Effectiveness of Multimodal Chiropractic Care Featuring Spinal Manipulation for Persistent Spinal Pain Syndrome Following Lumbar Spine Surgery: Retrospective Chart Review of 31 Adults in Hong Kong

Abstract

BACKGROUND The term "persistent spinal pain syndrome type 2" (PSPS-2) has been proposed by the International Association for the Study of Pain to replace the term "failed back surgery syndrome". This retrospective study aimed to evaluate effectiveness of multimodal care featuring chiropractic spinal manipulation (CSMT) in 31 adults in Hong Kong with PSPS-2. MATERIAL AND METHODS We identified new adult patients with PSPS-2 receiving CSMT from 2016 to 2018. Demographic and clinical data and baseline/follow-up numeric pain rating scale (NPRS) and Oswestry Disability Index (ODI) scores were extracted. Multiple linear regression was used to examine posttreatment NPRS and ODI reduction, with clinical variables as covariates. RESULTS Of 6589 patients with low back pain, 31 met criteria (mean age 52.2±13.7 years). Surgeries included laminectomy (81%), discectomy (13%), and fusion (6%). Mean baseline NRPS was 6.6±1.9; ODI was 43.8±15.1%. Patients received CSMT (100%), drop technique (81%), passive modalities (65%), soft tissue manipulation (13%), flexion-distraction (13%), and mechanical traction (13%). Mean posttreatment NPRS was 0.6±1.0; ODI was 2.4±3.3%. All patients had a minimum clinically important difference for NPRS (≥2/10) and ODI (≥30%). One year after treatment, 48% maintained improvement, 42% experienced recurrence; in 10%, follow-up was unavailable. Regression analysis identified younger age, shorter symptom duration, and greater baseline NPRS as predictors of NPRS reduction; and greater baseline ODI as a predictor of ODI reduction (all P<0.05). CONCLUSIONS Patients with PSPS-2 improved with multimodal care featuring CSMT, which was more effective in patients with younger age, shorter symptom duration, and higher baseline pain or disability levels.

Figure 1

Identification of patients from the electronic health records. Figure created by RT using Microsoft Word (Version 2205).

Figure 2

Lumbar spine imaging following laminectomy. Lateral lumbar radiograph, taken at an outside facility, with (A) markings drawn by a previous provider and (B) T2-weighted lumbar mid-sagittal magnetic resonance image ordered by the chiropractor shows removal of the laminae and spinous processes from the L4/5 to L5/S1 levels (arrows). This 49-year-old woman presented with a 1-year history of severe right-sided sciatic pain, right leg numbness and weakness, and severe low back-related disability following laminectomy. With 12 visits of spinal manipulation and mechanical traction over a 3-month span, she experienced a near-complete resolution of symptoms. Her symptoms recurred by the 1-year follow-up after concluding treatment.

Figure 3

Drop table technique. The patient is positioned prone on the table with the segments to be manipulated overlying the cushioned drop section of the table. The tension is set so that the patient’s body weight by itself will not cause the section to drop. Additional force is applied (in this case, using contacts from both hands at L5 and the ilium), which exceeds the resistance of the drop mechanism, causing the table section to drop a short distance vertically beneath the patient (arrow). Image from EC.

Figure 4

Flexion-distraction technique. An automatic flexion-distraction table (Chirobot^®, Chirotech Innovation Co., Ltd., Taiwan) is used. The patient lies prone, and the chiropractor fits the table to match the patient’s height, with or without use of the ankle bolsters, depending on patient tolerance/comfort. The table is then set to automatically flex and extend to neutral (parallel) a small amplitude (arrows) at a frequency of 10 to 30 cycles per min for 10 to 15 min. Image from EC and modified by RT to include arrows using GIMP GNU Image Manipulation Program version 2.10.30.

Figure 5

Mechanical lumbar traction. The patient lies supine on the table (MID Spine Decompression Device, WIZ Medical, Korea) and is supported by straps around the torso and pelvis. The device is set to apply a traction force ranging from 30% to 60% of the patient’s body weight, which varies according to the patient’s tolerance level and clinical judgement. The ratio of hold to rest time is 2: 1, and traction sessions last for 15 to 20 min. Image from EC and modified by RT for de-identification purposes using GIMP GNU Image Manipulation Program version 2.10.30.

Figure 6

Instrument-assisted soft tissue manipulation. The patient lies prone, and the practitioner applies a thin layer of emollient (lubricant) to the targeted area of the lower back, then gently and repeatedly strokes a massage tool (Strig, Korea) along the paraspinal muscles. Image from EC and modified by RT to include arrows using GIMP GNU Image Manipulation Program version 2.10.30.