witha corresponding (Fig. 34 andB). andevidence of discal desiccation Thisreportdiscusses a caseof a 50-year-old male tig.3: Pre-spinaldecompression complaining of a two monthhistoryof severe lowerback T2-weighted mid-sagittal(A)and painwithprogression to leftsidedsciatica. Thepatient axial (B)MRimagesthroughthe previous physicians, hadsought consult withmedical L5/51levelsobtainedusingan chiropractors andanacupuncturist. Thevarious attempts upright weight-bearing position. pharmaceuticals, of muscle relaxants, specific chiropractic Thereis a largefocalleft paracenprovided manipulative techniquel andacupuncture did tral extrudeddischerniationwhich lis posteriorlydisplacingthe left 5l notoffersignificant results. &-' l" plainfilmradiographs During thistrialof divergent care, andMRimages of thelumbar spinewereobtained. The position radiographs wereperformed in theweight-bearing projections. andincluded anteroposterior andlateral They revealed a slightlevorotatory lumbar scoliosis andsignificantflattening of thelumbarlordosis, These filmssuggest anacuteclinicalpresentation. Thediscspaceat L5/51 demonstrated approximately 50%lossof height;noother signsof degenerative change wereseen(i.e.sclerosis, (Fig. spondylophytosis) 2). TheMRIwasperformed onan upright unitandtheimages weretakenin theneutral (weight-bearing) position seated usingstandard imaging protocols. TheT1-andT2-weighted sagittalandaxialimageswerereviewed bya chiropractic radiologist andcollectively revealed discal dehydration anddesiccation at the L4l5levelwithunderlying degenerative bulging of thedisc, There wasnodischerniation at thislevel.A leftparacen(extrusion) traldischerniation waspresent at theL5/S1 level,whichposterolaterally displaced theleft i| - nerveroot. Thisscanwasobtained prior to anyspinaldecompression therapy.Notethat on theaxial scan,thereis brightsignalintensity an within the discrepresenting annulartear. Thepatient anepidural injection considered in lieuof his previous two monthfailureof conservative andpharmaall nonceutical trials.Howevel in anattempt to exhaust therapy invasive measures, a trialof spinaldecompression utilizing wassought.Theorthopedic theDRX-9000 priorto decompression wasdifficult examination therapy pain.Straight dueto thepatients' LegRaising test,Fabre's test,double legraising, aswellasLinder's orthopedic maneuvers couldnotbeperformed dueto pain.Thelimitedorthopedic lowerbackmotionsensiresults confirmed painsintotheposterior tivitywithperiodic shooting aspect pain,nonoted of theleftleg.There wasnoabdominal in bowelor bladder change control andtheneurological paraesthesias. revealed no lowerextremity examination Fig.2: Lateral& APweight-bearing lunbar spineradiographs revealinga nild levorotatorylumbar scoliosis with rightlateralflexionandleftposteilorrotationof L4 upon 15. Notethe flatteningof thelunbar lordosiswith approximately50% lossof discspacepresent at theLS/SIlevel.These changesare thoughttobe an antalgicposture.Noothersignsof degenerative changeare seenin thelumbarspine. Vo l 5 3: Iss uu 2 Without of contraindication forspinaldecompresevidence siontherapy, 20 thepatientwasrecommended to receive sessions ona DRX-9000 of spinaldecompression unit. protocol consisted Therapy of treatments threetimesper weekfor fourweeksandthentwo timesperweekfor four of 14cycleincrements. weekswithdecompression sessions E D uc;err On.q.LA nvgR rott,q t- C utR opnar:tl c: E coNoutc s 3 Decompression wasfollowed by15minutes of myofascial workandthenl5 minutes of (coldpacks) cryotherapy keptat a constant circulating temperature between 40to 50 Fahrenheit. degrees Fig.4: Post-spinal decompression T2-weighted mid-sagittal(A)and axial(B)MRimagesthroughthe L5/51levelsobtainedusingan upright weight-bearing position. Observe thattherehasbeen of theprevious complete resolution extrudeddischerniationat the imageswere L5/51level.These performed approximately7.5 monthsafterthefirstof 17spinal on treatmentsusing decompressi Therewas theDRX-9000. resolution of the complete patient'sbackandleft legpain. jobentailed Thepatient's muchtraveland decompressions wereprovided onlyseven at theexamining doctors' office;however, thepatient continued treatment at various doctors withinNorthAmerica utilizing the DRX-9000 unit.These treatments were applied in fivediffering citiesbyfivedifferentdoctors of chiropractic. Each differing doctorprovided two sessions. Treatment protocols havebeenestablished bythe (Axiom distributor of theDRX-9000 Worldwide)andwe wereadvised theseprotocols werefollowed locations. thus at thevarious allowing consistent maintenance of thispatient's care. Theseventreatments occurring at theprescribing doctor's officeareoutlined inTable 1. Theforceapplied wasbased of radicular onthepatient's weightof 125lbs.Relief following andeight symptoms began thefirsttreatment, weeksof follow-up 100%reduction of all careprovided lowerbackandlegcomplaints. Approximately 7.5months MRIre-evaluation of following theinitialdateof treatment, lumbar spinewasobtained. These scans were thepatient's performed center andusingthesame at thesameimaging (weightprotocols standard imaging fora neutral seated position. bearing) Theimages werereadbya medical radiologist.Thescans through theL5/S1 leveldemonstrated milddecreased signalintensity withinthediscconsistent withdesiccation anddegenerative change, aswellasa paracentral extruded complete resolution of theprevious There isno longer evidence of thecalsac discherniation. deformation or displacement of the51nerveroot(Fig. 4A 4 C r r r n o r n A!.fr r ' E.,) \o M r e j EDIJCATIONAL painrecurdenies lowerbackor sciatic andB).Thepatient treatments. rence sincespinaldecompressive DISCUSSION painistradiof disc-mediated Conservative treatment techniques, including byvarious tionally accomplished traction, spinalmanipulation, core manual traditional ADVERTORIAL VtIr 5J; ]SSUE 2 TREATff,ENr OFAN, SlStj,rtEmRUDED Ug!f{GD|'S6,,h|FRN|ATION: A DNX$O0O SPNAIDE$.MPNTSSION,UNft,.A CASEREF6iT] stabilization and/orMcKenzie exercises.l All of thesetreatmentshavebeenstudied andyieldvarying results, believed to belimitedbytheadministration of care,patient compliof initialsymptomatology, ance, degree andthelackof utilized objective outcome measures. These modalities all actto theoretically decompress thedisc,rehydrate thedisc, pressure andreduce exerted onthepainproducing aspect pharmaof thedisc.Common medical include approaches ceuticals andiorsurgical intervention of various degrees including discectomy or removal of theimplicative fragment only. reduction herniation results showing in thesizeof discal havebeenreported bywayof CTscanning duringmotorIn ourcasestudy, theaffects of spinal izedtraction,a'1e wereobjectively substantiated decompression using pre-andpost-treatment MRimaging. A knownindicator of functional discimoairment isthe presence of herniation.r failureof thedisc Biological induce occurs whenstructural discalterations anomalous positioning responses.s Theuseof weightbearing cellular duringMRimaging in thiscaseis inferred to haveplaced position, functional oursubject's discin a biomechanically extruded herniation Complete reduction of thevisualized to the imolies beneficial functional alterations intervertebral discduringspinaldecompression. yieldstrongpositive Whilevarious studies results utilizing forthetreatment traction of lumbar discherniation,a,5 a number of articles in theliterature suggest varied or no significant difference A proposed against a control.6'e explanation forthewidespread outcomes isfromsevere 0f an interesting note,a limited survey of practicing chiropractors methodological flaws,thelackof clinical 40%haveexperienced datawhichsuprevealed roughly at least portscriteria forpatient selection, and aswellasinter-operator onejobrelated injury, mostin theupperextremity variability inthemodeof administering manipulation of a thetreatment.r0'r3 occurring duringthesetupor manual patient.20 Others believe thevarying results maybeaccounted forby lt isoursupposition thattheuseof lessphysiproprioceptive theparaspinal musculatures' response to alternative methods of spinal treatment, callydemanding pulldelivered thelinear during manual traction.la One decompression, canyieldhighresults while suchasspinal potential study, whichutilized a gravitational traction unit,analyzed limiting forworkrelated thedoctors injuries. of thesemuscles viasurface theactivity EMGandfound relaxation of theparavertebral muscles earlyin thecourse coNclustoN of treatment. butthiswassoonfollowedbVreactive provided contraction.l5 Spinal decompression aneffective means therapy of treatment forthispatients symptoms resulting from (extrusion) Thedivergent results of theresearch towards manually discal herniation withassociated impingement applied traction werea catalyst for investigations which of theadjacent nerveroot.Asseenbythiscase, and wouldyieldconsistent Because of thiscamethe outcomes. supported byresearch, theapparent affects of spinaldeintroduction generally of motorized traction units.lt isbelieved that compression therapy arequickto prevail, withtheaideof airbladders, aswellasa motorized mech- occurring lt is inferred within10treatments.2l fromthis anismusingharnesses andangleof pulladjustments, the of spinaldecompression viatheDRX-9000 studytheeffects flawsof manual traction couldbeovercome.la Based on affecting boththebiomechanics aremultifactorial, aswell guarding thepremise thatparavertebral muscle isthe of thedisc. Theimmediate asthepathophysiology reliefof differing factorbetween spinal decompression in thispatient andspinal symptoms suggests a reduction of inflammatraction, AxiomWorldwide hasadopted a technology to its toryinfiltrates affecting fibers; whilethe thenocioceptive spinaldecompression unitswhichcanapplyfeedback decomoressive forces increased to thediscallowed mechanisms allowing thestrength of pullto beadjusted in imbibition andcomplete reduction of thevisualized proprioceptive accordance to thepatients' response. extruded herniation. Motorized traction hasshownto decrease intradiscal pressure bya factorthatisproportionally inverse to the tension applied, andfinalpressures canreachbelow-100 mmH9.16 Inonestudy. utilizing motorized axialdecompression, 71o/o of thesubjects reported an80%or more reduction in symptomatology.l6 Twootherstudies showed of a 50%reduction in theallof thepatients a minimum subjective lowerbackandlegsymptoms.rT'18 Objective of thesefindings correlations wasconfirmed in allof the participants in onegroupbyimprovement of dermatomal (DSSEPs).18 potentials somatosensory evoked Quantitative VL)L 5l: lssur 2 ELluc ,+tton proved MRimaging to bea useful andnon-invasive techof decompression niquein monitoring theefficacy therapy protocols to thiscase.Thestandardized asit applies employed bytheoperators of theutilized decompression unitsmayhavecontributed to thefavorable results seen. Thelackof uniformity in treatment techniques hasbeen suggested asanareaof errorforpastclinical trials.rl Decompression of thespineproved to besuperior to the otherformsof conservative carewhenapplied to our patient. Thepatients' results werebothsubjectively quantified. favorable andobjectively a I- A l tv utttottI.tL C utnot,ttet:t tt; Ec c tN c tl r ,u c : s 5 TREATMENT OFAN L5/S1EXTRUDED USIilG DISCHERNIATION A DRX.9TX}O SPINALDECOMPRESSTON UNIT A CASEREPORT REFERENCES 12. Beurskens AJ,Lindeman AJ,vanderHeijden GJ,deVetHC,Koke E,Regtop PG.Theefficacy for lumbarback W,Knipschild of traction 1.MooneyV, SaulJA,SaulJS.Clinical symposia: evaluation and pain:design Physiol of a randomized clinical trial.J Manipulative treatment 1996;48:5-8. of lowbackpain.lconLearning Systems T h e r 1 9 9 5 ; 1 8 : 1 4 1 7 . 2.Cramer GD,Darby SA.Basic andclinical anatomy of thespine, 13. Beurskens AJ,deVetHC,Koke AJ,Lindeman E,Regtop W,vander p.32-7. spinal cord, andANS. f i ed.St.Louis: Mosby; 1995. 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AUTHORINFORMATION generation Dr.Yochum isa second chiropractor anda cumlaudegraduate of theNational College of Chiropractic. Heisdirector of theRocky Chiropractic Radiological Mountain Center;adjunctfaculty in theDept.of Radiology,Southern California of Health University (formerly Sciences LACC); radiology, andinstructor in skeletal University of Colorado School of Medicine. Dr.Maolaisa magna cumlaudegraduate of theNational College of Chiropractic. Heisa post-graduate instructor fortheSouthern California University of Health Sciences (formerly LACC) anda formerradiology andorthopedic instructor at the Colorado of Chiropractic, College Denver, Colorado. Foradditional copiesof thisarticleor moreinformation pleasecontact: regardingthe DRX-9000 AxiomWorldwide, Inc. 9423CorporateLakeDrive,Tampa,F[ 33634-2359 Phone: 877-438-0663 6 C H t R O P R ,r cr r t:Ec;clr ' r o M tcs ED U C ,\T toN .A l . AD VER T OR tAT . V o t . 5 . 1 :l ssu r 2