In Part II, Dr. James Cox shares a number of the better studies he uses to show how chiropractic can be of value in treating stenosis and sciatica. Dr. Don Aspegren discusses how the literature helps create a level playing field with medical doctors.
James Cox, DC, DACBR, is the originator of the Cox flexion-distraction technique. He is an internationally recognized author, lecturer, and clinical researcher on chiropractic protocols related to biomechanics, diagnosis, and treatment of spine pain. He specializes in treating radiculopathies in Ft. Wayne, Indiana.
Don Aspegren, DC, MS, is on staff at a hospital--Exempla Lutheran Medical Center in Denver, Colorado. He was Dr. Cox's resident for two years.
Radicular Signs/Symptoms Point to Mechanical Compression
Dr. James Cox says Takahashi's study on the connection between radicular pain and mechanical compression is of value to field practitioners. As nerve root pressure increased, the study found, so did patients' neurological deficits:
* 10 mm of pressure=circulation reduced, nutrition impaired
* 20 mm of pressure=numbness down the
* 41 mm of pressure=patient can stand upright despite leg pain
* 50-75 mm of pressure=nerve function altered
* 53 mm of pressure=faverage amount of pressure from a disc hernia measured at the time of surgery)
* 60 mm of pressure=neurologic deficits seen as motor weakness, loss of reflexes
* 82 mm of pressure=patient can no longer stand upright
* 104-256 mm of pressure=paralysis, foot drop
1. Takahashi K, Shima I, Porter RW. Nerve root pressure in lumbar disc herniation. Spine (Phila Pa 1976). 1999 Oct 1; 24(19):2003-2006.
The importance of this scale, says Dr. Cox, lies in DCs' ability to recognize changes as the result of treatment. "We know by the millimeters of pressure on the nerve how it matches the patient's signs and symptoms. Some patients will be leaning to one side when they first come in. Two weeks later, if they're standing up straight, we know the pressure is diminishing on that nerve--it's mechanical. When we correlate that type of knowledge with our clinical practice, we begin to appreciate what's going on inside the spine."
Chemical, Nonchemical Radicular Pain Sources
"Some authors," says Dr. Cox, "think that chemical inflammation of the dorsal root ganglion and the nerve root is a great cause of radicular pain." For further discussion of chemical inflammation of disc and neural intermediates, see:
2. Cox JM. Low Back Pain: Mechanism, Diagnosis, Treatment. 7th ed. Lombard, IL. Lippincott, Williams & Wilkins. 2011. P. 129
"The first change in disc degeneration is a circumferential tear where the outer layers of the annulus disc begin to split apart, often caused by rotational movement--bending, twisting, lifting. A circumferential and radial tear of the annular fibers of the disc will produce inflammatory change that produces chemical inflammation of the disc, resulting in discogenic pain.
3. Kandel ER, Schwartz JH, Jessell TM. Principles of Neural Science. Norwalk, CT: Appleton & Lange, 3rd edition. 1996.
4. Hickey D, Hukins D: Relation between the structure of the annulus fibrosus and the function and failure of the interevertebral disc. Spine 1980; 5(2):106-16.
Dr. Cox says the "high-intensity zone" is a term coined by radiologist Michael...