Resolution of Post-Surgical Low Back Pain in a Patient with Chronic Cauda Equina Syndrome: A Case Study
David J. Paris DC1, Alec L. Schielke DC2
1Staff Chiropractor VA Northern California Health Care System
2 Staff Chiropractor San Jose VA Medical Center
Published: December 2017
Journal of the Academy of Chiropractic Orthopedists
December 2017, Volume 14, Issue 4
This is an Open Access article which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The article copyright belongs to the author and the Academy of Chiropractic Orthopedists and is available at: http://www.dcorthoacademy.com. © 2017 Paris/Schielke and the Academy of Chiropractic Orthopedists.
Objective: The purpose of this report is to describe the management of a patient experiencing post-surgical low back pain, secondary to a corrective thoracolumbar surgical fusion, as a consequence of traumatically-induced chronic cauda equina syndrome.
Clinical Features: A 59-year-old male with low back pain, buttock pain, anal hyperesthesia constipation, and urinary retention presented on consult for consideration of chiropractic care for low back pain. This patient was involved in a motorcycle collision 18-months prior, which resulted in a burst fracture of the first lumbar vertebral body, requiring corpectomy of L1 and spinal fusion T12-L2. This patient continued to have low back pain, chronic cauda equina syndrome with neurogenic bladder and perianal hyperesthesia following the spinal fusion. His residual neurologic defects were considered stable by his neurologist and primary care providers.
Intervention and Outcome: Care consisted of two separate trials of chiropractic care, totaling 13 visits over a 4-month period. The care provided to this patient included graded lumbosacral mobilization, thoracic, lumbar and sacral spinal manipulation, moist heat, and rehabilitation exercises. Following this course of care, the patient reported improvement of his low back pain.
Conclusion: In this case, management of post-surgical low back pain with concomitant chronic cauda equina syndrome responded favorably to a course of chiropractic care, over two separate trials, including spinal manipulation therapy.
The use of lumbar spinal manipulation and spinal rehabilitation for the management of low back pain is not well documented for patients with concomitant chronic cauda equina syndrome (CES). The authors of this report were able to identify only a single case report involving spinal manipulation for the management of low back pain (LBP) in a patient with chronic CES (1).
In patients experiencing acute CES symptomatology, manipulation is an absolute contraindication (2,3). Post-surgically, chronic CES is known to be associated with back pain and neurologic deficits (4). Cauda equina syndrome may involve LBP, radicular pain in the lower extremities, saddle anesthesia, urinary incontinence, or lower extremity motor and/or sensory deficits (4,5). Acute CES is a medical emergency, however there is controversy regarding the risk of immediate (within 48 hours) versus delayed surgical intervention, as surgery in an emergency setting may involve suboptimal results and prolonged morbidity (6).
A 59-year-old male with low back pain of 18-months duration referred on consult by his primary care provider (PCP) for chiropractic care. This patient experienced a motorcycle accident 18-months prior which resulted in a burst fracture of the first lumbar vertebral body (L1), necessitating emergency L1 corpectomy and T12-L2 fusion.
Following surgery, the patient was diagnosed with residual chronic CES and neurogenic bladder, which necessitated the need for intermittent self-catheterization to void his bladder. The patient also reported perianal hyperesthesia, which remained unchanged since the time of the surgery and was primarily noticeable while wiping after passing a bowel movement. This patient was able to defecate on his own via Valsalva maneuver on a 1-hour postprandial schedule. He also reported transient radicular pain, extending to his feet, while performing the Valsalva maneuver while voiding his bowels. No other lower extremity symptoms were noted by the patient.
This patient’s low back pain was described as a constant, “sharp ache” over the lumbosacral region and was worse with all end-range lumbosacral ranges of motion. The patient rated his average pain as a 4/10 on a Numeric Pain Rating Scale (NPRS) with range from 2/10 to 6/10, depending on provocative and palliative factors. The patient completed the NPRS, but refused to complete any other outcome measures. Patient described that his pain was relieved while laying down supine, with moist heat (e.g. with a hot tub), but the pain was worsened during any activity that involved prolonged lumbar flexion (e.g. sitting).
The patient had received chiropractic care for LBP previous to this injury, but denied any chiropractic care since his accident and surgery 18 months ago. The patient also underwent physical therapy for the management of his low back pain, previous to this injury, for approximately 2-3 months. He noted this trial of physical therapy failed to provide significant relief.
The patient’s past medical history and surgical history, prior to the accident in question and subsequent surgery, are non-contributory with no noted prior injuries, surgeries, injections, or procedures related to the lumbar spine other than the motorcycle injury noted and subsequent surgery.
The patient is married with children and he enjoys regularly performing light home construction. He drinks socially and used recreational marijuana to improve his mood. Functionally, the patient reported an ability to walk a mile, and denied any difficulty climbing the stairs of his 3-story home. He utilized a cane while ambulating to assist with balance, which he notes is difficult at times due to loss of strength and coordination.
The patient underwent standard post-surgical lumbar spine x-ray examination, which revealed successful orthopedic fusion of T12-L2 along with generalized lumbar spinal degenerative joint disease (see Figure 1).
Figure 1: Computed tomography images of patient’s surgical repair
The physical examination revealed a 12-inch surgical scar over the patient’s left thoracolumbar paravertebral gutter. Lumbosacral active range of motion were decreased by approximately 20%, in all directions with no description of “pain” noted and only “soreness” if continued movement pushing end-ranges. The patient reported pain following palpation of his lumbosacral paravertebral muscles and moderate hypertonicity was noted, bilaterally. Bilateral lower extremity manual muscle testing bilaterally graded as 4-4+/5, including extensor hallucis longus with only exception plantar flexion graded 4/5 bilaterally. Deep tendon reflexes were rated as 3+ on the right quadriceps tendon, 2+ on the left quadriceps tendon, 0 on Achilles tendon bilaterally with reinforcement. Babinski’s test was negative, bilaterally. Bilateral hypoesthesia to pinwheel and light touch was noted along the posterior calves (S1/S2 dermatomes). No other sensory deficits were detected in the regions of the L1-L5 dermatomes. Perianal hyperesthesia was reported by the patient and was not examined, per patient’s request. Seated and supine Straight-Leg Raise tests were negative, bilaterally, with note of localized low back pain when the legs were raised above 45 degrees. When the Valsalva maneuver was performed that patient denied lower extremity symptoms (i.e. pain or paresthesia). The patient was hesitant to perform an aggressive Valsalva maneuver, due to a fear of fecal incontinence during the exam. On evaluation patient also continues to report a history of low back pain and diffuse leg paraesthesias while straining to void his bowels since accident (i.e. positive Dejerine’s triad).
The patient was diagnosed as follows: 1) status-post corpectomy and thoracolumbar fusion T12-L2 with chronic CES and neurogenic bladder, 2) chronic low-back pain with myofascial contribution as sequelae of injury, subsequent surgical intervention and deconditioning, and 3) lumbar degenerative joint disease, per the radiology report.
Care consisted of two separate trials of care totaling 13 chiropractic visits over a 4-month period. The first trial of care involved 6-visits and care was extended past the first trial of care, based on improved LBP. Therapies included graded lumbosacral mobilization, thoracic, lumbar and sacral spinal manipulation, moist heat, and rehabilitation exercises. Treatment began with graded mobilization over the lumbosacral area (sacral extension) while prone, high velocity-low amplitude (HVLA) chiropractic spinal manipulation (diversified technique) was applied to the mid-thoracic spine along with hydrocollator therapy for 10-minutes, during each visit. As a safely measure, pre-manipulative positional stress was utilized and symptoms were assessed prior to each treatment. Rehabilitation exercises began with supine single-leg, knee to chest stretching for 30 seconds in 3 separate positions (same shoulder, opposite shoulder and across waist).
Improvement in low back pain was noted immediately post-treatment at each visit. After each of the first 3 visits, the patient reported lasting improvement from his LBP. Drop table chiropractic manipulation therapy was applied to the patient’s lumbosacral area midway into initial trial of care (3rd visit), as was the introduction of Quadruped Reach (also known as “Bird Dog”), Side Bridge and Curl-up exercises (also known as McGill’s Big 3). These were chosen as they are considered to be safe exercises for low back pain patients (8,9). The patient continued to respond positively and had no difficulties understanding or performing his home-based exercises. Handouts were dispensed detailing his home exercises instructions with progressions. He was instructed to progress when he was able to perform 3 sets of 12-15 repetitions with good control of movement, performed and demonstrated on follow-ups visits at clinic, without worsening of pain following performance of the exercises. The patient was instructed that mild post-exercise soreness may be experiences and is considered to be a normal side-effect of this activity. Side bridge was instructed initially at 8-10 slow repetitions with 2 breath holds in the elevated position done 1-2 times daily. Quadruped Reach was instructed initially with 3-4 repetitions, which were easily performed and demonstrated in-office. These exercises were progressed, on initial visit, to 10-12 repetitions with 5-6 second hold, 1-2x daily. The patient was instructed to perform Curl-Up exercise for 12 repetitions with a 2-breath hold, 1-2 times daily. All exercise progressions were based on the patient’s ability to achieve a minimum of 2 times daily with adequate comfort and good control as assessed by clinician. On the patient’s 6th visit, he was shown an eyes-open, one-legged standing balance exercise. Initially he could not do this for more than 2-3 seconds on either leg without a major correction or having to touch other foot to ground due to poor balance. No pain, weakness or fear-avoidance was noted on performance of this exercise. Of note, improving balance was a patient-specific goal of care as he noted he would like to sail comfortably on his sail boat and he was avoiding this, due to his imbalance issues.
Lumbosacral mobilization progressed to HVLA side-posture spinal manipulation (diversified technique) during final two visits in initial trial. Manipulation targeted the L4-S1 segments, with no adverse events reported. The patient noted a preference and greater pain relief from the drop-assisted spinal manipulation, subsequent visits continued utilization of drop table technique to the lumbosacral spine. Due to success with pain control and home exercise intervention, the patient was offered, and declined, a physical therapy consultation for a more focused progression and monitoring of home exercise plan.
The patient did not attend his follow-up re-examination and lost to follow-up, until he presented as a walk-in 6-months later requesting care as need for exacerbations. On this visit he rated his LBP as a 3/10, following recent snow shoveling and flare of LBP. He reported that he had intentionally missed his post-trial follow-up appointment as his LBP had resolved and he “felt great and didn’t feel he needed care.”
On his return following a 6-month absence, the patient presented without the need of a cane for ambulatory assistance and reported rarely using his cane. He denied any LBP for the last 6-months, rated as 0/10 NPRS, until this recent exacerbation as noted above. He further stated that he was able to continue to build his house remaining very active, “more active than ever”, also that he had taken up sailing again. He reported that his chronic CES symptoms were unchanged and he continued to experience perianal hyperesthesia and continued to require urinary catheterization and complies with follow-up evaluations from his neurologist to monitor his chronic CES.
Currently, patient continues to follow-up on an as-needed basis for the management of his LBP exacerbations. He has been advised to continue his activity level and other activities of daily living and was instructed to continue his home exercises, as instructed. He declined any other referrals or intervention and was happy to continue his home-based exercises.
This case is notable as cauda-equina syndrome (CES) represents a relative contraindication and when acute a medical emergency. There are few case reports noting the multimodal care chiropractors generally deliver in practice, along with spinal manipulative therapy involving these conditions. This case describes the successful chiropractic treatment of 18-month chronic low-back pain in a post-surgical patient with chronic cauda-equina syndrome. Multimodal care consisted of graded lumbar mobilization, spinal manipulation, moist heat, and home-based lumbar stability exercises.
There were no adverse events reported throughout this course of care and spinal manipulation appeared to be safe and efficacious in the long-term management strategy for this patient’s LBP with concomitant chronic CES. In this specific case, multimodal conservative chiropractic treatment including spinal manipulation, resolved this patient’s low back pain.
Clinicians should be aware of the absolute contraindication of spinal manipulative therapy in patients with acute CES. However, awareness of only acute CES guidelines and recommendations may prevent referral of patients with chronic CES and spinal pain complaints for conservative management, such as spinal manipulative therapy, spinal rehabilitation exercises and other conservative measures.
As a retrospective study, this case involves some limitations. First, only a NPRS and the patient’s subjective interpretation of increased function were assessed as outcomes. The patient’s response to care would have be better evaluated using additional outcomes assessments, particularly an outcome measure involving the patient’s functional status. Secondly, although mobilization and two chiropractic techniques were used (drop table and diversified side-posture HVLA) there can be no statement on efficacy of those other than the stated individual patient preference. No generalized effectiveness can be gained from this type of individual case-report.
Select patients with chronic CES may benefit from spinal manipulative therapy for the management of LBP. However, further research in the form more rigorous testing, beyond case reports, is needed to establish the safety and efficacy of this approach to care.
While the effectiveness and safety of this management strategy is not able to be applied to the general population from this report, it does provide some insight into the clinical management of patients with chronic CES via conservative care. It appears spinal manipulation therapy and spinal rehabilitation exercises may be considered as a viable consideration in the treatment of spinal pain complaints among select patients with chronic CES.
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