Abstract
Adjacent segment pathology is an adverse effect of spinal fusion that precipitates accelerated spinal degenerative changes at vertebral segments contiguous with the fused vertebrae. The accelerated degeneration related to ASP can be challenging to manage, as it can lead to conditions such as radiculopathy and can create the need for reoperation. In the present case, a 50-year-old woman with a previous spinal fusion presented with a 1-year history of progressive low back pain, lumbar radiculopathy, and sciatica. Osteopathic manipulative treatment was used to manage her pain, and the patient reported that the treatment provided long-term resolution of her sciatica symptoms. This case demonstrates an effective use of osteopathic manipulative treatment in the conservative management of lumbar radiculopathy related to adjacent segment pathology.
Adjacent segment pathology (ASP) is an adverse effect of spinal fusion that can lead to clinical symptoms and changes observed on radiography that affect patient care. Despite ongoing developments in spinal surgery, vertebral fusions increase stress on the contiguous vertebral segments and result in rapid degenerative changes.
1,2 A systematic review
3 found that the mean annual incidence of ASP ranged from 0.65% to 3.9%.
Radiculopathy is a common complication related to ASP and is often caused by nerve root compression from disk herniation or spondylosis.
1 Vertebral degeneration related to ASP is thought to potentiate the etiologic factors of nerve root compression.
1 The diagnosis of radiculopathy is often made using magnetic resonance (MR) imaging and electrodiagnostic testing results.
4 Nonsurgical options, such as physical therapy, interventional injections, medication, osteopathic manipulative treatment (OMT), or a multimodal approach, are frequently part of the initial conservative treatment plan in the management of radiculopathy.
5 Studies
1,2 have examined the efficacy of different surgical approaches in the management of ASP-related radiculopathy, including additional bone removal, extension of the fusion, nonfusion dynamic stabilization, and transforaminal endoscopic surgery. To our knowledge, this is the first published report to describe the use of OMT to manage somatic dysfunction associated with ASP-related radiculopathy. The current report describes the case of a woman with progressive low back pain and sciatica caused by a previous spinal fusion, as well as the conservative management of her symptoms through the use of OMT.
A 50-year-old woman presented to the osteopathic manipulative medicine clinic with a 12-month history of low back pain (LBP), which she described as a burning, sharp pain that radiated down her right lower limb to the anterior and lateral distal calf, stopping just above her ankle. The patient underwent a posterior spinal fusion to stabilize a T4-L4 S-shaped scoliotic curve 35 years previously. Cobb angle measures taken after the spinal fusion were 26° with a convex right curve from T4 to T11 and 25° with a convex left curve from T12 to L4.
One year earlier, 34 years after the spinal fusion, the patient presented to a physiatrist after a series of migraines and neck, back, and lower limb pain. At that time, an MR image of the thoracolumbar spine measured a thoracic curve at 35° convex right and a thoracolumbar curve at 31° convex left. An MR image of the lumbar spine taken at the same time demonstrated significant degenerative changes at L5-S1 and upward migration of disk fragment in the right lateral recess at L4-L5. Physical therapy was recommended, and the patient attended 1 to 2 sessions per week for approximately 12 months, but it did not improve her symptoms.
At the current presentation, the patient reported that her pain was a 6 out of 10 on a 10-point scale (1 being the least pain and 10 being the most) at worst and that it could bring her to tears while exercising. She denied weakness, numbness, or tingling in the lower limb. Her symptoms improved when she was resting in the supine position or in a swimming pool. She took nonsteroidal anti-inflammatory drugs for pain relief, as needed. She reported that her symptoms interfered with her ability to complete daily activities. She described an overall goal of decreasing her daily LBP and right sciatica pain, as well as improving her level of function without medication.
Physical examination of the musculoskeletal system while standing revealed somatic dysfunction in the right superior iliac crest and greater trochanter. Lumbar range of motion was decreased in flexion, extension, rotation, and sidebending. Oblique rotation to the right provoked pain near the right posterior superior iliac spine. A neurologic examination showed intact sensation to light touch and pinprick in the bilateral L2-S2 dermatomes. Manual motor examination revealed weakness on the right side, with 4 out of 5 strength on a 5-point motor examination scale (0 being no response and 5 being full strength against resistance) in the hip flexors, hip abductors, extensor hallucis longus, and ankle everters. The right patella deep tendon reflex was diminished. Straight leg raise test results were negative bilaterally for dural tension in seated and supine positions. The patient's symptoms and examination findings were clinically consistent with a right L4 radiculopathy, likely a consequence of ASP, and repeated lumbar MR imaging was recommended to confirm the diagnosis. In addition, a repeated postural test for Cobb angle measurements was recommended because of the potential of scoliotic curvature progression and possible fusion failure. Comparison with previous radiographic images was advised.
At the patient's first follow-up appointment, 7 days after initial presentation, she had not undergone the recommended MR imaging of the lumbar spine or postural study. During the appointment, OMT techniques (ie, counterstrain, myofascial release, muscle energy, and Still technique) were performed to address the somatic dysfunctions found in the patient's head and cervical, thoracic, lumbar, sacral, pelvic, and lower-limb regions. Considering the patient's likely lumbar ASP, indirect and passive techniques were used when addressing the lumbar spine and pelvic regions. The OMT was well tolerated, and somatic dysfunctions improved in all regions immediately after treatment.
At the second follow-up appointment, 15 days after initial presentation, the MR image of the lumbar spine and postural study had still not been performed. The patient reported that her pain was significantly reduced and intermittent, and that the pain in her lower back and right thigh were 1 out of 10. Using a similar approach as the previous appointment, OMT was performed to address the somatic dysfunctions in the head and cervical, thoracic, lumbar, sacral, pelvic, and lower-limb regions. Again, considering the patient's likely lumbar ASP, indirect and passive techniques were used when addressing the lumbar spine and pelvic regions.
Sixteen days after initial presentation, the postural study was performed, and results revealed stable scoliotic curves, including scoliosis of the thoracic spine convex to the right at 23° and scoliosis of the lumbar spine convex to the left at 24°. An MR image of the lumbar spine was obtained 17 days after initial presentation and confirmed the right L4 radiculopathy with an L4-5 disk protrusion impinging on the right L4 nerve root in the neural foramen.
At the third follow-up appointment, 24 days after initial presentation, the patient reported intermittent pain in her lower back and upper-right buttock, which, at worst, was a 1 on a 10-point pain scale. She denied lower-limb weakness, numbness, tingling, or radiation of pain distally in the right thigh or calf. She reported that the OMT helped reduce her pain and improve her range of motion and that her symptoms were much less frequent, which enabled her to better tolerate her daily activities. It was recommended that further evaluation be done if symptoms returned in the future.
In a follow-up telephone interview 12 months after her initial presentation, the patient reported lasting resolution of her LBP and sciatica symptoms. Her LBP was intermittent, between 0 and 2 on a 10-point pain scale. Her sciatica symptoms were infrequent and did not interfere with her daily activities. She was able to work 3 days per week, complete her daily activities, and volunteer regularly. She had been able to manage her LBP and sciatica symptoms with mindfulness, a daily yoga-stretching regimen, swimming pool exercise, and rest. Overall, she described an improved quality of life and high level of function.