Question
QUESTION: I've been seeing a chiropractor for over 1-1/2 years, three times weekly.  I'm in worse pain now then when I first started. The pain is mostly in my low back and down the front of my thighs.  Sometimes, it's also in my groin, and often, I'm dizzy and nauseated.  It's hard to hold back my urine and I use a pad.  My chiropractor says this is to be expected, since he's working back through 20 years of low back pain and its compensations that have also caused significant neck pain, hip pain and sciatica.  He says it may take up to 5 years of treatments until I'm able to walk normally.  Currently, I can't hardly walk.  I use a cane and can only walk about 1/4 of a block with it.  I do stomach crunches and leg lifts to strengthen those muscles, and recently he started using cold laser therapy on me, which is supposed to speed up my treatment.  He says I have a pinched nerve at L3 and after 19 months of treatment, he estimates I'm 30-35% better.  My MRI shows marked degenerative changes and degenerative disc disease throughout the lumbar spine.  Also, there are subchondral inflammatory changes involving the end plates of the L3 and L4 vertebral bodies.  Posterior disc bulging is noted at multiple levels without evidence of a focal disc herniation.  No central spinal stenosis or obvious acute herniated nucleus.  He says no medical doctor can help me, only a chiropractor.  My pain has worsened severely since I started with him.  At the beginning, I could walk, but had severe pain in my left hip.  After about 2 months, my hip was fine, but he said the hip pain was referred from my back at L3.  I have longstanding chronic back pain that got worse with a herniated disc in 1992 that I never fully recovered from.  However, I could still walk for over an hour, and work out.  I had pain, but it was bearable.  My then orthopedic doctor said sometimes that happens and you just have to live with the pain.  My chiropractor says that since the pain is so longstanding, that's why it's taking so long.  He says I've always had this pinched nerve, but was compensating for it with my neck, hip, upper back, etc. That's why I didn't feel such bad pain then.  I have also had C1-C5 problems from it, including dizziness, nausea and headaches. He says my pain is much worse now because he's worked through many of my compensations, so that the pain at L3 has nowhere to go now.  Is there anything you can recommend I try to lessen my pain, so that I can walk again?  I am 56 and otherwise in good health.  I've had 2 cortisone shots in the past few months that each gave me about 25% relief.  The first shot helped for about 2 weeks, and the second shot for only 2 days.  They were done with radioactive dye, so that they were placed correctly in my spine. Have you had patients you needed to see for this long continuously?  Is this normal, or should I stop going?
ANSWER: Dear Sharri,

I am completely shocked at what I have just read!!  I have never had to treat anyone for more than 3-4 months to reduce their pain significantly unless they have been in a car crash where they had sustained significant ligament damage to multiple areas of their spine or multiple disk bulges.  I cannot believe you have been seeing this doctor for so long, 3 times a week.

I am sorry to hear that you are going through this, and I would recommend that you absolutely do not go back to this chiropractor ever again.  There is absolutely no scientific proof to validate what he has been telling you and I would say that he is intentionally misleading you to keep you as a patient. As a matter of fact I think he may have done you more harm than good, and it definitely borders on malpractice!  You may even want to consider calling the state chiropractic board about this.

If I cannot get significant reductions in pain and improvements in function within the first 2-4 weeks of treatment, then I know that there is a problem.  Your case should have been re-evaluated, you should have been referred out for consultations with other doctors, or your chiropractor should have tried other approaches to help you.   

I have to ask, what the heck was this chiropractor doing for so long?  How were you being treated?  Why is he just now trying to help you with the laser...did he just purchase it?  I am actually pretty mad that you have had to endure this experience...I truly believe your treatment has been mishandled!  The least he could have done was send you for a pain management or accupuncture consult while he was treating you.

Now the fact that you are having trouble with urination is a huge red flag...this is a serious indication of impaired nerve function to the smooth muscle of the bladder and needs to be explored by a medical doctor with the possibility of co-treatment with a competent chiropractic physician.  There is a condition called cauda equina syndrome (CES) in which the lower spinal cord/nerves are compressed which may need surgical resolution.  Let me explain...

The spinal cord is the downward continuation of the brain stem, and it descends to about the level of the second lumbar vertebra (L2), tapering to a structure called the conus medullaris. This cone thins to a threadlike string called the filum terminale, extends as far as the tail bone and is composed of non-nervous tissue. The cauda equina surrounds the filum terminale.

The spinal cord serves as a conduit for the ascending and descending nerve tracts that connect the peripheral nerves (nerves in the arms/legs etc...)and spinal nerves with the brain. The cord projects 31 pairs of spinal nerves on either side (8 cervical, 12 thoracic, 5 lumbar, 5 sacral, 1 coccygeal) that are connected to the peripheral nerves. These lower peripheral nerves from the level of about L3 downward, compose the cauda equina (CE) named because it looks like a horses tail.

Symptoms of CES:  Radicular pain is a frequent, usually in association with sensory loss in the groin (saddle anesthesia), asymmetrical paraplegia with loss of the tendon reflexes and/or muscle loss (like not being able to walk), and bladder dysfunction. The principal causes of this syndrome are tumors, lumbar spinal stenosis, ruptured lumbar disk, arachnoiditis (inflammation of the spinal covering), and spinal fracture.  In your case is looks as if the chiropractor you are seeing may have made your condition worse due to the fact that you can't walk well now, and that you are having the bladder issues.  This needs to be looked into further.

CES may result from any problem that compresses the nerve roots of the tip of the spine. These nerve roots are particularly susceptible to injury because they have a poorly developed epineurium (the outer covering). When they are well developed, as in peripheral nerves, the epineurium protects against compressive and tensile (stretching) forces. The small blood vessels that supply nutrition and oxygen to the nerve roots have an area of relative poor supply that is compensated by the the surrounding cerebrospinal fluid (CSF).  Therefore if they are compressed, they can lose partial function quickly.  this is why CES is a condition that needs to be diagnosed and managed properly.  

The best way to do that is with a follow-up MRI looking specifically at the cauda equina nerves, blood tests looking for inflammation such as the ESR, C-reactive protein, and white blood cell counts.  Clinical correlation is needed with a functional examination including orthopedic testing, muscle strength, circumferential measurements of the legs, sensation testing and deep tendon reflexes.  As a matter of fact, all of this should have been done by your chiropractor a long time ago...not to mention you should have been re-examined periodically while under care.  Additionally, it would be appropriate to test the control of the anal sphincter to see if the nerve supply there has been altered as well.  I would suggest that you only let your medical doctor evaluate that.

Now, the dizziness, nausea, and neck pain may have some relevance, but most of the time when you have multiple symptoms such as that it is not coming from the low back (lumbar spine). Rather, you likely have separate problems in the neck that may or may not require chiropractic or medical management.  Your C1-C5 problems did not happen because of bulging disks in the lumbar spine, or a pinched nerve at L3.  Not to mention that the nerve root of L3 does not refer pain to the hip, it refers pain to the lower lateral side of the leg down to the knee.  This has been documented for years and is called a dermatome.  I want you to click on the links provided below to visualize the dermatomes so that you will understand where they go on the body:

http://www.apparelyzed.com/myo-dermatomes.html
http://www.apparelyzed.com/dermatome.html

Lastly, you probably do need ongoing care, but not from that guy!  You need to be diagnosed properly and then an appropriate treatment plan can be generated.  Please seek the care of a better doctor, medical and chiropractic.  You may also benefit from a newer technology called intervertebral disk decompression.  It is still a bit controversial. I do like the technology, although I think most doctors are charging too much for it.  Anyway explore the options by doing a google search on IDD therapy, Accuspina, DRX 9000, or Spinal Aid.  

Good luck Sharri, and feel free to get back in touch with me if you need to.

Respectfully,
Dr. J. Shawn Leatherman
www.suncoasthealthcare.net






---------- FOLLOW-UP ----------

QUESTION: Dr. Leatherman, Thank you so much for your response to my question.  I am very disappointed with my chiropractor and how he has been treating me.  I didn't fully understand your response and need to ask some follow-up questions and answer you questions to me.  You asked how I am being treated.  He does gentle adjustments, and doesn't do cracking.  He feels gentle adjustments are as good as cracking.  Does this make a difference in a patient's outcome?  Do you feel gentle or cracking is more effective?  Also, do you treat your patients by working through their prior compensations also?  Is that necessary to correct the original problem?  He feels I have both L3 and L5 problems.  Does an L5 problem refer pain to the hips?  You asked me what other approaches he's tried.  What other approaches are there?  It's been so long since he first evaluated me that I don't remember what he did.  I remember him testing my muscle strenth.  He continues to push against my legs and arms to test for weaknesses.  Is that part of a re-evaluation?  He would probably say that he is constantly re-evaluating me.  What goes into a revaluation?  He never checks my reflexes.  Do I need a new MRI so he can re-evaluate me?  What other kinds of doctors would he refer me out to for consultations?  He would never refer me out to anyone unless I begged him.  He feels he can cure me by himself.  He said my urination problem is just another symptom of a pinched nerve and will improve once the vertebra is off the nerve.  What kind of medical doctor should I see for the urination problem?  I went to a gynecologist who specialized in this a few years ago, and he said he could operate to fix the problem.  I also urinate when I sneeze, cough, or run.  It's become a worse problem since I started with the chiropractor.  What kind of doctor orders an MRI for cauda equina nerves?  My C-reactive proteins and white blood cell counts are fine.  I also didn't mention to you that I had a right knee replacement in January, 2005.  It wasn't put it properly, and I need to have a new replacement done.  I have recently developed significant arthritis, and in the past 2 years, I have gone from having average cartilage in both hips to having NO cartilage in my left hip and 1 mm in my right hip.  My old knee surgeon felt my hip pain was from arthritis and no cartilage and that I would need to have my hips replaced at some point.  My chiro feels strongly that the hip pain I have is really referred back pain and not true hip pain that requires replacements.  He says that if I go ahead with hip replacements, that my back pain will just try to throw off the pain to my left knee.  Eventually, it will wear down the cartilage in my left knee and I'll need a left knee replacement also.

What did my chiro say that makes you think he's intentionally misleading me?  Why do you say he may have done more harm than good?  What did he do that borders on malpractice?  I really need answers from you to these questions, so I can make an informed decision about my care going forward.  Since you responded to my original question, I was so angry with my chiro that I canceled my Monday and Wednesday appointments. He canceled my last Friday appt.  I now have almost no back pain, but nearly all of the pain is in my hips, and I'm very unstable when I walk. I feel like I'm doing better without seeing him.  I never feel better right after I see him or the next day or two.  I was just in constant pain.  At least I'm feeling a little better now.  I look forward to your answer to these questions.  Thank you very much.  Regards, Sharri

Answer
Dear Sharri,

Sorry it has taken me a couple of days to get back to you!

I know that you have many specific questions, but what I am going to try to do is answer many of them together rather than separately.  I will try to keep an objective opinion on this.

First of all any doctor who is unwilling to refer you to another doctor for a second opinion is in violation of not only their ethics, but is also violating your personal rights. This is unacceptable, and is just one reason for reporting to the state credential body.  I cannot believe that there is not one doctor in your town that the chiropractor would be willing to refer you to for a second opinion. What is he hiding?...maybe the fact that he has been treating you for more than 19 months and you've never had any relief or improvement (sounds like incompetence).

In fact you are now worse!  If he didn't make you worse, then he is still guilty of malpractice because he watched you deteriorate and did nothing to help you. He continued to treat you while you showed no improvement, if not malpractice, then certainly neglect. His care is not helping, it hurts you, you now have difficulty walking, and problems with your bowels and bladder, but he continues to treat you every week and tells you that you are getting better.  This is complete bullshit, it's fraud.  No doctor should ever handle a patient this way.

Also you say that he has never checked your reflexes...WHAT?  This is a basic component of even the weakest examination process.  This guy should have been re-examining you every 10-15 visits with a full exam process to evaluate your progress or deterioration.  This should have included a history of the current symptoms and how they affect you in relation to the first examination, blood pressure, height, weight, range of motion of the low back and hips, provocative orthopedic tests in which the doctor moves your body in various positions and applies pressure looking for damaged tissue and decreased function, sensation to the lower legs should have been tested with a pinwheel + hot/cold + vibration, and lastly you should have been filling out pain/dysfunction questionnaires to check your progress (all good physicians utilize these types of questionnaires).  

Concerning the MRI, yes I think you need to get a new one to evaluate your condition, and no do not take it back to your old chiropractor.  He is obviously not capable of evaluating your condition, nor is he capable of treating it.  Any doctor can order an MRI (chiropractor, medical doctor, podiatrist, osteopath, even nurse practitioners and physician assistants frequently order them)  Just make sure that you see someone who specializes in the spine for the best results. (orthopedist, chiropractor).  I still think that you may receive benefit from chiropractic care, but you additionally need to be evaluated by a medical doctor as you may need a surgical resolution to this problem.  I would recommend a neurosurgeon or an orthopedic surgeon with a spine fellow to evaluate your current status.

Concerning chiropractic physicians, please do not think that what you have experienced is representative of my profession.  Your chiropractor has grossly mismanaged your care and I am disgusted by that.  His explanation of working through compensations is crap at best.  Yes the spine does have compensations, and will change in relation to altered biomechanical stress, but you don't "address the compensations".  You treat the patient for their current problem, and when that has resolved or been corrected then you evaluate them  for any additional problems and determine if the additional problems require active treatment.  

The fact that the cartilage in your hips has deteriorated while your chiropractor was only addressing your back for the problem is proof enough that he completely ignored the hip.  Fact: you were degenerating in the hip joint (proven with radiology studies), you had pain in the hip and a knee replacement, but the doctor kept telling you that it all was from the back and ignored the other anatomy.  If you came in my office with foot pain, I wouldn't be adjusting your back unless the examination of the foot was completely negative (absolutely no problem). Then if I found nerve encroachment in the back that I could reproduce upon functional testing, and x-rays or MRI validated my findings, I would address the low back for a radicular problem...and if you didn't get better in two weeks, even a little better, then I would re-evaluate, possibly order more diagnostic tests, or refer you to another doctor (probably medical) for their opinion...maybe I missed something.  That would be standard medical/chiropractic protocol for managing a patient appropriately.

Concerning the adjustments, I utilize manual manipulation the majority of the time...yes cracking occurs.  But I also use no thrusting types of adjustments with a drop table, an instrument, and very gentle manual mobilization with pressure.  It is not so much the type of treatment utilized as all patients require different things, but rather if it is effective or not.  Some patients do better with light techniques, other prefer and get better with more aggressive techniques.  You should always modify their technique to what the patient needs, not what the patient or the doctor prefers.

Last point, yes the L5 area of the spine can refer pain to the hip, but normally it does not.  If the nerve roots are encroached/pressed upon, then the pain goes down the back of the leg to the outside of the calf area, and some to the foot.  Again check out the dermatome chart web link that I provided in the last response.  It is possible to have pain described as sclerotomal which means diffuse and not in the nerve distribution, but there is normally associated muscle spasms with this that are easily detected and when myofacial work is performed and stability exercises, this pain will lessen and many times disappear.

Ok Sharri, hope this helps.  Please do not give up, and make sure that you follow through with care from a competent professional.  I am truly sorry you have had to deal with this for so long.

Respectfully,
Dr. J. Shawn Leatherman
www.suncoasthealthcare.net