Manipulation or microdiskectomy for sciatica? A prospective randomized clinical study.

OBJECTIVE: The purpose of this study was to compare the clinical efficacy of spinal manipulation against microdiskectomy in patients with sciatica secondary to lumbar disk herniation (LDH). METHODS: One hundred twenty patients presenting through elective referral by primary care physicians to neurosurgical spine surgeons were consecutively screened for symptoms of unilateral lumbar radiculopathy secondary to LDH at L3-4, L4-5, or L5-S1. Forty consecutive consenting patients who met inclusion criteria (patients must have failed at least 3 months of nonoperative management including treatment with analgesics, lifestyle modification, physiotherapy, massage therapy, and/or acupuncture) were randomized to either surgical microdiskectomy or standardized chiropractic spinal manipulation. Crossover to the alternate treatment was allowed after 3 months. RESULTS: Significant improvement in both treatment groups compared to baseline scores over time was observed in all outcome measures. After 1 year, follow-up intent-to-treat analysis did not reveal a difference in outcome based on the original treatment received. However, 3 patients crossed over from surgery to spinal manipulation and failed to gain further improvement. Eight patients crossed from spinal manipulation to surgery and improved to the same degree as their primary surgical counterparts. CONCLUSIONS: Sixty percent of patients with sciatica who had failed other medical management benefited from spinal manipulation to the same degree as if they underwent surgical intervention. Of 40% left unsatisfied, subsequent surgical intervention confers excellent outcome. Patients with symptomatic LDH failing medical management should consider spinal manipulation followed by surgery if warranted.

Short-term effects of spinal manipulation on H-reflex amplitude in healthy and symptomatic subjects.

OBJECTIVES: The purpose of this study is to assess Hoffman (H) reflex after spinal manipulation (1) as a function of experimental position in healthy subjects and (2) in patients with low back pain. METHODS: An intervention study was performed to evaluate the effects of sacroiliac (SI) joint manipulation on motoneuron excitability, as measured by the H-reflex. Manual treatment of the SI joint was performed. Hoffman reflex amplitudes before and after SI joint manipulations were measured with subjects lying on the right side (n = 12 healthy subject) or with subjects lying supine (n = 5 healthy subjects), which required turning of subjects onto their sides for SI joint manipulation. Hoffman reflex amplitudes were also measured in 15 patients with low back pain. RESULTS: No significant changes in H-reflex amplitude in healthy subjects receiving manipulation to the SI joint were observed, provided that H-reflex testing and treatments were performed in the same position, that is, the subject was not moved during the experimental procedure. However, changes in motoneuron excitability after SI joint manipulation were observed in patients with low back pain. CONCLUSIONS: It appears that H-reflex responses after spinal manipulation are sensitive to movement/repositioning, and that the H-reflex depressions after manipulation documented in previous studies were movement artifacts rather than treatment effects. The relationship between etiology of low back pain and changes in H-reflex amplitude after spinal manipulation is not clear and needs further investigation.

Decrease in elbow flexor inhibition after cervical spine manipulation in patients with chronic neck pain.

OBJECTIVE: This study measured functional capacity and subjective pain in patients with chronic neck pain before and after manipulation of the cervical spine. DESIGN: Outcomes study on 16 patients with chronic neck pain. BACKGROUND: Muscle inhibition, i.e., the inability to fully activate a muscle, has been observed following joint pathologies and in low back pain conditions. Although chronic neck pain has been associated with changes in muscle recruitment and coordination in the shoulder and arms, the possibility of muscle inhibition has not been explored. METHODS: Biceps activation during a maximal voluntary elbow flexor contraction was assessed using the interpolated twitch technique and electromyography. Cervical range of motion and pressure pain thresholds were measured using a goniometer and an algometer. Manipulation of the cervical spine was applied at the level of C5/6/7, and functional assessments were repeated. RESULTS: Patients showed significant inhibition in their biceps muscles. Cervical range of motion was restricted laterally, and increased pressure pain sensitivity was evident. After cervical spine manipulation, a significant reduction in biceps inhibition and an increase in biceps force occurred. Cervical range of motion and pressure pain thresholds increased significantly. CONCLUSIONS: Significant dysfunction in biceps activation was evident in patients with chronic neck pain, indicating that this muscle group cannot be used to the full extent. Spinal manipulation decreased muscle inhibition and increased elbow flexor strength at least in the short term. RELEVANCE: Muscle inhibition in the biceps has not been previously documented in patients with chronic neck pain. Further research is needed to establish whether muscle inhibition is related to clinical symptoms and functional outcome. Spinal manipulation improved muscle function, cervical range of motion and pain sensitivity, and might therefore be beneficial for treating patients with chronic neck pain.