The patient was a 60-year-old male who had been seen on occasion by a chiropractor over a three- to four-year period for low back pain. The pain was local and cleared each time within several weeks. The patient never experienced radiating pain, leg weakness or sensory change. Three months prior to diagnosis, he returned to the chiropractor with gradual onset of low back pain. Unlike the previous episodes of low back pain, this pain did not come on with activity. Some improvement was noted with chiropractic manipulative therapy (CMT). The chiropractor took lumbar spine X-rays; they just indicated degenerative changes. CMT continued, and the patient said he felt better. He was advised to return if the pain progressed or if other symptoms developed.
The patient did not return for two months. When he did return, he told the chiropractor that the low back pain was progressing and that he had pain radiating down his left leg. He also said his "left ankle was weak." Examination showed he had weakness of dorsiflexion (anterior tibial) and weakness of great toe extension (extensor hallucis longus) on the left, with a left L5 sensory deficit. The chiropractic physician obtained an MRI; it showed tumor involvement of the L5 vertebra, with some focal bony collapse in the region of the left L5 foramen. The left L5 nerve root was entrapped. The chiropractor referred the patient to a neurosurgeon he knew through the AASP.
The neurosurgeon operated to decompress the left L5 nerve root and to obtain a tissue diagnosis. Following the operation, the patient immediately had increased strength and no longer had radiating leg pain. The pathological diagnosis was primary lymphoma of the L5 vertebra. The patient was treated for this condition with radiation. The tumor was cured and the soft bone reconstituted. There was no further bony collapse and no concern about the development of cauda equina syndrome. The neurosurgeon told the patient he should thank the chiropractic physician for making the difficult diagnosis and referring him in time for such a good outcome. The neurosurgeon also wrote the above in his letter to the chiropractic physician.
The Point
If the patient had seen a neurosurgeon hostile to chiropractic, the doctor might have said that the long history of low back pain was from the tumor (it was not) and that the patient had suffered from delayed diagnosis. A hostile doctor could have said that the patient might not have needed such an invasive procedure if diagnosed earlier. If the tumor had not been cured, a hostile doctor could have said that the tumor had been curable, but was found too late. Because of good cooperative spine care by the two spine physicians (the chiropractic physician and the neurosurgeon), none of this happened. The patient received excellent care from both doctors and was very appreciative of their cooperative efforts.
The American Academy of Spine Physicians
Elgin, Illinois
www.spinephysicians.org
aasp@spinephysicians.org
