What is Spinal Disc Decompression
What is Spinal Decompression?
By Thomas A. Gionis, MD, JD, MBA, MHA, FICS, FRCS, and Eric Groteke, DC, CCIC
The outcome of a clinical study evaluating the effect of nonsurgical intervention
on symptoms of spine patients with herniated and degenerative disc disease
is presented.
This clinical outcomes study was performed to evaluate the
effect of spinal decompression on symptoms and physical findings of patients
with herniated and degenerative disc disease. Results showed that 86% of the
219 patients who completed the therapy reported immediate resolution of symptoms,
while 84% remained pain-free 90 days post-treatment. Physical examination findings
showed improvement in 92% of the 219 patients, and remained intact in 89% of
these patients 90 days after treatment. This study shows that disc disease—the
most common cause of back pain, which costs the American health care system
more than $50 billion annually—can be cost-effectively treated using
spinal decompression. The cost for successful non-surgical therapy is less
than a tenth of that for surgery. These results show that biotechnological
advances of spinal decompression reveal promising results for the future of
effective management of patients with disc herniation and degenerative disc
diseases. Long-term outcome studies are needed to determine if non-surgical
treatment prevents later surgery, or merely delays it.
INTRODUCTION: ADVANCES IN BIOTECHNOLOGY
With
the recent advances in biotechnology, spinal decompression has evolved into
a cost-effective nonsurgical treatment for herniated and degenerative spinal
disc disease, one of the major causes of back pain. This nonsurgical treatment
for herniated and degenerative spinal disc disease works on the affected spinal
segment by significantly reducing intradiscal pressures.1 Chronic low back
pain disability is the most expensive benign condition that is medically treated
in industrial countries. It is also the number one cause of disability in persons
under age 45. After 45, it is the third leading cause of disability.2 Disc
disease costs the health care system more than $50 billion a year.
The intervertebral disc is made up of sheets of fibers that form a fibrocartilaginous
structure, which encapsulates the inner mucopolysaccharide gel nucleus. The
outer wall and gel act hydrodynamically. The intrinsic pressure of the fluid
within the semirigid enclosed outer wall allows hydrodynamic activity, making
the intervertebral disc a mechanical structure.3 As a person utilizes various
normal ranges of motion, spinal discs deform as a result of pressure changes
within the disc.4 The disc deforms, causing nuclear migration and elongation
of annular fibers. Osteophytes develop along the junction of vertebral bodies
and discs, causing a disease known as spondylosis. This disc narrows from the
alteration of the nucleus pulposus, which changes from a gelatinous consistency
to a more fibrous nature as the aging process continues. The disc space thins
with sclerosis of the cartilaginous end plates and new bone formation around
the periphery of the contiguous vertebral surfaces. The altered mechanics place
stress on the posterior diarthrodial joints, causing them to lose their normal
nuclear fulcrum for movement. With the loss of disc space, the plane of articulation
of the facet surface is no longer congruous. This stress results in degenerative
arthritis of the articular surfaces.
This is especially important in occupational repetitive injuries, which make
up a majority of work-related injuries. When disc degeneration occurs, the
layers of the annulus can separate in places and form circumferential tears.
Several of these circumferential tears may unite and result in a radial tear
where the material may herniate to produce disc herniation or prolapse. Even
though a disc herniation may not occur, the annulus produces weakening, circumferential
bulging, and loss of intervertebral disc height. As a result, discograms at
this stage usually reveal reduced interdiscal pressure.
The early changes that have been identified in the nucleus pulposus and annulus
fibrosis are probably biomechanical and relate to aging. Any additional trauma
on these changes can speed up the process of degeneration. When there is a
discogenic injury, physical displacement occurs, as well as tissue edema and
muscle spasm, which increase the intradiscal pressures and restrict fluid migration.6
Additionally, compression injuries causing an endplate fracture can predispose
the disc to degeneration in the future.
The alteration of normal kinetics is the most prevalent cause of lower back
pain and disc disruption and thus it is vital to maintain homeostasis in and
around the spinal disc; Yong-Hing and Kirkaldy-Willis7 have correlated this
degeneration to clinical symptoms. The three clinical stages of spinal degeneration
include:
Stage of Dysfunction. There is little pathology and symptoms are subtle or
absent. The diagnosis of Lumbalgia and rotatory strain are commonly used.
Stage of Instability. Abnormal movement of the motion segment of instability
exists and the patient complains of moderate symptoms with objective findings.
Conservative care is used and sometimes surgery is indicated.
Stage of Stabilization. The third phase where there are severe degenerative
changes of the disc and facets reduce motion with likely stenosis.
Spinal decompression has been shown to decompress the disc space, and in the
clinical picture of low back pain is distinguishable from conventional spinal
traction.8,9 According to the literature, traditional traction has proven to
be less effective and biomechanically inadequate to produce optimal therapeutic
results.8-11 In fact, one study by Mangion et al concluded that any benefit
derived from continuous traction devices was due to enforced immobilization
rather than actual traction.10 In another study, Weber compared patients treated
with traction to a control group that had simulated traction and demonstrated
no significant differences.11 Research confirms that traditional traction does
not produce spinal decompression. Instead, decompression, that is, unloading
due to distraction and positioning of the intervertebral discs and facet joints
of the lumbar spine, has been proven an effective treatment for herniated and
degenerative disc disease, by producing and sustaining negative intradiscal
pressure in the disc space. In agreement with Nachemon’s findings and
Yong-Hing and Kirkaldy-Willis,1 spinal decompression treatment for low back
pain intervenes in the natural history of spinal degeneration.7,12 Matthews13
used epidurography to study patients thought to have lumbar disc protrusion.
With applied forces of 120 pounds x 20 minutes, he was able to demonstrate
that the contrast material was drawn into the disc spaces by osmotic changes.
Goldfish14 speculates that the degenerated disc may benefit by lowering intradiscal
pressure, affecting the nutritional state of the nucleus pulposus. Ramos and
Martin8 showed by precisely directed distraction forces, intradiscal pressure
could dramatically drop into a negative range. A study by Onel et al15 reported
the positive effects of distraction on the disc with contour changes by computed
tomography imaging. High intradiscal pressures associated with both herniated
and degenerated discs interfere with the restoration of homeostasis and repair
of injured tissue.
Biotechnological advances have fostered the design of Food and Drug Administration-approved
ergonomic devices that decompress the intervertebral discs. The biomechanics
of these decompression/reduction machines work by decompression at the specific
disc level that is diagnosed from finding on a comprehensive physical examination
and the appropriate diagnostic imaging studies. The angle of decompression
to the affected level causes a negative pressure intradiscally that creates
an osmotic pressure gradient for nutrients, water, and blood to flow into the
degenerated and/or herniated disc thereby allowing the phases of healing to
take place.
This clinical outcomes study, which was performed to evaluate the effect of
spinal decompression on symptoms of patients with herniated and degenerative
disc disease, showed that 86% of the 219 patients who completed therapy reported
immediate resolution of symptoms, and 84% of those remained pain-free 90 days
post-treatment. Physical examination findings revealed improvement in 92% of
the 219 patients who completed the therapy.
METHODS
The study group included 229 people, randomly chosen from 500 patients who
had symptoms associated with herniated and degenerative disc disease that had
been ongoing for at least 4 weeks. Inclusion criteria included pain due to
herniated and bulging lumbar discs that is more than 4 weeks old, or persistent
pain from degenerated discs not responding to 4 weeks of conservative therapy.
All patients had to be available for 4 weeks of treatment protocol, be at least
18 years of age, and have an MRI within 6 months. Those patients who had previous
back surgery were excluded. Of note, 73 of the patients had experienced one
to three epidural injections prior to this episode of back pain and 22 of those
patients had epidurals for their current condition. Measurements were taken
before the treatments began and again at week two, four, six, and 90 days post
treatment. At each testing point a questionnaire and physical examination were
performed without prior documentation present in order to avoid bias. Testing
included the Oswetry questionnaire, which was utilized to quantify information
related to measurement of symptoms and functional status. Ten categories of
questions about everyday activities were asked prior to the first session and
again after treatment and 30 days following the last treatment.
Testing also consisted of a modified physical examination, including evaluation
of reflexes (normal, sluggish, or absent), gait evaluation, the presence of
kyphosis, and a straight leg raising test (radiating pain into the lower back
and leg was categorized when raising the leg over 30 degrees or less is considered
positive, but if pain remained isolated in the lower back, it was considered
negative). Lumbar range of motion was measured with an ergonometer. Limitations
ranging from normal to over 15 degrees in flexion and over 10 degrees in rotation
and extension were positive findings. The investigator used pinprick and soft
touch to determine the presence of gross sensory deficit in the lower extremities.
Of the 229 patients selected, only 10 patients did not complete the treatment
protocol. Reasons for noncompletion included transportation issues, family
emergencies, scheduling conflicts, lack of motivation, and transient discomfort.
The patient protocol provided for 20 treatments of spinal decompression over
a 6-week course of therapy. Each session consisted of a 45-minute treatment
on the equipment followed by 15 minutes of ice and interferential frequency
therapy to consolidate the lumbar paravertebral muscles. The patient regimen
included 2 weeks of daily spinal decompression treatment (5 days per week),
followed by three sessions per week for 2 weeks, concluding with two sessions
per week for the remaining 2 weeks of therapy
On the first day of treatment, the applied pressure was measured as one half
of the person’s body weight minus 10 pounds, followed on the second day
with one half of the person’s body weight. The pressure placed for the
remainder of the 18 sessions was equivalent to one half of the patient’s
body weight plus an additional 10 pounds. The angle of treatment was set according
to manufacturer’s protocol after identifying a specific lumbar disc correlated
with MRI findings. A session would begin with the patient being fitted with
a customized lower and upper harness to fit their specific body frame. The
patient would step onto a platform located at the base of the equipment, which
simultaneously calculated body weight and determined proper treatment pressure.
The patient was then lowered into the supine position, where the investigator
would align the split of table with the top of the patient’s iliac crest.
A pneumatic air pump was used to automatically increase lordosis of the lumbar
spine for patient comfort. The patient’s chest harness was attached and
tightened to the table. An automatic shoulder support system tightened and
affixed the patient’s upper body. A knee pillow was placed to maintain
slight flexion of the knees. With use of the previously calculated treatment
pressures, spinal decompression was then applied. After treatment, the patient
received 15 minutes of interferential frequency (80 to 120 Hz) therapy and
cold packs to consolidate paravertebral muscles.
During the initial 2 weeks of treatment, the patients were instructed to wear
lumbar support belts and limit activities, and were placed on light duty at
work. In addition, they were prescribed a nonsteroidal, to be taken 1 hour
before therapy and at bedtime during the first 2 weeks of treatment. After
the second week of treatment, medication was decreased and moderate activity
was permitted.
Data was collected from 219 patients treated during this clinical study. Study
demographics consisted of 79 female and 140 male patients. The patients treated
ranged from 24 to 74 years of age (see Table 1). The average weight of the
females was 146 pounds and the average weight of the men was 195 pounds. According
to the Oswestry Pain Scale, patients reported their symptoms ranging from no
pain (0) to severe pain (5).
PATIENT GROUPS
The patients were further subdivided into six groups:
single lateral herniation 67 cases
single central herniation 22 cases
single lateral herniation
with disc degeneration 32 cases
single central herniation
with disc degeneration. 24 cases
more than 1 herniation
with disc degeneration 17 cases
more than 1 herniation
without disc degeneration 57 cases
RESULTS
According to the self-rated Oswestry Pain Scale, treatment was successful
in 86% of the 219 patients included in this study (Table 2, page 39). Treatment
success was defined by a reduction in pain to 0 or 1 on the pain scale. The
perception of pain was none 0 to occasional 1 without any further need for
medication or treatment in 188 patients. These patients reported complete resolution
of pain, lumbar range of motion was normalized, and there was recovery of any
sensory or motor loss. The remaining 31 patients reported significant pain
and disability, despite some improvement in their overall pain and disability
score.
Diagnosis MRI
Results on self-rated Oswestry Pain Scale after treatment.
In this study, only patients diagnosed with herniated and degenerative discs
with at least a 4-week onset were eligible. Each patient’s diagnosis
was confirmed by MRI findings. All selected patients reported 3 to 5 on the
pain scale with radiating neuritis into the lower extremities. By the second
week of treatment, 77% of patients had a greater than 50% resolution of low
back pain. Subsequent orthopedic examinations demonstrated that an increase
in spinal range of motion directly correlated with an improvement in straight
leg raises and reflex response. Table 2 shows a summary of the subjective
findings obtained during this study by category and total results post treatment.
After 90 days, only five patients (2%) were found to have relapsed from the
initial treatment program.
Percentage of patients that had improved physical exam findings post treatment.
Ninety-two percent of patients with abnormal physical findings improved post-treatment.
Ninety days later only 3% of these patients had abnormal findings. Table
3 summarizes the percentage of patients that showed improvement in physician
examination findings testing both motor and sensory system function after
treatment. Gait improved in 96% of the individuals who started with an abnormal
gait, while 96% of those with sluggish reflexes normalized. Sensory perception
improved in 93% of the patients, motor limitation diminished in 86%, 89%
had a normal straight leg raise test who initially tested abnormal, and 90%
showed improvement in their spinal range of motion.
SUMMARY
In conclusion, nonsurgical spinal decompression provides a method for physicians
to properly apply and direct the decompressive force necessary to effectively
treat discogenic disease. With the biotechnological advances of spinal decompression,
symptoms were restored by subjective report in 86% of patients previously thought
to be surgical candidates and mechanical function was restored in 92% using
objective data. Ninety days after treatment only 2% reported pain and 3% relapsed,
by physical examination exhibiting motor limitations and decreased spinal range
of motion. Our results indicate that in treating 219 patients with MRI-documented
disc herniation and degenerative disc diseases, treatment was successful as
defined by: pain reduction; reduction in use of pain medications; normalization
of range of motion, reflex, and gait; and recovery of sensory or motor loss.
Biotechnological advances of spinal decompression indeed reveal promising results
for the future of effective management of patients with disc herniation and
degenerative disc diseases. The cost for successful nonsurgical therapy is
less than a tenth of that for surgery. Long-term outcome studies are needed
to determine if nonsurgical treatment prevents later surgery or merely delays
it.
Thomas A. Gionis, MD, JD, MBA, MHA, FICS, FRCS, is chairman of the American
Board of Healthcare Law and Medicine, Chicago; a diplomate professor of surgery,
American Academy of Neurological and Orthopaedic Surgeons; and a fellow of
the International College of Surgeons and the Royal College of Surgeons.
Eric Groteke, DC, CCIC, is a chiropractor and is certified in manipulation
under anesthesia. He is also a chiropractic insurance consultant, a certified
independent chiropractic examiner, and a certified chiropractic insurance consultant.
Groteke maintains chiropractic centers in northeastern Pennsylvania, in Stroudsburg,
Scranton, and Wilkes-Barre.
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McDevitt C. Proteoglycans of the intervertebral disc. In: Gosh, P, ed. The
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Bogduk N, Twomey L. Clinical Anatomy of the Lumbar Spine. New York: Churchill
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