432- The Best Non-Surgical Management of Radiculopathy

Welcome to the Evidence Based Chiropractor where each week we deliver the latest chiropractic research and marketing strategies all in the time it takes to get to your office. Now here's your host, Dr. Jeff Langmaid.

Hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langmay. This week we are back with brand new research just released in the Journal of Clinical Medicine. It is all about non surgical approaches to the management of lumbar disc herniation associated with radiculopathy. And there is a ton of stats and clinical pearls that you're going to be able to utilize in practice literally today. Because before we dive in, let me say a few words about Patient Pilot by the smart chiropractor. If you'd like to generate more reactivations into your practice, it is all about having the automations you need for consistency and the accountability you need to see the results. We've shipped some massive, massive upgrades over the last couple weeks and it's certainly over the last couple months that have made Patient Pilot the patient reactivation system within chiropractic. 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But as I said at the top, today's episode, it's going to be all around a brand new research study. I'm gonna drop a link to the study down in the show. Notes the official title is Non Surgical approaches to the management of Lumbar Disc herniation associated with radiculopathy and this is a narrative review. Well, why is this a big deal? We'll start this the way we do many studies that start or have the Topic of low back pain in it, and that is almost everybody's going to deal with low back pain at some point in their life. The lifetime incidence is up to 85% of individuals worldwide will have an issue with low back pain at some point in their life. Now most of these individuals will fall between 30 and 50 years old, with slightly higher prevalence in men than women. Well, let's talk about disc herniation. Lumbar region is the number one place for disc herniations, with L4, L5 and L5 S1 being the most common. Probably no new news there for you, but important to set the stage. Lumbar disc herniation is associated with radiculopathy. When an extruded disc presses or contacts a lumbar nerve root, what does that result in? Well, it can of course result in a few different things. Local pressure, right. Literal compression or neurochemical inflammation can cause the pain. So remember that when you look at a disc herniation, always remember there are two things that can be going on. One is that literally the disc is pressing on the nerve. There's a mechanical compression, but do not negate the fact that there can also be chemical inflammation. So sometimes this is why sometimes you can see where there's not that much compression, but there's a lot of pain, chances are that's chemically related. Sometimes you can see that there is a ton of pressure and there's less pain and there is more numbness, tingling, things like that. That can be because there's not as much of an inflammat inflammatory component, but there's a more of a compressive component. So important to consider that when you're evaluating patients. Radiculopathy of course is characterized by things like pain, numbness, tingling, weakness, and it's usually unilateral. When it's bilateral, that is usually because there is a central stenosis component that affects things bilaterally. When it's a radiculopathy, it's usually unilaterally. And some physical exam findings, of course that we see typically involve deep tendon reflex challenges, sensory reduction, loss of dermatomal distribution, muscular weakness, all of those things are potentially seen upon a physical examination when somebody has radiculopathy. So research has suggested in the past that in the absence of deteriorating neurological signs and symptoms, in the absence of saddle anesthesia, bowel or bladder incontinence, caudal equina syndrome, that non surgical approaches in the absence of non surgical approaches should be considered before surgical approaches. A few weeks ago I briefly touched On a study I think we highlighted last year, which highlighted, in my opinion, that just everybody who is considering surgical intervention for a disc herniation that doesn't have a red flag should be going to a chiropractor. Why? Because many who did got well and those who didn't get well with the chiropractic care that they received. There was no negative impact on the surgical outcome. Therefore, it is, in my opinion, only upside to seeing a chiropractor prior to any surgical intervention. In my opinion, it should be mandatory. If we're going to talk about guidelines, we'll talk about those later on this episode. If we're gonna so clinical guidelines. If we're gonna talk about evidence based care. If we're going to talk about Hippocratic oath, do no harm. If we're gonna talk about and not just pay lip service to exhaust conservative care. All right, how fast can we check this box and get him to surgery if we're gonna talk about it with, in, in reality and with really the patient's best outcome in mind, There is really no elective spine surgery that should happen without having chiropractic at least worked on before that surgical intervention. Because often it will be avoided, the surgery that is. And if it's not, there's no negative impact on that outcome. So lumbar disc herniations is a consequence. Here's some interesting things, things that I picked up on in this study. Maybe those early stats. You are familiar with some of this. You might not be. It's actually a consequence of degenerative changes in the annulus fibrosis. So those changes, those degenerative changes in the annulus can include a few different things. One, reduction in water concentration in the nucleus. Two, elevation of type 1 collagen ratio in the nucleus and the inner annulus. Three, damage in collagen and extracellular material for an upregulation of matrix protein expression. Mmp, that's important. And all of this can have a higher rate of cell death and an intensified inflammatory response. So those are some things that are going on really at that micro level. When we look at the annulus fibrosis, those are some of the degenerative changes that can lead to disc herniation and all the pain that comes downstream from that. So we know collagen fibers are what provide the annulus with structural integrity. But it is really important to keep in mind there's always these bell shaped curves or continuums here when there's an excessive or prolonged mechanical stress that can actually lead to disc degeneration and cause imbalances in that extracellular matrix and cause degradation. So, again, there's going to be too much of a good thing, so to speak. Just like salt on a dish, right? You put a little bit of salt, it's great. You over salt the dish, eh, not so good. Same thing can happen in many cases with our body. There is a point at which strength, dynamic strength and flexibility is built from challenge, right? Just our muscles, right? You got to work the muscle to build the muscle. The same is true amongst almost nearly everything our minds, nearly everything in who we are and what we do as human beings. But there is a tipping point where too much becomes really disruptive and it actually can cause challenges. And that's basically what this is saying where, hey, collagen fibers are what provide structural integrity. And, you know, movement's critical there for nutrition, for strength, for flexibility. However, if you have excessive or prolonged stress. And here's the. Here's the clincher on that. What does that mean? Well, here's the clincher. It's different for everybody. And that's the real challenge, right, is that we are so dynamic. People weigh more or less. People's biomechanical structure of their spine is different. You know, people have different genetics, people have different work, people have different fun. People have different. All of these different factors play a role where it's impossible to say how much is too much. The answer is it depends. And that's a challenging answer for many people out there that want to have a direct answer. But it's important for us to keep in mind as clinicians, as we guide and direct our patients. So, herniated discs can lead to pressure on the longitudinal ligament and cause local inflammation. And this can cause, of course, low back pain. And when disc material exerts and causes direct contact with the thecal sac or a nerve root, that's what results, of course, in that nerve root ischemia or the inflammation and radiculopathy. So, disc herniations, of course, are classified in a variety of different ways. Bulges, protrusions, extrusions, sequestrations, and all of those have different technical classifications. But I'll give you a warning. I have seen all of these used so interchangeably across MRI reports that I always like to get my eyes on it because, you know, you see these terms used so interchangeably, even though there are distinct differences from a technical perspective. What are those distinct differences? Disc bulge. This is when the circumference of the disc exceeds beyond the regular margin of the vertebral. Body while maintaining the circumference of the disc. So it's usually asymmetrical. Bulging disc protrusion is when the base width of the protrusion is wider than the diameter of the disc disc that is herniated and projects beyond the normal disc margins without damage to the annulus fibrosis. Important to keep in mind there. A disc extrusion occurs when there is damage to the annulus fibrosus allowing the nucleus to extend beyond the margins. And when a disc is sequestered that means there's been a fragment, right? A piece of that pulpulsus has gone out into space. And sometimes they can get into some pretty hairy places in the corners there as I've seen happen many, many times. They can sequestered disc might sit in that lateral recess and cause no pain. But then you're going from 0 out of 10 to 10 out of 10 whenever it just starts to catch on. Those corners where those nerve roots are going through, that can be a super precarious situation. So that's how they defined a lot of what's going on with the disc and how it causes radiculopathy. Now let's dive into some of what they found in terms of the best non surgical options. So we know in 2023 the World Health Organization released a consensus guideline highlighting the fact that non surgical interventions needed to happen first. We also know that patients undergoing conservative treatment typically experience benefits in about 80% of cases within four to six weeks. So couple things there. 1, 80% of cases that people have radiculopathy will find benefit with conservative means really important second component within four to six weeks. So don't shortchange your patients. Sometimes it sometime everything doesn't happen on the first visit and that's okay. So teach patients, understand patients and be cognizant of patience. That doesn't mean, you know, again, don't swing the pendulum the other way. It doesn't mean automatically like over treat and say you need to come in for one gazillion visits. You know that's not the truth. But what is important is that you actually tell the truth, which is this is going to be a process. It might take some time. And don't hesitate to look at some four to six week markers. We see this in physical therapy all the time. But sometimes I see what, what I'll what quote unquote evidence based. Chiropractors get really skittish on taking care of people if they're not seeing a result within one to two visits. If Somebody's highly inflamed, that's a big issue. And something's going to take time. When we think about ligament and collagen reformation, that could take weeks or months. When you think about changing habits, that takes time. Strength and flexibility don't happen in one or two treatments, right? So getting out of pain or reducing pain typically can happen pretty quickly. But to make long term changes takes a little bit. Every process takes time. So what they highlighted in this study, which I thought was really, really cool, is the strength of evidence for some of these conservative options. And the strength of evidence for some of these conservative options are as follows. They looked at self patient education and self management, level B. So there's a moderate amount of evidence there. So patient education, self management, good thing to do. McKenzie method, level B. That is moderate evidence. That is a good thing to do. Mobilization and manipulation, level B. Great thing to do. Exercise therapy, level B, great thing to do. Traction, great thing. Neural mobilization, great thing. When I say great thing, I mean there's research that supports it at least a moderate level. So those are, that's the great news because probably a lot of what I just said, I went through that pretty quickly. But probably a lot of what I just said is what you're already doing in your practice and maybe there's some new tools you can bring in. So with a moderate level of evidence, the items that were highly suggested include the following. Recap, Patient education and self management. Empowering your patients. McKenzie Method. Many docs out there, especially sports specific docs, love that. Mobilization and manipulation, right there. Exercise therapy, right on. Traction, level B, short term, so moderate, level C, a little bit less in the long term. And neural mobilization, really, really important components. Now what were some items that they said? Well, the research really isn't there yet. Electrode diagnosis based management was one of them. Laser and ultrasound. Not that you can't get benefit with that, but it might not be your primary modality. Electrotherapy and dry needling, again, those things can certainly help. But I would look towards your primary items. Patient empowerment. Again, patient education. Here's the good news. We do a great job as that as chiropractors. Manipulation and mobilization. Our core tenet of what we do, Exercise therapy, critical. When we're looking at rehabilitation from a disc injury, many of us do it. Neuromobilization. Chances are we're combining that with a lot of our manipulation and mobilization and exercise therapy and then McKenzie method as well. So a lot of great stuff. This study just further supports much of probably what you're already doing in practice. And that is just about the best study you can imagine. Because when you get improved confidence, when you get better clarity about hey, what I'm doing is what's out there and it is what is recommended at pretty much the highest level possible, that's a great place to be. Now, tying back to last week's episode, it doesn't mean that you're going to be flooded with referrals just because you're doing the right thing. Unfortunately you have to get out there and build systems and processes. But if a lot of what I just described in terms of how you're approaching radiculopathy makes sense and is what you're doing in your practice, and then you're probably in a darn good position to get out there and tell that story because that is then how people can get referred into your practice. So a lot of great take home messages in this one. I liked it. Before we wrap up, I want to say a few words about Stop Pain Clinical. They're topical energizers that I recommend they support this podcast. 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