The Diagnosis And Conservative Treatment Of The Lumbar Disc Syndrome

THE DIAGNOSIS AND CONSERVATIVE TREATMENT OF THE LUMBAR DISC SYNDROME

BY

FRANKLIN SCHOENHOLTZ, D.C. Diplomate, American Board of Chiropractic Orthopedists

LECTURE DELIVERED ON APRIL 29,1977 AT THE AMERICAN COLLEGE OF CHIROPRACTIC ORTHOPEDISTS CONVENTION PALM SPRINGS, CALIFORNIA

THE CLINICAL DIAGNOSIS OF THE LUMBAR DISC SYNDROME Discussions of disorders of the spine must begin with separating lumbar intervertebral disc disease from normal, predictable sequences of morphological alterations. For the purpose of this lecture I shall concern myself with the general highlights of the diagnosis and conservative treatment of the lumbar disc syndrome. The lumbar disc syndrome represents one of the most common causes of back and leg pain. It is a multi-faceted symptom complex and must be recognized as such if the diagnosis and treatment are to be correct. Initially, careful and methodical analysis of the patient’s signs and symptoms are essential to base the nature of the clinical manifestations of the affected disc and to determine which disc and nerve roots are at fault. If the doctor will take his time to hear what the patient is telling him he can assess the behavior of the syndrome. Such an examination should provide significant information necessary to establish a valid diagnosis. The doctor should weigh all of the subjective and objective clinical features in order to correlate the data with the pathophysiological changes of the disc. It is interesting that at times I have to restrain myself based upon subjective history, not to lead the patient into the diagnosis of a lumbar disc lesion. The clinician sees with disturbing regularity missed diagnoses of lumbar disc lesions. However, it is also important that he does not polarize his thinking to the opposite spectrum and then classify all back and leg pain to abnormalities of the lumbar intervertebral disc. There are many approaches to a detailed examination. The plan that I follow is to critically analyze the subjective factors and then evaluate the objective manifestations of the clinical picture. A most important consideration in determining a diagnosis is that negative findings are of equal importance as positive findings. SUBJECTIVE COMPLAINTS OF PAIN Generally speaking patients seek your services because of pain. Patients will, if given the opportunity to express themselves, describe all the essential characteristics of their pain. During an acute attack the pain may be in the lumbar region with or without radicular involvement. The patient may have a difficult time in delineating and localizing the exact site of the pain. However, in the case of leg pain the patient is usually quite accurate in describing its location. Intensity, as well as patterns of pain may be influenced by other considerations of which the patient is keenly aware, such as, acute unguarded movements. The nerve roots may have become so irritable that any slight movement may be capable of causing

severe aggravation of the pain. A sudden cough or sneeze may produce an accentuation of the pain. The patient soon becomes aware of positional relief. He may assume certain postures in order to decrease the tension and the pressure on the nerve root. The patient learns that by decreasing vertical stress he can attain some relief of pain. This he does by usually assuming the fetal position with hips and knees fully flexed while laying in bed. THE DOCTOR-PATIENT PSYCHOLOGICAL PAIN RELATIONSHIP Pain is a psychological phenomenon with both physical and emotional components and the doctor is called upon constantly to make value judgments. Due to the difficulty and chronicity of the lumbar disc syndrome we often find ourselves agonizing with the patient over an extended period of treatment when improvement is not as we had expected. Because of the normal tendency to prefer praise to blame we may become frustrated and even display subtle hostility towards the patient. Most of us have had the experience of treating a lumbar disc patient that should have improved with our therapy, yet, with considerable regret we find that the patient may be unresponsive. The patient’s attitude toward us often plays a significant role in determining the success of our therapy. When patients feel that you are annoyed with their complaints they often develop their own hostility and with covert criticism announce with triumph at each visit, “Your treatment is not helping.” This statement renders the doctor powerless to retaliate. At times the doctor, with a sense of punishment, attempts to “punt” by banishing the patient with a referral to a specialist when it is not necessary. All of us want to succeed. We want to provide a valuable service to the patient, as well as, gain a sense of accomplishment that we are practicing our profession well. When doctor-patient hostility develops it is our responsibility to take time to explain to the patient the complexities involved in the treatment of lumbar disc disease. The patient needs reinforcement and reassurance. During the treatment program the chronic lumbar disc patient has to have confidence that the doctor understands him and his problems and is kind and gentle in both word an manner. SENSORY DISTURBANCES During the course of root compression the sensory fibers may be compressed causing paresthesia and later loss of sensation in the affected detmatome. This is a most interesting phenomenon, for it appears to provide the only example of a pathognomonic sensation. Because of the subjective aspect of sensory testing, an abnormal

sensory pattern is considered of clinical significance only if it can be correlated with the other radicular signs and symptoms. It should be remembered that dermatome distributions vary from individual to individual and considerable overlap may exist. MOTOR DEFICITS Abnormalities in motor function are considered objective. Yet, clinically one of the major concerns of the patient is that he has a weakness or complete loss of function in a group of muscles. This may occur with a disc lesion affecting the L-5 nerve root. In this instance the patient is unable to dorsiflex his foot and he notices that he “slaps his foot while walking.” This abnormal gait is caused by either a weakness or paralysis of the anterior tibial or peroneal muscles. When the S-1 root is affected the patient loses the ability to stand on his toes because of motor dysfunction. Due to the overlap of nerve supply this may present confusion to the examiner because there is no definite rule that may be absolutely applied in evaluating motor deficits. REFLEX CHANGES Deep tendon reflexes in relationship to lumbar disc disease is usually confined at the levels of L4-L5 and L5-S1. Generally in progressive disc disease we see far more patients with symptoms that are attributable to posterior lateral protrusions and as a result asymmetrical findings are clinically significant. Impairment of L5 nerve root is not always associated with reflex absence at the knee.

The difference between palpatory findings in acute, subacute, and chronic disc lesions are both quantitative and qualitative. With acute and subacute lesions the differential findings are relatively few; however, if the lesion persists, the types of findings gradually change, i.e., the early evidence of over stimulation gradually gives way to evidence indicating fatigue of the affected area. Muscle spasm and pain are usually associated with derangement of the lumbar disc and may not be associated with nerve root involvement. PALPATION AND PERCUSSION Palpation can produce pertinent information providing it is accurately interpreted. It is a routine procedure for the doctor and he can usually determine by eliciting tenderness along the iliac crest as to what structural protective shift has taken place. Palpation of the affected sciatic notch will usually confirm radicular involvement and can be readily explained by the hypersensitivity of the fibers of an affected root transversing the sciatic notch. Percussion may be less informative than palpation but in some cases fist percussion over the lumbar spin in the mid-line will produce radiating leg pain. When pleximeter percussion over the spinous process evokes a positive response you have a sound index of the sensitivity of the affected tissues and nerve root. However, when percussion at that level yields no pain or discomfort, it does not eliminate the possibility of a lumbar disc involvement. STRAIGHT LEG RAISING

A diminution or absence of the ankle jerk is usually pathognomonic of involvement of S1. When this reflex is lost the level most involved is usually the L5-S1 disc. POSTURAL CHANGES During an acute attack the patient assumes an antalgic position in which he exhibits a flattened lumbar spine. The entire trunk appears to be projected forward so that the affected leg is flexed at the hip and knee. When the nerve root is under tension and traction the patient develops a lateral list which is referred to as a “sciatic scoliosis.” The patient attempts to relieve the pain by involuntarily shifting his trunk to decrease root compression. Sciatic scoliosis is a variable clinical feature in that the trunk may shift from side to side in the same patient depending on the relationship of the nuclear sequestrum. MUSCLE SPASM During an acute attack we always have lumbar muscle spasm. This is a reflex protective mechanism in which the patient has no control It is apparent to the expert clinician and is always palpable. The muscles are tense and rigid to the touch and the spasm is responsible for the flattening of the lumbar spine and the lateral list to one side.

This test is often confused with the Lasegue Test. It is considered the most important of all leg tests and is used in all acute and subacute attacks of lumbar disc lesion. It is performed with the patient lying supine and the extended leg is flexed on the trunk at the hip by the examiner. Generally, a positive straight leg raising test on the affected side is accompanied by mild restriction of the unaffected leg. Added consideration of this maneuver on the uninvolved side may produce pain on the opposite side. The explanation of this phenomenon is that you raise the normal leg you cause the lower lumbar nerve roots on the opposite side, especially the L5-S1 root to move slightly down. LASEUGE TEST This test is performed with the patient attempting to extend his knee from 90 degrees to 180 degrees while he is supine. When a lumbar disc lesion is present causing root irritation to the limit to which the knee can be extended is diminished. Pain is produced in the leg and back beyond this point. Pain can also be reproduced by this maneuver by sharply dorsiflexing the foot thus stretching the sciatic nerve and tractioning the nerve root.

SITTING ROOT TEST This test is performed with the patient sitting on the examination table with his legs hanging free. The knee is extended to the point of resistance and then the clinician places his hand over the occiput and flexes the cervical spine sharply. The sudden traction of the sensitive nerve root caused by forward flexion induces pain along the distribution of the nerve pathway. RADIOGRAPHIC EXAMINATION Radiographic study of the lumbar spine is mandatory in the examination of these patients who exhibit clinical manifestations of lumbar disc disease. The decision of the relevance of radiographic abnormalities is beset by many pitfalls. In my view, in nearly every case the clinical findings take precedence over x-ray changes. Rarely, the radiograph may show an overriding lesion that clinical examination did not detect then only is it diagnostic taken alone. The radiographs should be of excellent quality and should be taken in accordance with all details of an established technique. The series should include anteroposterior, lateral, obliques and a lateral spot of the L5-S1 joint. X-rays of the lumbar spine may reveal the following abnormalities: 1. 2. 3. 4. 5.

Diminished intervertebral space Osteophytic production Anterior or posterior subluxation of a vertebra Sacralization of the 5th lumbar vertebra Congenital defects and other pathological processes

CONSERVATIVE TREATMENT AND MANAGEMENT OF THE LUMBAR DISC SYNDROME The approach to the treatment of a patient with a disc lesion is a difficult feat. The proper selection of one method over another method depends on the specific patient. After practicing for 15 years I still have not arrived at absolute, firm guidelines for patient management. The varied clinical picture of disc injury leads to the dilemma of treatment choice. The deciding factor in treatment selection is one of the most difficult to evaluate. At one end of the spectrum is the patient completely intolerant of any pain and at the other end is the patient who is completely casual in response to his condition. The goals to be established in a conservative program should be threefold: 1. 2. 3.

Relief of pain Increase of functional capacity Slowing of the disease progression

The quality of results in patients with lumbar disc lesions depends upon the criteria that, although manipulation is the crux

of the matter, first and foremost it is only a part of the whole procedure. Manipulation is our chief modality among the various physical methods of treatment. However, since this lecture was designed, mindful of the fact that the following speaker is to discuss the manipulative approach to lumbar disc syndrome, I shall offer alternative modes of therapy at this time. To achieve the maximum benefit from any form of therapy the doctor must be allowed discretionary latitude not only in choice of modality but also in the intensity and time of its use. Variations in treatment must be made in response to the patients reaction which may change from visit to visit. It is my intention to present principles of different techniques and their efficacy in the conservative management of acute and chronic lumbar disc lesions. BEDREST One of the most important factors in the treatment of an acute disc lesion is an adequate period of bed rest. A firm mattress is recommended. Bed boards have fallen out of favor and in fact, in many instances, they will actually increase the level of pain noted by the patient. The patient should lie in a position so that his hips and knees are flexed. The patient is warned against sleeping in a prone position which will result in extension of the lumbar spine. Of prime importance is the duration of bed rest. Frequently, patients are allowed to return to their occupation before the inflammatory process of the disc lesion has diminished. The patient should be informed that after an acute disc attack a minimum of 2 to 3 weeks is required at complete bed rest. Gradual mobilization is then instituted over a period of 10 to 14 days if the patient has relief of pain and paravertebral muscle spasm. It is of great importance to note that any patient with neurological deficits or with progressive atrophy of the lower extremities should be referred for surgical consultation. This patient may not be a candidate for conservative management and a reevaluation should be considered in order to establish a favorable prognosis. When you feel your conservative treatment program will be effective, you should clarify and warn the patient that it is unrealistic to expect a person with a frank disc protrusion to return to full activities in less than one month. Compromise on this point is frequently sought by the patient but in the long run it will not be to his benefit. You should be quite candid in explaining to the patient that surgical procedures may require a prolonged period of rehabilitation in itself and that the choice of a conservative program may preclude the necessity of operative intervention. The modality of bed rest is of great importance so that the inflammatory reaction may diminish. It is hoped that the edema and hyperemia of the soft tissue surrounding the protrusion will

subside, allowing the patient to become free of his acute pain and peripheral neurological involvement. The relief may or may not be permanent, thus the prognosis would still have to be considered guarded. PHYSICAL THERAPY Physical therapy, historically, is one of the newest and yet one of the oldest fields. It is one of the newest because only in the past 35 years has it become recognized as an integral part of practice. It is one of the oldest because the first man who bathed a wound in a stream instituted the practice of hydrotherapy; and the first man who rubbed a bruised muscle introduced massage. History reveals primitive cave paintings of early man lying under the sun to receive the benefits of its warmth. I do not feel it is necessary for practitioners to know the physics of the various modalities used in our practices to be able to recommend their benefits. However, it is essential for the doctor to understand the clinical principles of the therapy so that he can design a treatment program that will provide effective patient management. The principles of physical therapy are: 1. 2. 3.

Prevention of morbidity Maintenance of a normal physiological state Restoration of functional loss in the anatomical structure TRACTION

In many instances traction has gained the reputation of being a specific treatment for a lumbar disc lesion. The supposition that traction separates the lumbar vertebra and permits the disc to return to its “container” is without basis and is an untenable conclusion. There is a great controversy surrounding home pelvic traction. Some authorities feel it is a cumbersome apparatus which makes bed rest less comfortable. They feel that the therapeutic value is highly dubious and probably nonexistent except for enforcing a program of bed rest However, other authorities feel home pelvic traction produces distraction of the vertebra, allowing the intervertebral foramina to increase in size, thus reducing inflammatory reaction. Motorized intermittent traction is supplanting all other methods of traction and properly applied may provide the following values: 1. 2. 3. 4.

Decreases muscle spasm Has a massage-like effect upon the muscles and ligamentous structures Diminishes swelling and promotes better circulation in the tissue thus helping to reduce inflammatory reaction Helps to prevent the formation of adhesions between the nerve roots and the adjacent capsular structures THERMAL THERAPY

HEAT: No one as yet has been able to demonstrate clinically the superior value of any specific thermal therapy. Heat will increase circulation, aid in muscular relaxation and improve nutritional status of tissues. In injury it often will alleviate pain and stiffness. This type of therapy would serve as a prelude to treatment that will influence the successful management of the condition. HYDROCOLLATOR PACKS: Hydrocollator packs have a predominantly superficial thermal effect. The temperature pattern with hydrocollator packs is, however, not the same as with infrared, for the rise is far quicker with the hydrocollator pack, and there is the alternating quick rise and more gradual fall of temperature, as the hydrocollator pack is ordinarily applied therapeutically. Furthermore, the intense sensory stimulation with hydrocollator packs may play a significant role in the apparently greater relaxation. MICROWAVE AND SHORT WAVE THERAPY: Broadly speaking, the therapeutic indications for microwave diathermy differ little, if at all, from those applicable to short wave diathermy. Microwave irradiations find their chief value in bringing about a significant rise in the temperature and a local increase in blood supply in deeper structures. The obvious advantage of microwave therapy is that with it, it is possible to heat the deeper tissues without undue heating of the more superficial tissues. With the modern equipment now available it is possible to localize heat to the specific area to be treated and to control and measure the dosage. The technique of application is simple and the patient is comfortable and free from apprehensions. COLD THERAPY: Ice massage provides surface anesthesia. The patient usually responds in 4 stages; cold, burning, aching and numbness. When the skin is cold it becomes extremely red and a histamine-like reaction occurs during the remaining 3 phases. The patient may become conscious of a tender mass over the site of maximum pain that is not palpable to the examining fingers. When this sensation abates the pain is relieved and the treated area is numb. Gentle stretching of the muscle can then start, helping to relieve muscle tension and rigidity. Ice, as well as cold packs on the skin act as a vasoconstrictor and decrease localized hemorrhage. It acts as a decongestant to an area that has been injured, thus reducing swelling and edema. Clinically it decreases muscle fatigue and helps break the spasm to facilitate gentle limbering movements. ETHYL CHLORIDE AND FLURO-METHANE SPRAY: When localized lumbar paraspinal muscle pain seems to emanate from a specific site, surface anesthetics, such as ethyl chloride or fluromethane spray, occasionally are helpful. When the lumbar region has been sufficiently cooled it should be possible to stretch the muscle to its normal resting length. This is probably the most important part of this therapy. ULTRASOUND: This modality produces a “micro-massage” of the cellular tissues, thus producing mechanical vibrations which increase the blood supply, stimulating the metabolism and producing an analgesic effect. Further results include breaking

up tissue deposits (such as scar tissue and calcium deposits) and promotion of their absorption. All of these therapeutic effects play an important role in improving mobility and relieving pain. ULTRASOUND IN ASSOCATION WITH MUSCLE STIMULATION: Ultrasonic sonations combined with muscle stimulation causes a mechanical pumping by electrical impulse. By its mechanical action ultrasound helps soften microscopic fibrous tissues and scars. This therapeutic combination promotes dissipation of metabolic waste products of the muscle group being treated, thus helping to restore a normal physiological state. MUSCLE STIMULATION: This is an alternating current used for muscle stimulation. The current causes muscles to contract and helps the patient activate a muscle without using it to move a joint (similar to an isometric exercise). Consideration should be given to the fact that this therapy also allows an alienated muscle to be brought into action in which another muscle has taken over by substitution. GALVANISM: Galvanic current is used with the anode active to relieve pain and to lessen tissue swelling. The latter probably results in promoting an osmotic effect by ionizing the salts in the tissue fluids. The pain relieving effect is considered a clinical fact but the cause remains obscure. INTERFERENTIAL CURRENT: Recent developments have shown that this unique modality is quite effective in the management of musculoskeletal joint disorders. Interferential currents are generated as an interference phenomenon which permits higher intensity currents to be used in the field of muscle stimulation. It has been my experience that a pronounced effectiveness is obtained through a combination with vacuum massage which allows the frequency to rapidly over excite muscles beyond their capabilities to respond. This produces an anti-spasmotic and depressant effect, thus relieving muscular rigidity and eliciting a definite analgesic response.

Anatomical structures can be held in normal or corrective position which permit only limited movement. The purpose is to prevent component structures of the joint from exceeding normal physiological limits and to provide firm support where indicated. The relief from pain after application of supportive appliances is often immediate and dramatic. PRINCIPLES AND OBJECTIVES OF IMMOBOLIZATION 1. 2. 3. 4.

To immobilize, support and stabilize To approximated tissue in order to promote healing To reinforce and protect To substitute for defects in fibrous tissue temporarily LUMBOSACRAL BRACE

When fitting a lumbosacral brace appliance the steels should be accurately molded to the sacrum and to the lumbar lordsis. Bending irons are a necessity in any orthopedic practice. Correction and stabilization should be reevaluated in attaining the optimal lordotic curve during the patient management. The steels should have the tendency to hold the thorax slightly backwards; it should not press it forward. If the curve of the steel is less than that of the patient’s lordosis as he stands upright, the effect would then be to force the thorax forward and that posture would then be contraindicated to good muscular tone. This is a common failing which makes an otherwise acceptable brace less effective. PLASTER JACKET This custom made appliance is utilized with great efficacy by the chiropractic orthopedist. Patients often get dramatic relief by its application. The success of this device is that it not only provides the patient with the essential principles of immobilization but it can be worn for an indefinite period of time. One of the advantages is that even though it is plaster, it is so designed that it may be taken off at night so that excessive muscular fatigue does not occur.

It has been my clinical judgment that the subacute patient responds favorably and tolerates this type of therapy well.

Over the years of successful employment of this plaster jacket in my own practice I have felt that if a unilateral hip spica could be made part of the jacket we would add another dimension that would insure added immobilization.

MECHANICAL VIBRATION: The physiological effect of this mode of therapy will increase blood and lymph flow, thus reducing edema and congestion. This type of deep mechanical massage is tolerated by the patient as it often reduces pain by stretching and relaxing rigid muscles.

Other than a plaster jacket my recommendations are a plastozote, thermo plastic flexion body jacket, as well as the steel reinforced chairback brace because of their extreme lightweight durability. All of the above lumbar devices are fitted to the patient’s own measurements.

MASSAGE: This mode of therapy was known in antiquity and may be helpful in the modern day conservative management of low back pain. Paraspinal muscle spasm can be relaxed by gentle massage. This particular therapy provides a mechanical effect in helping the return of venous blood, lymph and catabolites into the mainstream of circulation. LUMBAR IMMOBLIZATION

EXERCISE THERAPY When a patient has a lumbar disc lesion one of this basic symptoms is a loss of function usually accompanied by pain. A program of low back exercises should include an understanding that you are treating the muscle spasm which is a secondary reflex reaction in addition to attempting to reduce the lumbar lordosis.

Within our profession there is mild disagreement as to the benefits of flexion vs. extension exercises. There are those who feel that the flexion approach only exacerbates symptoms by added stress on the anterior portion of the disc thus causing the posterior tear in the annulus to widen. It is my feeling that when exercises are to be introduced they should be initiated only at the subacute stage and that is probably the critical factor in the treatment. As a result, I, personally, prefer the flexion approach. A flexion exercise program can accomplish 4 basic goals: 1. 2.

3. 4.

Subluxation or overriding facets can be placed in a position where they are diminished The spine can be placed in a position of stability where the shearing strains are minimized in the lower lumbar disc levels. The intervertebral foramina are opened, allowing maximum room for exit of the nerve roots. Strengthening of the abdominal musculature and flexors of the spine. Both of these muscle groups have been shown to be important in supporting the spine and alleviating gravitational stress of the intervertebral disc.

The goals and reasons for the effectiveness of the lumbar exercises outlined above are theoretical and open to debate. Their efficacy is based upon and empirical and clinical basis which has been clearly shown in practice. TRANSCUTANEOUS NERVE STIMULATION: Once again interest has become in vogue with the use of electrical currents for the relief of chronic pain, particularly, pain of neurogenic origin. The prime indication for the use of a dorsal column stimulator is the long standing and intractable nature of the pain.

skilled therapists or informational feedback from a biofeedback recording machine. It has to be understood that these techniques are in their infancy and they are not applicable to all patients. If behavioral patterns are successfully modified the long term results have yet to be assessed. LIFESTYLE ADAPTATION TO THE CONDITION Every chore the patient does from housekeeping to getting in and out of a car must be analyzed in terms of body mechanics. The patient must practice both defensive and protective movements until they become second nature. In conservative management a frequent deficiency is that the doctor does not design a program that will teach the patient how to cope with daily living habits. The patient should be instructed to reduce obesity, improve mobility and avoid excessive muscular stress. We have to help the patient resume activities that will not create recurrent attacks of low back pain. The doctor should take time to stress the advantages of this program to the patient, reviewing the potential problems of what may occur in the future if such a regimen is not followed. SUPPLEMENTS Stress vitamins (B complex) are effective in order to enhance neural metabolic integrity, especially in acute conditions. In the long range management, vitamin C is of extreme value in all of the collagen diseases. Recommended dosage of 2000 mg. daily should be considered during the supportive phase of lumbar disc disease. TREATMENT PROGRAM

Some patients may derive significant improvement from this modality and will also appreciate some degree of improvement within the limited anatomical area affected by transcutaneous stimulation. The physiological aim is that the treatment will stimulate larger myelinated afferent fibers to block at the level of the spinal cord, the passage of pain impulses carried by smaller afferent fibers. When the patient responds to this type of therapy he can be supplied with a portable stimulator which can be used when he feels it is necessary. BEHAVORIAL CONDITIONING AND BIOFEEDBACK Modification of behavior has been applied to the clinical sciences. Specific behavior can be conditioned by positive reinforcement. In regard to musculo-skeletal pain, conditioning is predicated on the assumption that chronic pain responses are learned behaviors. In a clinical atmosphere, positive techniques are carried out by

From visit to visit, changes in the patient’s progress and therapy should be fully explained to him. As the treatment program proceeds the doctor and the patient will benefit from an occasional review of their progress. Reexamination during the course of therapy is of extreme value for it is quite possible for another disorder to appear. The doctor must never lose sight of the maximum objective --- restoration, in every way possible --of optimum health and function. EPILOGUE In the study of disc disease clinical science is still attempting to establish treatment guidelines. Wide divergence in management of patients, even within our own profession, causes honest academic and intellectual differences. When reviewing those patients who have been exposed to a multi-disciplined approach it becomes apparent that a large measure of the recovery rate depends on such factors as: the starting point, body types, hereditary influences, occupational demands, methodology of

approach, quality of primary care, etc. It has been my attempt to present a broad overview of the lumbar disc syndrome. In my opinion, until investigations contain the multiplicity of total conservative care, end results will continue to be incomplete.

Copyright Dr Franklin Schoenholtz 2009