017- Microdiskectomy vs Chiropractic Care- The Landmark Study

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Hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langmaid. Today we're going to talk about one of the most important chiropractic studies ever produced. So I am completely psyched. The weather is turning from winter to spring and summer here in Tampa and I'm sure for most of you out there as well, the weather is turning and today we're going to talk about an awesome piece of chiropractic research. It is titled My Manipulation or Microdiscectomy for Sciatica, A Prospective Randomized Clinical Study. This was produced by jmpt, the Journal of Manipulative and Physiological Therapeutics in October of 2010 and I can't wait to dive in. Before we do, let me take one moment and say a few words as always about Rocktape. Rocktape is proud to be a sponsor of the Evidence Based Chiropractor. Rocktape offers the world's best kinesiology tape, pain relief, topicals, mobility tools and functional fitness accessories. New from Rocktape is Rocksauce Chill, a powerfully cool pain relief topical in a convenient roll on with 6% menthol. It's stronger than the freeze competition. They are more than just a tape company, they are a movement company. Learn more and get access to your medical discount by visiting rocktape.com Also last month, a few weeks back we had a interview with Dr. Capo Dr. Steve over at Rocktape, one of the medical directors there and it is packed with so if you haven't checked out that episode, please do so. But today we are going to talk about one of my favorite studies, one of my personal favorites, Manipulation or Microdiscectomy for Sciatica. A randomized clinical study and it was produced by JMPT Volume 33 Number 8 in October of 2010. So where does the importance reside? Well, sciatica secondary to lumbar disc herniation is a common problem seen in fact physician offices of all kinds every day. So as chiropractors we see sciatic complaints secondary to lumbar discs literally every day in practice. We are not alone. Primary care doctors, they are seeing this every day in practice. Neurologists are seeing this every day in practice. Physical therapists are seeing this every day in practice. Orthopedic and neurosurgeons are seeing this every day in practice. And the radiologists who read films of any Creed or denomination do, Maryland or D.C. are seeing this every day in practice. So sciatic complaints, radicular complaints secondary to disc herniation is one of the most common complaints, if not most common complaint in the lumbar spine, seen by practitioners of all varieties every day in practice. Previous research has shown us that certain chiropractic techniques can decrease intradiscal pressure. I'll touch on this one because just a few weeks ago we looked at the flexion Distraction study. If you haven't checked out that episode, please do so. But the bottom line is the research has shown that flexion distraction technique decreases or reduces intradiscal pressure, which therefore provides relief with radicular pain. So that's an important piece to put together with this study. And the bottom line is, as far as that goes, it's thought to be a contributing factor to the mechanism of action and positive clinical outcomes related to chiropractic. So we can decrease intradiscal pressure. You can therefore improve the clinical outcomes. And really that decrease in intradiscal pressure is thought to be one of the mechanisms of action. So conservative care typically recommended by physicians, specifically primary care doctors, for what we're talking about today, which is a disc herniation causing sciatic pain, is typically physical therapy, analgesics, epidural steroid injections. And believe it or not, I know I'm saying this kind of preaching to the choir here, but certainly there are many docs out there that are not referring these patients to chiropractors. And often, in my opinion, a lot of it's due to the fact, again, that we haven't positioned our practice and explained well what we are able to provide patients and also build the value for what sort of patients are the best to send to our office. So it's not just on them, some of that is on us. The lack of referrals, but hopefully our podcast and the evidence based chiropractor as a whole. The goal is to start turning that tide by providing value, positioning your practice and providing education to the docs in your community. And ultimately that's what builds and provides the foundation of all referral relationships. Now here's one of the great parts about this study. This study took patients that had already failed traditional conservative care. So I don't think there's any doubt that all of us would agree. On rare occasions, there's a time and a place for surgical intervention if all conservative options have been exhausted, if the Patient's just not able to get well. There are certainly those cases where that is the last option is ultimately the option that serves the patient best. But let me say a few quotes from this study because I think it really frames it appropriately. The researchers in the study found unilateral lumbar radiculopathy secondary to lumbar disc herniation at L3, 4, 4, 5 and 5 1. So that's what they were looking at. They found these patients must have also failed at least three months of non operative management, including treatment with analgesics, lifestyle modification, physiotherapy, massage therapy and or acupuncture. We'll go back to that in a moment. One of the final quotes I'd like to bring up is they found, quote, most of the patients who were considered surgical candidates for the treatment of radiculopathy from lumbar disc herniat improved with standardized spinal manipulative care to the same degree as those who had undergone surgery. Of those who had failed spinal manipulation treatment, subsequent surgical intervention provided excellent outcome. So that is a lot to dive into. But let's take a look at that. So patients had failed three months of non operative management, including treatment with analgesics, lifestyle modification, physiotherapy, massage therapy and oracupuncture. So these patients had already gone. Typically what we see with primary primary care is that they'll refer to conservative care. And it could be, to be honest with you, many times it's quite arbitrary. They might say go here, there or somewhere else, not based on any clinical direction, but where they have a relationship. So this study actually took patients who had already failed physical therapy, already failed NSAIDs, already failed lifestyle modification. And these study found second half of that, the second quill, the those patients, these are patients with radiculopathy secondary to a lumbar disc herniation improved to the same degree as those who underwent surgical intervention. Let me repeat that. They found these patients, these people who had failed traditional conservative care, then went in one of two arms of the study. One arm was to chiropractic care, the other arm was to surgical intervention. And what they found was these patients improved to the same degree as those who had undergone surgery. That is completely powerful. And that is why this study really knocks me on the floor. The second part of this, and I think it's even, not even more important, but something that also is important to know is that if those patients then failed chiropractic care, spinal manipulation, the subsequent surgical intervention provided an excellent outcome. So this is Certainly something in my opinion, that all patients with radiculopathy secondary to lumbar disc herniation could stand going through a course of conservative care regarded with chiropractic. Because even if they fail, in the rare event that those patients fail, they're still able to get significant improvement with ultimately a surgical outcome if necessary. So let's look at a couple other things. 60% of patients with sciatica and had failed other medical management benefited from spinal manipulation to the same degree as if they underwent surgical intervention. 60%, if we look at the actual percent, 60% benefited to the same degree. So that is awesome. 10 to 20% was the number for well established failure rate of microdiscectomy in the relief of radiculopathy secondary to lumbar disc herniation. So if you go straight to surgery, there's a 10 to 20% chance it might not reach your goals or expectations. As far as that goes, that's going to be the surgeon's discretion. And I trust that most of us, if and when we refer to a surgical intervention that we're referring to people that we can rely on and we feel like has very good clinical expertise. But I think it places it even more important that again, when they looked at the patients who had undergone spinal manipulation or chiropractic care and had not received their result, then they had even better results surgically because at that point almost everything had been exhausted. So it really gives the surgeon a great opportunity to work with a patient that is approached appropriate for them. So this study just hits on so, so many cylinders for me. You can look at the Roland Morris Disability index and chiropractic and surgery, they have equal results. This study just hits on so many different items that I really recommend checking it out and downloading it and diving deep. Now, if you're a member of the evidence based chiropractor, you can pick this up in the member's vault. Also, it's the August 2014. So I highlighted this in August 2014. If you want to get this paper, come on with the evidence based chiropractor. Join our membership. This is the kind of content that we're putting out to build relationships and frame relationships each and every month. If you haven't heard of it, I'm glad I was able to bring it to your attention. If you have, I recommend revisiting it. It's an extremely important part of what we do as chiropractors. It's an extremely important piece of literature for chiropractic as a whole. So please again, check it out. I hope you enjoyed this week's episode. Have a great week in practice and I'll talk to you soon.

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