Case of the Week 5-20-13: Lumbar Disc Replacement Intervention! | Modern Manual Therapy Blog

Case of the Week 5-20-13: Lumbar Disc Replacement Intervention!

image courtesy of Science Direct
An intern who just graduated asked me what I thought about disc replacement surgery. His grandmother was scheduled for lumbar disc replacement and he wanted her to try our practice.

She had been seeing her chiropractor regularly for 50 years, and tried PT for 10 weeks. Either one may as well been the same, because neither helped her. Here is what we did. Her grandson scheduled her for a cervical evaluation as she also had chronic neck pain, but did not feel hopeless about that.

I booked her for a full 1 hour consultation and had another intern start her history of her cervical spine. After finishing with another patient, I jumped in and said, "Excuse me, Miss, but you are not here for your neck." I proceeded to educate her on the following points

  • there are only a handful of sizes of disc replacements, but are there only a handful of sizes of people?
    • chances are the disc may be too small - which leads to future fusion
    • either way, some studies show greater than 50% need a spinal fusion, which also has a 40-60% failure rate
    • success of that surgery is often defined as the patient is still alive and the hardware was not rejected
    • if you're feeling better, the surgeon takes the credit, if you're not, they say it takes 1-2 years to fully recover
  • she kept asking about the degeneration and decreased spaced, etc... on the left side
    • I asked her if the left side of her back was older than the right side
  • I told her when the symptoms worsened in the past few years, a day before the onset, her MRI would have looked the same
Then I proceeded with education about thought viruses... etc, which took about 20-30 minutes prior to objective measures. Baseline prior to MDT examination was constant lumbar and radiating left  LE pain to below the knee, worse in standing and walking. First movement to look at was sidegliding in standing to the left (involved side - meaning shoulders left, hips right). This was very limited compared to SGIS to the right, which was full, but increased left LE pain. 

Repeated sidegliding in standing to the left peripheralized left LE pain, and remained worse as a result. She guarded during each passive overpressure. So I decided to try a lumbar rotation in flexion (lumbar roll) with left side loading (bottom side). This decreased her lumbar pain and LE pain. I had her breathe diaphragmatically, which she was excellent at! I lightly guided her right knee down to the table and told her to periodically rotate her trunk backward to the table (rotate right). After about 10 minutes, her right knee was touching the table and her right scapula was almost there! Very spry! Her LE and lumbar pain were completely gone. 

Next up - the best functional test after MDT centralizes/abolishes pain... WALKING! She rolled off of the table, and immediately had improvement in gait. It was no longer antalgic, she was walking faster and more upright. She said "Do you see how well I'm walking now?" We all did! We had her walk on/off for about 5 minutes. The Sx remained gone. SGIS to the left was tried again, but this brought back her LE complaints. Another 4-5 minutes in rotation in flexion loading on the left and she was completely pain free. We instructed this for HEP. Take home messages
  • cancel your surgery, she was anxious about this, but we reassured her that she could always schedule another one 
    • it was cancelled 5 days later
  • keep performing this exercise several times/day and hold for 5-10 minutes
  • apologize to your grandson as he was right
As a bonus, my intern finished her cervical exam/treat which was also just as simple. Involved left side (pain and limited). Right sidebending was full. Repeated cervical retraction with sidebending overpressure to the left abolished her cervical pain.

30+ years of pain that just required a bit of loading and a lot education. She is in the capable hands of her grandson but I would be happy to see her again. Last week he said she was doing fine and very happy. The bottom line is that, like many individuals, she falls into the 87% the meet the rapid responding category.


  1. Hello, what is that overpressure you are talking about? Axial Joint Compression through the spine or ist it more a corrective pressure like hte Mulligan Technique?

  2. Just wondering why you went straight to sgis instead of sagittal plane mvts first? Thanks

  3. It's passive pressure into the end range, just the extra bit of joint play everyone has passively versus active. It's not HARD it's far, some people thing it's forceful but it shouldn't be.

  4. Sagittal plane is taught in the early MDT Courses, once you've seen some faculty practice in CSU updates or trained some Diplomats like I have in fellowship, you see that they often go to the frontal plane for unilateral pain because it's a loading issue to the painful side. It's for the same reason why someone with LBP flexes constantly to stretch, but needs to load into extension. Someone with L LBP and L LE pain often "stretches" repeatedly to the right but does not load to the ipsilateral side.

  5. Great case study! Good to see anytime surgery can be avoided when pts feel that is the only option. Will share

  6. Hi! i'm having a hard time understanding the exercise that you performed with her. Any chance pictures or a video can be posted?

  7. It's a simple lumbar rotation in sidelying. Similar to a manipulation position but with the involved side down. This is to load it opposed to stretching it as many traditional manual therapies do