Spinal Manipulation on someone with a partial sacralization of the L5 vertebrae

Spinal Manipulation on someone with a partial sacralization of the L5 vertebrae (Full Version)

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Alex Brenner PT MPT OCS -> Spinal Manipulation on someone with a partial sacralization of the L5 vertebrae (March 4, 2004 5:49:00 AM)
I was wondering what the thoughts were out there on manipulating someone with low back pain that has a partial sacralization of the L5 vertebrae? Our radiologist typically will read the x-ray as a normal variant if they mention it at all. I have talked with other providers including orthopaedic surgeons who call this phenomena a normal variant. I know that it occurs often, but it is hard for me to believe that it can not be a source of pain. I also would like to know if anyone has had success manipulating the lumbar spine or SI joints to treat this? How do the chiros out there feel about manipulating this? ArmyPT, OCS

Andrew M. Ball PT PhD -> Re: Spinal Manipulation on someone with a partial sacralization of the L5 vertebrae (March 4, 2004 6:27:00 AM)
You may want to ask this kind of question on Chiroweb.com --- but be aware that you're likely to get a slew of unprofessional anti-PT's-doing-manipulation-in-the-first-place before someone answers your question at face value. Not many of them have ever met a PT who does manipulation, so understand that the "shock" effect will take a little while to die down. As for me, if I can get positive results with something less than a grade V, I tend to go that way. While manipulation is legal in my state (provided MD orders --- although there is a push to simply place manipulation without orders squarely in PT practice here), any PT who uses it is likley to be a poster-child for political attack should the patient either be harmed, or perceive harm. In that vein, it's hard to answer your question without knowing more about the specific patient in terms of osteoporosis, fracture risk, etc. Drew [This message has been edited by Andrew M. Ball PT PhD (edited March 04, 2004).]

chiroortho -> Re: Spinal Manipulation on someone with a partial sacralization of the L5 vertebrae (March 4, 2004 2:49:00 PM)
Drew, I wish you'd go to chiroweb and see the answers that armypt got...he asked a good question as a gentleman and he got civil answers. Guys like armypt are welcome on DC forums anytime. If you don't look for trouble you probably won't get it. And if you get it anyway, ignore it. ------------------ ChiroOrtho

Barrett -> Re: Spinal Manipulation on someone with a partial sacralization of the L5 vertebrae (March 4, 2004 2:54:00 PM)
ArmyPT syas: "...but it is hard for me to believe that it can not be a source of pain." Why would this hurt at all, and if so, why not in everybody who has it?

chiroortho -> Re: Spinal Manipulation on someone with a partial sacralization of the L5 vertebrae (March 4, 2004 3:03:00 PM)
Barrett, Good question, and I agree with you. I've seen this type of incomplete segmentation many, many times on older patients that deny that they've had any prior history of LBP until the week before when they picked up the trash can, etc. Congenital anomalies are interesting, and the sacrum is the area of the spine at which anomalies are most common. As an aside, and for your consideration, I only very rarely use the terms "sacralization" or "lumbarization" anymore, choosing rather to call "it" a transitional lumbosacral vertebra. ------------------ ChiroOrtho

Shill -> Re: Spinal Manipulation on someone with a partial sacralization of the L5 vertebrae (March 4, 2004 3:26:00 PM)
Army, What is the intent behind manipulating this? Getting it to move better? Its partially fused. That isnt going to change. Typically, if it is partially fused on one side it is likely nearly fused on the other side as well, and likely that the level above it is the mobile and perhaps even the painful segment. The transverse processes and the iliolumbar ligamentous structures in these situations do not allow for much motion. I think you are beating a dead horse to try to mobilize or manipulate this type of situation. Go around it. (treat the other levels, if you like to manipulate things). Steve

mcap56 -> Re: Spinal Manipulation on someone with a partial sacralization of the L5 vertebrae (March 4, 2004 3:32:00 PM)
Where it has been studied, it has not been proven to be a source of LBP. Those patients with it did not report any more back pain than those without. Of course, those were just a few studies I came accross a while ago. Why is it so important to manipulate this patient in the first place. What do you hope to acheive??? cap

chiroortho -> Re: Spinal Manipulation on someone with a partial sacralization of the L5 vertebrae (March 4, 2004 3:40:00 PM)
Steve, Frequently one side will be fused either completely or via pseudarthrosis, while the other side will be essentially normal. And as to your question about why manipulate the area at all, you have asked the primary question that we who utilize manipulation must always ask...are we affecting the actual pain generator. I know that I have had many patients that have not responded to manip of area "X", but when I moved up or down a bit, voila. ------------------ ChiroOrtho [This message has been edited by chiroortho (edited March 04, 2004).]

Shill -> Re: Spinal Manipulation on someone with a partial sacralization of the L5 vertebrae (March 4, 2004 4:12:00 PM)
chiroortho, Do you have a good source for the information regarding the other side being normal? To me, it seems like it couldnt truly be normal, as there would not be much movement, the joint surface would sclerose, from lack of movement and nourishment, and eventually fuse far sooner than normal joints. But,... that is my honest guess, I have nothing to back it up. I do have a professor friend in the gross anatomy lab, I could check with him to see his thoughts, if interested...

chiroortho -> Re: Spinal Manipulation on someone with a partial sacralization of the L5 vertebrae (March 4, 2004 4:15:00 PM)
Steve, try this: Spine: Volume 26(2) 15 January 2001 pp 226-229 Partial Lumbosacral Transitional Vertebra Resection for Contralateral Facetogenic Pain Brault, Jeffrey S. DO; Smith, Jay MD; Currier, Bradford L. MD† From the Departments of *Physical Medicine and Rehabilitation and †Orthopedic Surgery, Spine Division, Mayo Clinic, Rochester, Minnesota. Acknowledgment date: October 13, 1999. First revision date: January 31, 2000. Acceptance date: March 21, 2000. Address reprint requests to Jay Smith, MD Mayo Clinic, E-10 200 2nd Street Rochester, MN 55905 Device status category: 1. Conflict of interest category: 12. Abstract Study Design. Case report of surgically treated mechanical low back pain from the facet joint contralateral to a unilateral anomalous lumbosacral articulation (Bertolotti's syndrome). Objectives. To describe the clinical presentation, diagnostic evaluation, and management of facet-related low back pain in a 17-year-old cheerleader and its successful surgical treatment with resection of a contralateral anomalous articulation. Summary of Background Data. Lumbosacral transitional vertebrae are common in the general population. Bertolotti's syndrome is mechanical low back pain associated with these transitional segments. Little is known about the pathophysiology and mechanics of these vertebral segments and their propensity to be pain generators. Treatment of this syndrome is controversial, and surgical intervention has been infrequently reported. Method. A retrospective chart analysis and radiographic review were performed. Results. Repeated fluoroscopically guided injections implicated a symptomatic L6-S1 facet joint contralateral to an anomalous lumbosacral articulation. Eventually, a successful surgical outcome was achieved with resection of the anomalous articulation. Conclusion. Clinicians should consider the possibility that mechanical low back pain may occur from a facet contralateral to a unilateral anomalous lumbosacral articulation, even in a young patient. Although reports of surgical treatment of Bertolotti's syndrome are infrequent, resection of the anomalous articulation provided excellent results in this patient, presumably because of reduced stresses on the symptomatic facet. © 2001 Lippincott Williams & Wilkins, Inc. ------------------ ChiroOrtho

Jeep -> Re: Spinal Manipulation on someone with a partial sacralization of the L5 vertebrae (March 4, 2004 5:13:00 PM)
[QUOTE]Originally posted by Barrett: ArmyPT syas: "...but it is hard for me to believe that it can not be a source of pain." Why would this hurt at all, and if so, why not in everybody who has it? [/QUOTE] For the same reason that not everyone with a disc bulge/herniation has pain, and the lesion is an incidental finding on a CT/MRI for something else.

Alex Brenner PT MPT OCS -> Re: Spinal Manipulation on someone with a partial sacralization of the L5 vertebrae (March 4, 2004 10:32:00 PM)
[QUOTE]Originally posted by Barrett: Why would this hurt at all, and if so, why not in everybody who has it? [/QUOTE] Barrett, I am not sure, but read below. The patient in question was a 19 year old basic trainee, no previous hx of low back pain. He was in the band in high school (Saxaphone) and never had problems. He is in good physical shape. He comes to Army basic training and after the third week he starts developing right sided low back pain. He is managed in physical therapy for 2 weeks but must continue to Army train. He is no better, no worse on 2 week follow up. On physical exam he has full AROM in all planes(pain to right L5-S1 and right PSIS regions only with forward flexion and when placed into a right quadrant position). Pelvic alignment all WNL. PA glides at the L5 vertebrae shows hypomobility and reproduction of the same pain. X-rays were ordered and show a unilateral sacrilazation of the right L5 transverse process. On film, the transverse process seems to form a joint on the right ilium, same level and area where he is hypomobile and where he points to his pain. To make a long story short, I manipulated his right SI joint (using same technique as seen in latest PT journal; Physical Therapy Vol 84 Number 2, Feb 04, Page 182). There was an audible cavitation and on immediate recheck of AROM he had pain-free flexion and was pain free when placed in the right quadrant position. I have not seen him back. I am not sure what I moved if anything. What are the thoughts on this? ArmyPT, OCS

Alex Brenner PT MPT OCS -> Re: Spinal Manipulation on someone with a partial sacralization of the L5 vertebrae (March 4, 2004 11:03:00 PM)
[QUOTE]Originally posted by mcap56: Why is it so important to manipulate this patient in the first place. What do you hope to acheive??? cap[/QUOTE] Mcap, Spinal manipulation is a treatment shown to be effective in acute low back pain (Flynn et al. Spine 2002;27:2835-2843. This soldier had acute low back pain and subsequently a transitional lumbar vertebrae or whatever you want to call it. What I want is to get this soldier better and back to training and to war without back pain. Also, I would like to see if anyone else has had success manipulating the lumbar spine on someone known to have this anomaly. Just my thoughts, ArmyPT,OCS

Barrett -> Re: Spinal Manipulation on someone with a partial sacralization of the L5 vertebrae (March 5, 2004 2:12:00 AM)
ArmyPT, I could say a great deal about this sort of approach to care, which seems to be simply a matter of reading something and then trying it to see if it "works" for you. The studies you refer to strike me as the end result of just caving to the possible complexity of the problem as suggested by the mountains of literature gone before and an ignorance of literature that might have been truly relevant. This thread doesn't have room for all that might be said, by me anyway. I think you got lucky. I manipulated thousands of people in the 70s because I was driven then by experiences like yours. I eventually concluded that my approach ignored too much of what we were learning about backache and neurogenic pain and that my method needed to change drastically. I haven't manipulated anybody since and no longer feel as if I'm trusting to luck when I coerce another in directions I'm unsure of with forces I can't really control and toward tissues that might not tolerate it.

Alex Brenner PT MPT OCS -> Re: Spinal Manipulation on someone with a partial sacralization of the L5 vertebrae (March 5, 2004 4:31:00 AM)
[QUOTE]Originally posted by Barrett: I think you got lucky. I manipulated thousands of people in the 70s because I was driven then by experiences like yours. I eventually concluded that my approach ignored too much of what we were learning about backache and neurogenic pain and that my method needed to change drastically. I haven't manipulated anybody since and no longer feel as if I'm trusting to luck when I coerce another in directions I'm unsure of with forces I can't really control and toward tissues that might not tolerate it.[/QUOTE] Barrett, I am not sure what to say. I feel I am successful in treating acute low back pain with manipulation. That of course is not all I do. I use manipulation as an adjunct to therapuetic exerise and other interventions. I did not read the above referenced article and decide to "try it". I was merely referring to an well written clinical trial that showed manipulation was effective in treating acute low back pain. I was trained in these manual techniques as a student (well before 2002 when the article came out) and then honed them in the clinic and through continuing education. Just my thoughts. ArmyPT, OCS

Alex Brenner PT MPT OCS -> Re: Spinal Manipulation on someone with a partial sacralization of the L5 vertebrae (March 5, 2004 4:33:00 AM)
Here are the lumbar films AP and lateral views if anyone is interested. [IMG]http://img28.photobucket.com/albums/v85/brennerak/AP.jpg[/IMG] [IMG]http://img28.photobucket.com/albums/v85/brennerak/lateral.jpg[/IMG]

Alex Brenner PT MPT OCS -> Re: Spinal Manipulation on someone with a partial sacralization of the L5 vertebrae (March 5, 2004 5:44:00 AM)
[QUOTE]Originally posted by SJBird5: My impression is that Flynn is very pro-manipulation. ArmyPT, if you are generally treating a younger population - and generally a healthy population, then I would expect those patients coming in with acute low back pain would lead you to perceive that you are successful. Doesn't most simple, acute low back pain self-resolve in a good 8-12 weeks without any interventions (when looking at studies with a control)? I'm using the term "acute" here to mean a recent onset of symptoms - not as some physicians will use it as a description of the intensity of pain.[/QUOTE] You are right about Dr. Flynn, in fact he was was one of my professors. When I see acute low back pain, I am meaning I see it either the day it happens or within 3-5 days from when the episode started. I would like to say I am successful in treating this type of low back pain with manipulation.

Shill -> Re: Spinal Manipulation on someone with a partial sacralization of the L5 vertebrae (March 5, 2004 1:54:00 PM)
ArmyPT, The fact that you were able to bring about a rapid change for the good in this soldier's complaints is worthy of praise. The technique is worthy of further review. It would also be nice to know how he is doing, RE: any long term continued relief. Im not necessarily a huge fan of manipulation, perhaps because I need more training on it, or because I think it is often over utilized by those who are skilled in it, but your rationale for doing it seems sound. A case study on this would be valuable, and spur the drive for more research. The latest JOSPT has a great review on how to go about this, though I imagine you already know. Also, You should be commended for remaining professional in the face of opinions offerred by the masses, when they tell you things like "you got lucky". What you got in this case, is a quick relief of symptoms, which is the goal of all therapists. Long term follow up would let you know how real the results are, but nevertheless, you got good results that ARE based on some research!! Nice job, Steve

Barrett -> Re: Spinal Manipulation on someone with a partial sacralization of the L5 vertebrae (March 5, 2004 3:11:00 PM)
Even your old professor will tell you that he's made people worse with manipulation and, if he continues to use it, will do so again. Given the nature of the structures potentially affected, the literally blind application of forceful passive movement and the possibility of anomalous anatomy impossible to see without dissection, manipulation remains a method of care with inherent problems many would rather ignore. I've heard several thousand patients tell me they were made worse by it and for the most part the manipulator remained completely unaware of this. When asked back in the 60s why he didn't throw passes the legendary football coach Woody Hayes said, "When you throw a pass three things can happen and two of them are bad." I think manipulation has a similar outcome, and when it "works" luck has more to do with it than thoughtful application of the knowledge we've gained about backache the past thirty years.

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