Letters to the Editor  |   May 2014
Author Affiliations
  • James A. Lipton, DO
    Staff Physiatrist, Veterans Administration Medical Center, Hampton, Virginia; Clinical Track Professor of Physical Medicine and Rehabilitation/Osteopathic Manipulative Medicine, Edward Via College of Osteopathic Medicine–Virginia Campus, Blacksburg; Adjunct Professor of Osteopathic Manipulative Medicine, New York Institute of Technology College of Osteopathic Medicine, Old Westbury
  • Geoffrey A. McLeod, DO, USAF, MC
    Edward Via College of Osteopathic Medicine–Virginia Campus, Blacksburg
Article Information
Neuromusculoskeletal Disorders / Pain Management/Palliative Care / Low Back Pain
Letters to the Editor   |   May 2014
The Journal of the American Osteopathic Association, May 2014, Vol. 114, 341. doi:
The Journal of the American Osteopathic Association, May 2014, Vol. 114, 341. doi:
We appreciate Dr Gilliss' comments regarding our case report.1 The opportunity to share ideas and common zeal for the use of osteopathic manipulative medicine for the management of somatic dysfunction is welcomed. 
After a thorough medical history, physical examination, and appropriate workup, we believe that focusing on the impressive imaging was important because the patient did not present with classic signs. The eventual moot point of the patient's somatic dysfunction, perhaps being caused by her boot and use of crutches, was addressed conservatively by correction of her gait and use of osteopathic manipulative treatment (OMT). As indicated by our title, the patient's disk herniation was an unexpected finding. A heightened index of suspicion after the patient's revelation and persistent condition led to imaging, and thankfully so. 
Having coauthored the guidelines for the osteopathic medical profession on the management of low back pain,2 I (J.A.L.) can say the word guideline is self-explanatory. Dr Gilliss' comments seem to suggest that one should use OMT in some other fashion, perhaps using high-velocity, low-amplitude technique on the lumbar spine and that such use would best be performed without knowing of the presence of this massive lumbar herniated disk. Or, his comments suggest that OMT might be performed knowingly, even after imaging documented a large herniated disk, and if so, we then defer to his expertise. However, Dr Gilliss' position that spinal stenosis should present a certain way is yet another reason to have published our case report, as it is clear in this image that spinal stenosis presented in a nonclassic fashion. 
Dr Gilliss' opinions regarding surgery are not lost upon our esteemed surgical colleagues, those who have undergone successful surgical procedures, or the surgeon who operated in this case. Although it is our duty as osteopathic physicians to choose which of our abilities we employ in treating a patient, this patient's herniation was quite large and did require surgical evaluation. Expert surgical evaluation led to a successful surgical outcome, which speaks to the effect of the removed disk as a remaining source of the patient's somatic dysfunction. 
We thank Dr Gilliss for his comments, and we hope our experience and this discussion will be educational for our colleagues and of benefit to our patients. 
Lipton JA, McLeod GA. An unexpectedly progressed lumbar herniated disk [case report]. J Am Osteopath Assoc. 2013;113(12):926-929. doi:10.7556/jaoa.2013.072. [CrossRef] [PubMed]
Clinical Guideline Subcommittee on Low Back Pain. American Osteopathic Association guidelines for osteopathic manipulative treatment (OMT) for patients with low back pain. J Am Osteopath Assoc. 2010;110(11):653-666. Accessed March 13, 2014.