Friday, September 28, 2018 9:00 AM–10:00 AM best papers Friday: 148. Biological and clinical outcomes of chiropractic spinal manipulative therapy in the treatment of patients with acute inflammatory radiculopathy secondary to lumbar disc herniation: a pilot study

Abstract

BACKGROUND CONTEXT Acute sciatica secondary to lumbar disc herniation (AS/LDH) is thought to be caused by mechanical compression of the spinal nerve root and/or chemical inflammatory mechanisms involving pro-inflammatory cytokines (IC) such as interleukin (IL)-1α, IL-8and tumor necrosis factor (TNF)-α). Although chiropractic high velocity low amplitude (HVLA) spinal manipulative therapy (CSMT) is commonly used to treat AS/LDH patients, randomized controlled studies demonstrating efficacy have not been carried out to date. In addition, preliminary studies have reported decreases in serum ICs following CSMT. PURPOSE To evaluate the feasibility of conducting a randomized controlled trial (RCT) of the clinical and biological effects of chiropractic spinal manipulative therapy (CSMT) on in vivo IC expression and clinical outcomes in patients with acute sciatica and lumbosacral disc herniation (AS/LDH). STUDY DESIGN/SETTING Randomized controlled clinical trial. Enzyme linked immunosorbent assay (ELISA) of serum and disc tissue inflammatory cytokine content. PATIENT SAMPLE Inclusion: AS/LDH ofless than 6 months’ duration with a McCulloch criteria score of 5/5. Exclusion: red flag condition, cauda equina syndrome, progressive neurological deficit. OUTCOME MEASURES VAS and Roland Morris Disability scores and serum IC levels at baseline, 6, 12 and 24 weeks. Physical examination findings of nerve root tension signs, motor and sensory spinal nerve root deficit and Schober's test of lumbar flexion recorded at all data collection points. IC levels measured by ELISA in disc tissue, nerve root and disc lavagate collected in patients undergoing surgery. METHODS Patients with AS/LDH of less than 16 weeks duration were randomized to 6 weeks of CSMT or the approximately 6 weeks surgical wait list. Standardized neurological and lumbar spine examinations, VAS and Roland Morris Disability scores, and serum IC levels were assessed at baseline, 6, 12 and 24 weeks. ICs were also measured in disc tissue, nerve root and disc lavagate collected during surgery. Research ethics approval was obtained. RESULTS A total of 40 of 44 (91%) invited patients participated and were randomized. A total of 13 patients avoided surgery. Post-CSMT improvement was associated with longer duration of sciatica, absence of cross-over sign and motor deficit, reduced lumbar flexion increment and lower IC levels at baseline. CONCLUSIONS It appears feasibleto conduct a RCT with patients randomized to CSMT or a waitlist control group. There may be a sub-group of AS/LDH patients who will significantly benefit from HVLA CSMT. A large scale clinical trial is now required to test this preliminary finding.