Gregory J. Snow, DC
Assistant Clinical Professor,
Palmer College of Chiropractic West,
90 E. Tasman Drive,
San Jose, CA 95134-1617
OBJECTIVE: To discuss the case of a patient with severe, multilevel central canal stenosis who was managed conservatively with flexion-distraction manipulation; to introduce a cautious approach to the application of treatment, which can reduce the risk of adverse effects and might make an apprehensive doctor more comfortable treating this condition; and to propose a theoretic mechanism for relief of symptoms through use of chiropractic manipulation.
CLINICAL FEATURES: A 78-year-old man had low back pain and severe bilateral leg pains. Objective findings were minimal, yet magnetic resonance imaging demonstrated severe degenerative lumbar stenosis at L3-L4 and L4-L5 and to a lesser degree at L2-L3.
INTERVENTION AND OUTCOME: Flexion-distraction manipulation of the lumbar spine was performed. Incremental increases in traction forces were applied as the patient responded positively to care. He experienced a decrease in the frequency and intensity of his leg symptoms and a resolution of his low back pain. These improvements were maintained at a 5-month follow-up visit.
CONCLUSION: Successful management of symptoms either caused by or complicated by lumbar spinal stenosis is presented. Manipulation of the spine shows promise for relief of symptoms through improving spinal biomechanics. Further study in the form of a randomized clinical trial is warranted.
From the Full-Text Article:
This case demonstrates the management of symptoms in a patient with severe, multilevel stenosis, disk protrusion, and spinal degeneration. A cautious, progressive approach during the application of treatment was used in an effort to decrease the risk of adverse reaction. I recommend that this type of cautious approach be considered in those instances in which the doctor does not feel comfortable applying a high-velocity, low-amplitude thrust, even if there is a lack of absolute or relative contraindications.
The presentation in this case was not that of the typical patient with stenosis, inasmuch as there was no evidence of neurogenic claudication and symptoms were exacerbated by flexion rather than extension. Nevertheless, the presenting symptoms of chronic low back pain and bilateral leg pain were consistent with those of a patient with early-onset or minimally symptomatic stenosis. The presence of minimal symptoms in a patient with severe stenosis is not unusual; it has been shown that there is no relationship between severity of pain and degree of stenosis.  Examination findings were minimal, consisting of local tenderness and global decrease in ranges of motion. The patient’s symptoms were not reproduced with any orthopedic tests, and no neurologic deficits were revealed. It was therefore inconclusive whether this patient’s symptoms were caused by the presence of severe, multilevel, central canal stenosis or were instead complicated by it. As noted by Mireau and Kirkaldy-Willis,  the functional lesion might be the cause of symptoms even when the stenosis is demonstrated by computed tomography or MRI. In my opinion, regardless of the cause of the symptoms, the presence of severe LSS had to play a significant role in the management of this patient.
The possibility exists that some practitioners are hesitant to treat a patient with severe central canal stenosis despite the absence of absolute contraindications. Thus a patient who would otherwise benefit from chiropractic care might go untreated or undergo unnecessary surgical intervention. This report is presented to document the successful management of symptoms without using a high-velocity, low-amplitude thrust in such a case. The treatment methods are described to provide an alternative approach for those clinicians looking to err on the side of caution or to manage patients whom they might otherwise not treat.
Several limitations characterize this study. Because the case report deals with a single patient, the findings cannot be applied to the general public. This was not an experimental design. Outcome measures were based primarily on subjective feedback (a VRS), which potentially allowed for the introduction of bias, placebo effect, and decreased reliability of findings. The patient was seen at a college chiropractic clinic, where one individual (an intern) was responsible for treatment and daily notes and another (the author) was responsible for overseeing the case. The lack of personal interaction between the patient and myself on a treatment-by-treatment basis might have decreased the quality of both subjective and objective information. I recommend that a well-designed, controlled, double-blind study with a larger sample size be conducted on the efficacy of chiropractic treatment and central canal stenosis.
This case report demonstrates successful management of symptoms either caused by or complicated by central canal stenosis. The flexion-distraction technique might provide an effective method of improving spinal biomechanics, allowing for the normal dynamic increase in canal size and subsequent symptomatic relief. Further study of this method is warranted to determine whether it can regularly provide relief for afflicted patients seeking nonsurgical management.