Roger Wilhelm, D.C.

The bulging disc and the protruded disc are the categories most often seen in chiropractic clinical practice. The category and magnitude of disc herniations can only be determined by advanced imaging, especially MRI and/or CT.

Effectiveness

There is a long and rich history showing the effectiveness of spinal manipulation for the management of low back and leg pain (radiculopathy), briefly reviewed below:

••••

In 1954, RH Ramsey, MD, published a study titled (1):

Conservative Treatment of Intervertebral Disk Lesions

This study appeared in the Instructional Course Lectures of the American Academy of Orthopedic Surgeons. Dr. Ramsey states:

“The conservative management of lumbar disk lesions should be given careful consideration because no patient should be considered for surgical treatment without first having failed to respond to an adequate program of conservative treatment.”

“From what is known about the pathology of lumbar disk lesions, it would seem that the ideal form of conservative treatment would theoretically be a manipulative closed reduction of the displaced disk material.”

“Many forms of manipulation are carried out by orthopaedic surgeons and by cultists and this form of treatment will probably always be a controversial one.”

“The patient lies on his side on the edge of the table facing the surgeon and the leg that is up is allowed to drop over the side of the table, tending to swing the up-side of the pelvis forward. The arm that is up is allowed to drop back behind the patient, tending to pull the shoulder back. The surgeon then places one hand on the patient’s shoulder and his opposite forearm on the patient’s iliac crest. Simultaneously, the shoulder is thrust suddenly back, rotating the torso in one direction while the iliac crest is thrust down and forward, rotating the pelvis in the opposite direction. This gives the lumbar spine a twist that frequently causes an audible and palpable crunch. This procedure is then repeated with the patient on his other side. The patient is then turned on his back and his hips and knees are hyperflexed sufficiently to forcibly flex the lumbar spine which tends to open up the disk spaces posteriorly.”

••••

In 1969, physicians JA Mathews and DAH Yates from the Department of Physical Medicine, St. Thomas’ Hospital, London, published a study titled (2):

Reduction of Lumbar Disc Prolapse by Manipulation

The authors evaluated a number of patients that presented with an acute onset of low back pain and radiculopathy that did not respond to rest. Diagnostic epidurography showed clinically relevant small disc protrusions with antalgia and positive lumbar spine nerve stretch tests. These patients were then treated with long-lever rotation manipulations of the lumbar spine. The manipulations were repeated until abnormal symptoms and signs had disappeared. Following the manipulations there was resolution of signs, symptoms, antalgia, and reduction in the size of the protrusions. Drs. Mathews and Yates state:

“The frequent accompaniment of acute onset low back pain by spinal deformity suggests a mechanical factor, and the accompanying abnormality of straight-leg raise or femoral stretch test suggests that the lesion impinges on the spinal dura matter of the dural nerve sheaths.”

“Rotation manipulations apply torsion stress throughout the lumbar spine. If the posterior longitudinal ligament and the annulus fibrosus are intact, some of this torsion force would tend to exert a centripetal force, reducing prolapsed or bulging disc material.” 

“The results of this study suggest that small disc protrusions were present in patients presenting with lumbago and that the protrusions were diminished in size when their symptoms had been relieved by manipulations.”

These authors conclude: “it seems likely that the reduction effect [of the disc protrusion] is due to the manipulating thrust used.”

••••

In another study from 1969, BC Edwards compared the effectiveness of heat/massage/exercise to spinal manipulation in the treatment of 184 patients that were grouped according to the presentation of back and leg pain. The study was published in the Australian Journal of Physiotherapy (3). This study was reviewed by Augustus White, MD, and Manohar Panjabi, PhD, in their 1990 book, Clinical Biomechanics of the Spine (4). Drs. White and Panjabi make the following points pertaining to the Edwards article:

“A well-designed, well executed, and well-analyzed study.”

In the group with pain radiating into the buttock, “the results were slightly better with manipulation, and again they were achieved with about half as many treatments.”

In the groups with pain radiation to the knee and/or to the foot, “the manipulation therapy was statistically significantly better,” and in the group with pain radiating to the foot, “the manipulative therapy is significantly better.”

“This study certainly supports the efficacy of spinal manipulative therapy in comparison with heat, massage, and exercise. The results (80 – 95% satisfactory) are impressive in comparison with any form of therapy.”

••••

In 1977, the third edition of Orthopaedics, Principles and Their Applications was published (5). It contains a section titled:

Treatment of Intervertebral Disc Herniation With Manipulation

“Manipulation. Some orthopaedic surgeons practice manipulation in an effort at repositioning the disc. This treatment is regarded as controversial and a form of quackery by many men.  However, the author has attempted the maneuver in patients who did not respond to bed rest and were regarded as candidates for surgery. Occasionally, the results were dramatic.

Technique. The patient lies on his side on the edge of the table facing the surgeon, and the uppermost leg is allowed to drop forward over the edge of the table, carrying forward that side of the pelvis.  The uppermost arm is placed backward behind the patient, pulling the shoulder back.  The surgeon places one hand on the shoulder and the other on the iliac crest and twists the torso by pushing the shoulder backward and the iliac crest forward.  The maneuver is sudden and forceful and frequently is associated with an audible and palpable crunching sound in the lower back.  When this is felt, the relief of pain is usually immediate.  The maneuver is repeated with the patient on the opposite side.”

••••

In 1987, physicians Paul Pang-Fu Kuo and Zhen-Chao Loh published a study pertaining to lumbar disc protrusions and spinal manipulation, titled (6):

Treatment of Lumbar Intervertebral Disc Protrusions by Manipulation

The authors performed a series of eight manipulations on 517 patients with protruded lumbar discs. Their outcomes were quite good, with 84% achieving a successful outcome and only 9% not responding. Only 14% suffered a reoccurrence of symptoms at intervals ranging from two months to twelve years. These authors state:

“Manipulation of the spine can be effective treatment for lumbar disc protrusions.”

“Most protruded discs may be manipulated. When the diagnosis is in doubt, gentle force should be used at first as a trial in order to gain the confidence of the patient.”

“During manipulation a snap may accompany rotation. Subjectively it has dramatic influence on both patient and operator and is thought to be a sign of relief.”

“Gapping of the disc on bending and rotation may create a condition favorable for the possible reentry of the protruded disc into the intervertebral cavity, or the rotary manipulation may cause the protruded disc to shift away from pressing on the nerve root.”

••••

In 1989, the Journal of Manipulative and Physiological Therapeutics published a case study of a patient with an “enormous central herniation lumbar disc” who underwent a course of side posture manipulation (7). The patient improved considerably with only 2 weeks of treatment. The authors state:

“It is emphasized that manipulation has been shown to be an effective treatment for some patients with lumbar disc herniation.”

••••

In 1995, chiropractors PJ Stern, Peter Côté, and David Cassidy published a study titled (8):

A Series of Consecutive Cases of Low Back Pain with Radiating Leg Pain Treated by Chiropractors

The authors retrospectively reviewed the outcomes of 59 consecutive patients complaining of low back and radiating leg pain, and were clinically diagnosed as having a lumbar spine disk herniation. Ninety percent of these patients reported improvement of their complaint after chiropractic manipulation. They concluded:

“Based on our results, we postulate that a course of non-operative treatment including manipulation may be effective and safe for the treatment of back and radiating leg pain.”

••••

In 2006, physicians Valter Santilli, MD, Ettore Beghi, MD, and Stefano Finucci, MD, published an article in The Spine Journal titled (9):

Chiropractic Manipulation in the Treatment of Acute Back Pain and Sciatica with Disc Protrusion

The purpose of this study was to assess the short- and long-term effects of spinal manipulations on acute back pain and sciatica with disc protrusion. It is a randomized double-blind trial comparing active and simulated manipulations for these patients. The study used 102 patients. The manipulations or simulated manipulations were done 5 days per week by experienced chiropractors for up to a maximum of 20 patient visits, “using a rapid thrust technique.” Re-evaluations were done at 15, 30, 45, 90, and 180 days. The authors found:

“Active manipulations have more effect than simulated manipulations on pain relief for acute back pain and sciatica with disc protrusion.”

“At the end of follow-up, a significant difference was present between active and simulated manipulations in the percentage of cases becoming pain-free (local pain 28% vs. 6%; radiating pain 55% vs. 20%).”

“Patients receiving active manipulations enjoyed significantly greater relief of local and radiating acute LBP, spent fewer days with moderate-to-severe pain, and consumed fewer drugs for the control of pain.”

••••

In 2014, an interdisciplinary group of physicians, chiropractors, and researchers published a study in the Annals of Internal Medicine, titled (10):

Spinal Manipulation and Home Exercise with Advice for Subacute and Chronic Back-Related Leg Pain

This study included 192 patients who were suffering from back-related leg pain for at least 4 weeks. Treatment lasted 12 weeks. The authors concluded:

“For leg pain, spinal manipulative therapy plus home exercise and advice had a clinically important advantage over home exercise and advice (difference, 10 percentage points) at 12 weeks.”

“Spinal manipulative therapy with home exercise and advice improved self-reported pain and function outcomes more than exercise and advice alone at 12 weeks.”

“For patients with subacute and chronic back-related leg pain, spinal manipulative therapy in addition to home exercise and advice is a safe and effective conservative treatment approach, resulting in better short-term outcomes than home exercise and advice alone.”

••••

In another 2014 study, a group of multidisciplinary researchers and chiropractic clinicians from Switzerland presented a prospective study involving 148 patients with low back and leg pain. The study was published in the Journal of Manipulative and Physiological Therapeutics and titled (11):

Outcomes of Acute and Chronic Patients with Magnetic Resonance Imaging–Confirmed Symptomatic Lumbar Disc Herniations Receiving High-Velocity, Low-Amplitude, Spinal Manipulative Therapy:

The purpose of this study was to document outcomes of patients with confirmed, symptomatic lumbar disc herniations and sciatica that were treated with chiropractic side posture high-velocity, low-amplitude, spinal manipulation to the level of the disc herniation. The authors concluded:

“The proportion of patients reporting clinically relevant improvement in this current study is surprisingly good, with nearly 70% of patients improved as early as 2 weeks after the start of treatment. By 3 months, this figure was up to 90.5% and then stabilized at 6 months and 1 year.”

“A large percentage of acute and importantly chronic lumbar disc herniation patients treated with chiropractic spinal manipulation reported clinically relevant improvement.”

“Even the chronic patients in this study, with the mean duration of their symptoms being over 450 days, reported significant improvement, although this takes slightly longer.”

“A large percentage of acute and importantly chronic lumbar disc herniation patients treated with high-velocity, low-amplitude side posture spinal manipulative therapy reported clinically relevant ‘improvement’ with no serious adverse events.”

“Spinal Manipulative therapy is a very safe and cost-effective option for treating symptomatic lumbar disc herniation.”

••••

In 2016, Richard Deyo, MD, MPH, and Sohail Mirza, MD, MPH published a review in The New England Journal of Medicine, titled (12):

Herniated Lumbar Intervertebral Disk

Drs. Deyo and Mirza advocate 6 weeks of non-pharmacological conservative care for patients with a herniated lumbar disc, as long as there are no neurological red-flags. They note that some patients will benefit with 12 weeks of conservative care. They clearly indicate that chiropractic spinal manipulation is both safe and usually effective in the management of patients suffering with discogenic radiculopathy, stating:

A randomized trial of chiropractic manipulation for subacute or chronic back related leg pain “showed that manipulation was more effective than home exercise with respect to pain relief at 12 weeks.”

“A randomized trial involving patients who had acute sciatica with MRI-confirmed disk protrusion showed that at 6 months, significantly more patients who underwent chiropractic manipulation had an absence of pain than did those who underwent sham manipulations (55% vs. 20%).”

Safety

In 1981, a study was published in the journal Spine, titled (13):

The Relevance of Torsion to the Mechanical Derangement of the Lumbar Spine

The authors applied rotational stresses to the lumbar spine discs of cadavers. They noted that the limit of lumbar spinal segmental rotation was not created by the disc, but rather by the facet joint. During rotational stress, the compression facet is the first structure to yield at the limit of torsion, and this occurs after about 1-2° of rotation. The authors state:

“Much greater angles are required to damage the intervertebral disc, so torsion seems unimportant in the etiology of disc degeneration and prolapse.”

“Because of the protection offered by the compression facet, the intervertebral disc is subjected to relatively small stresses and strains in the physiologic range of torsion. By the time the facets are damaged, the disc is rotated only about one-third to one-tenth of its maximum angle and is bearing a small fraction of the torque required to rupture it.” 

“Except in cases of extreme trauma and as a sequel to crushing of the apophyseal joints, axial rotation can play no major part in the mechanical derangement of the intervertebral disc in life.”

••••

In 1983, the same group (as #13) published an updated cadaver study in journal Spine, titled (14):

The Mechanical Function of the Lumbar Apophyseal Joints

Based upon their experiments, the authors concluded that the facet joints “prevent excessive movement from damaging the discs: the posterior annulus is protected in torsion by the facet surfaces and in flexion by the capsular ligaments.” They note that the facets only allow at most 2° of rotation, and also note that the disc will completely recover from all rotational stresses that are less then 3°. The authors state:

“In flexion, as in torsion, the apophyseal joints protect the intervertebral disc.”

“The function of the lumbar apophyseal joints is to allow limited movement between vertebrae and to protect the discs from shear forces, excessive flexion, and axial rotation.”

••••

In 1995, a third updated article was published by this group, appearing in the journal Clinical Biomechanics, titled (15):

Recent Advances in Lumbar Spinal Mechanics and their Clinical Significance

Once again, these authors note that rotational loading of the lumbar spinal motor unit will always damage the facet joints “long before the disc.” Despite the supposition that lumbar spinal manipulation, and especially primary rotational manipulation, may injure the intervertebral disc, these cadaver biomechanical studies indicate that such injuries are not biomechanically possible.

••••

In 1993, chiropractor J. David Cassidy, chiropractor Haymo Thiel, and physician (orthopedic surgeon) William Kirkaldy-Willis published a “Review of the Literature” article, titled (16):

Side Posture Manipulation for Lumbar Intervertebral Disk Herniation

These authors cite the above studies (13, 14, 15) on human cadavers that show the annulus of the disc is quite resistant to rotational stresses. Specifically, a normal disc did not show failure until 22.6° of rotational stress, and a degenerated disc could withstand an average of 14.3° of rotational stress. They conclude “torsional failure of the lumbar disk first requires fracture of the posterior joints” before there is any annular tearing. These authors state:

“The treatment of lumbar disk herniation by side posture manipulation is not new and has been advocated by both chiropractors and medical manipulators.”

“The treatment of lumbar intervertebral disk herniation by side posture manipulation is both safe and effective.”

••••

In 2018, a team of Canadian researchers from multiple universities and health care facilities published a study in the European Spine Journal, titled (17):

Chiropractic Care and Risk for Acute Lumbar Disc Herniation:
A Population-based Self-controlled Case Series Study

The objective was to investigate the association between chiropractic care and acute lumbar disc herniation and contrast this with the association between primary care physician care and acute lumbar disc herniation. This is the first population-based epidemiologic investigation of the association between chiropractic care and acute lumbar disc herniation. The study subjects included the entire population in Ontario’s (CAN) provincial healthcare system over an 11-year period, representing over 100 million person-years of observation. The authors were able to identify all surgically managed cases of acute lumbar disc herniation, visits to chiropractors, and to primary care providers. These authors state:

“If chiropractic treatment occurs before a lumbar disc herniation progresses to radiculopathy or neurologic deficit and is thus diagnosed, then the [chiropractic] treatment itself can be erroneously blamed for causing the lumbar disc herniation.” 

“This systematic error—known as protopathic bias—is a type of reverse-causality bias due to processes that occur before a diagnosed or measured outcome event.”

“Given that deteriorating outcome can initially present as low back pain, it is possible that these patients seek chiropractic care in the prodromal phase of deteriorating outcome, implying that an observed association between chiropractic care and acute deteriorating outcome may not be causal.”

“Since patients also commonly see primary care physicians for back pain and this healthcare encounter is unlikely to cause disc herniation, an observed association between PCP visits and acute deteriorating outcome could be attributed to care seeking for the initial symptoms of deteriorating outcome (protopathic bias).”

“The risk for acute lumbar disc herniation with early surgery associated with chiropractic visits was no higher than the risk associated with primary care physician visits.”

“Our analysis suggests that patients with prodromal back pain from a developing disc herniation likely seek healthcare from both chiropractors and primary care physicians before full clinical expression of acute lumbar disc herniation.”

“We found no evidence of excess risk for acute lumbar disc herniation with early surgery associated with chiropractic compared with primary medical care.” 

The analysis “suggested a positive safety profile for chiropractic care relative to the baseline risk represented by primary care physician care.”

Prevention

In 2013, a study on more than 3,000 occupational low-back injured patients from the state of Washington was published in the journal Spine (18). These patients were followed prospectively for 3 years. The authors found that, after adjusting for severity of injury and other variables, that having chiropractic care significantly reduced the odds of having a future back surgery. The authors state:

“In Washington State worker’s compensation, injured workers may choose their medical provider. Even after controlling for injury severity and other measures, workers with an initial visit for the injury to a surgeon had almost nine times the odds of receiving lumbar spine surgery compared to those seeing primary care providers, whereas workers whose first visit was to a chiropractor had significantly lower odds of surgery [by 78%].”

“Approximately 43% of workers who saw a surgeon had surgery within 3 years, in contrast to only 1.5% of those who saw a chiropractor.”

••••

Very recently (December 2022), a study was published evaluating the odds of patients suffering from lumbar disc herniation and radiculopathy over a period of 1-2 years. The study was published in the BMJ Open, titled (19):

Association Between Chiropractic Spinal Manipulation and Lumbar Discectomy in Adults with Lumbar Disc Herniation and Radiculopathy

The study was developed by a multidisciplinary research team. The authors assessed two matched cohorts of 5,785 patients with a mean 37 years. They note that it is common for patients with lumbar disc herniations and radiculopathy to receive chiropractic care or undergo surgery to remove herniated disc material, a procedure called discectomy. Prior studies have found that patients who initiate care for low back pain with a chiropractor have significantly reduced odds of having discectomy.

In this study, the relative odds for discectomy were significantly reduced in the chiropractic cohort compared with the cohort receiving other care over 1-year (by 69%) and 2-year follow-up (by 77%). This study shows that patients initially receiving chiropractic care for lumbar disc herniation with radiculopathy have reduced odds of discectomy over 1-year and 2-year follow-up.

••••

The discussion and studies presented here indicate:

• Chiropractic spinal manipulation is very effective for the management of discogenic low back pain and discogenic radiculopathy.
• Chiropractic spinal manipulation is very safe in the management of discogenic low back pain and discogenic radiculopathy.
• There is evidence that chiropractic care can reduce the need for discectomy back surgery.

REFERENCES

1. Ramsey RH; Conservative Treatment of Intervertebral Disk Lesions; American Academy of Orthopedic Surgeons, Instructional Course Lectures; 1954; Vol. 11; pp. 118-120.
2. Mathews JA and Yates DAH; Reduction of Lumbar Disc Prolapse by Manipulation; British Medical Journal; September 20, 1969; No. 3; pp. 696-697.
3. Edwards BC; Low Back Pain and Pain Resulting from Lumbar Spine Conditions: A Comparison of Treatment Results; Australian Journal of Physiotherapy; 1969; Vol. 15; No. 3; pp. 104-110.
4. White AA, Panjabi MM; Clinical Biomechanics of the Spine; Second edition, JB Lippincott Company; 1990.
5. Turek S; Orthopaedics, Principles and Their Applications; JB Lippincott Company; 1977; page 1335.
6. Kuo PP and Loh ZC; Treatment of Lumbar Intervertebral Disc Protrusions by Manipulation; Clinical Orthopedics and Related Research; February 1987; No. 215; pp. 47-55.
7. Quon JA, Cassidy JD, O’Connor SM, Kirkaldy-Willis WH; Lumbar Intervertebral Disc Herniation: Treatment by Rotational Manipulation; Journal of Manipulative and Physiological Therapeutics; June 1989; Vol. 12; No. 3; pp. 220-227.
8. Stern PJ, Côté P, Cassidy JD; A Series of Consecutive Cases of Low Back Pain with Radiating Leg Pain Treated by Chiropractors; Journal of Manipulative and Physiological Therapeutics; Jul-Aug 1995; Vol. 18; No. 6; pp. 335-342.
9. Santilli V, Beghi E, Finucci S; Chiropractic Manipulation in the Treatment of Acute Back Pain and Sciatica with Disc Protrusion: A Randomized Double-blind Clinical Trial of Active and Simulated Spinal Manipulations; The Spine Journal; March-April 2006; Vol. 6; No. 2; pp. 131–137.
10. Bronfort G, Hondras M, Schulz CA, Evans RL, Long CR, PhD; Grimm R; Spinal Manipulation and Home Exercise with Advice for Subacute and Chronic Back-Related Leg Pain: A Trial with Adaptive Allocation; Annals of Internal Medicine; September 16, 2014; Vol. 161; No. 6; pp. 381-391.
11. Leemann S, Peterson CK, Schmid C, Anklin B, Humphreys BK; Outcomes of Acute and Chronic Patients with Magnetic Resonance Imaging–Confirmed Symptomatic Lumbar Disc Herniations Receiving High-Velocity, Low Amplitude, Spinal Manipulative Therapy: A Prospective Observational Cohort Study with One-Year Follow-Up; Journal of Manipulative and Physiological Therapeutics; March/April 2014; Vol. 37; No. 3; pp. 155-163.
12. Deyo R, Mirza S; Herniated Lumbar Intervertebral Disk; New England Journal of Medicine; May 5, 2016; Vol. 374; No. 18; pp. 1763-1772.
13. Adams MA, Hutton WC; The Relevance of Torsion to the Mechanical Derangement of the Lumbar Spine; Spine; May/June 1981; Vol. 6, No. 3; pp. 241-248.
14. Adams MA, Hutton WC; The Mechanical Function of the Lumbar Apophyseal Joints; Spine; April 1983; Vol. 8; No. 3; pp. 327-330.
15. Adams MA, Dolan P; Recent advances in lumbar spinal mechanics and their clinical significance; Clinical Biomechanics; January 1995; Vol. 10; No. 1; pp. 3-19.
16. Cassidy JD, Thiel HW, Kirkaldy-Willis WH; Side Posture Manipulation for Lumbar Intervertebral Disk Herniation; Journal of Manipulative and Physiological Therapeutics; February 1993; Vol. 16; No. 2; pp. 96-103.
17. Hincapié CA, Tomlinson GA, Côté P, Rampersaud YR, Jadad AJ, Cassidy JD; Chiropractic Care and Risk for Acute Lumbar Disc Herniation: A Population-based Self-controlled Case Series Study; European Spine Journal; July 2018; Vol. 27; No. 7; pp. 1526–153.
18. Keeney BJ, Fulton-Kehoe D, Turner JA, Wickizer TM, Chan KCG, Franklin GM; Early Predictors of Lumbar Spine Surgery after Occupational Back Injury: Results from a Prospective Study of Workers in Washington State; Spine; May 15, 2013; Vol. 38; No. 11; pp. 953-964.
19. Trager RJ, Daniels CJ, Perez JA, Casselberry RM, Dusek JA: Association Between Chiropractic Spinal Manipulation and Lumbar Discectomy in Adults with Lumbar Disc Herniation and Radiculopathy: Retrospective Cohort Study Using United States’ Data; BMJ Open; December 16, 2022; Vol. 12; No. 12; Article e068262.