Management of acute lumbar disk herniation initially presenting as mechanical low back pain

To describe the clinical management with spinal manipulation of a male patient with risk factors for lumbar disk herniation initially suffering from what appeared to be mechanical low back pain that evolved into radiculopathy; also to review issues pertinent to chiropractic/manipulative management of disk herniation.

The patient initially suffered from unilateral low back pain and nonradicular/nonlancinating referral to the ipsilateral lower extremity.

Disk herniation-in-evolution was included in the differential diagnosis, which was discussed with the patient, who then gave verbal informed consent for manipulative management. A day or so after the initial manipulation the presentation evolved to include S1 radiculopathy. Computed tomography, just after onset of radiculopathy, confirmed the clinical diagnosis of lumbosacral disk herniation. The patient continued with manipulative management and repeat computed tomography examination after clinical resolution about 2 months later revealed reduction in size of the apparently clinically significant herniation.

Risk factors for the development of disk herniation should be considered when assessing patients suffering from what appears to be mechanical low back pain. The role played by manipulation in the development of disk herniation in this case was believed to be circumstantial rather than causal. Manipulation was used in the treatment of this patient over a period of approximately 2 months; after this time, clinical and partial computed tomography imaging resolution was evident. Ongoing clinical (neurologic) evaluation of patients with manifest or suspected disk herniation is an important aspect of management. Good-quality trials of manipulation for patients with disk herniation are imperative for the chiropractic profession.