When assessing candidates for non-surgical spinal decompression, the following recommended criteria will ensure the highest level of favorable outcomes.
You, as the doctor, should always want a clear understanding of the patient’s source of complaint. An initial patient work-up should include a comprehensive history and physical examination, focusing your attention on the urgent issues. Use technology and, with decompression, Magnetic Resonance Imaging (MRI) is the modality of choice. Compliance, with inclusion and exclusion criteria parameters, is crucial.
As a result, it is incumbent upon the doctor not to abdicate the responsibility of interpreting MRI’s to general radiologists who have minimal training in spine MRI interpretation. By doing so, you are almost guaranteeing that, over time, a patient will get hurt. You, the performing doctor, should make the independent clinical decision to perform decompression.
What Patient and When to Use Decompression
Primary indications include discopathies (bulges, protrusions, prolapses, herniation and disc degeneration). Secondary indications can include sciatica and facet syndromes, should the condition result from compressive neuropathy secondary to disc pathology.
The most favorable age group is in the 30- to 60-year-old range, without the presence of severe degenerative changes and stenosis. Can the population of qualifying candidates be younger or older? Of course! Use good clinical judgment.
Although primarily indicated for single or multiple discogenic issues, the presence of a disc lesion is not the sole criteria. Correlation of symptoms, exam findings and imagery studies will sharpen your understanding of whether or not decompression protocol is justified.
As mentioned, absence of discogenic issues does not exclude a patient. The same holds true for the presence of one, as well. Seek the cause! Many present with MRI identified disc lesions, yet the complaint may derive from the sacroiliac joint, hip, piriformis and viscero-somatic origin, to name a few. Be clear on your understanding of the cause.
A list of contraindications would include sequestered disc fragments, some extruded discs and findings consistent with spinal cord or nerve compression. Imaging that demonstrates osteophyte complex, facet hypertrophy causing a mass effect, indentation, displacement, compression and the like, without signs or symptoms of neurological deficit, may be suitable for decompression, except when affecting the cord itself. Effacement of spinal cord or nerves secondary to disc lesions without myelopathy may also be suitable for decompression, but clinical correlation of all findings are required.
Of course, when faced with moderate to severe degeneration, desiccation and loss of disc height, vacuum phenomenon, non-contained disc disorders, transligamentous and vertical displacement of an extrusion can all have less than desirable outcomes.
The goal of decompression is to reduce intradiscal pressure while targeting a specific disc. Focused axial mechanical +Y translation (toe to head) traction has been shown to accomplish this. This reduction has a profound effect on the healing process via increased contact with blood supply and fibroblast migration. This, in addition to pain relief created by alleviating neurological compression by stretching soft tissue (i.e., stretch receptors, mechanoreceptors, etc.), makes decompression a logical and viable choice to the passive pain care regimen. Studies verify significant reduction of intradiscal pressures into the negative range to approximately -150 to -200mm/Hg, resulting in decompression of discs and nerve roots. This action promotes retraction of the herniation and facilitates the influx of oxygen, protein, and substrates. The promotion of fibro elastic activity stimulates repair and inhibits leakage of irritant sulphates and carboxylates from the nucleus.1
Since spinal decompression is relatively new in healthcare, the research has yet to catch up. However, preliminary studies, although limited, are very favorable in outcomes targeted in reduction of pain and an increase in activities of daily living. A six-week course of twenty decompression treatments significantly reduced the severity of chronic low back pain in 89% of treated patients from 6.4 to a 3.1 on the visual analog scale, where 0 is no pain and 10 is severe pain, after two weeks, and to 0.8 after completion of treatment. Oswestry Disability scores improved from 23.7 to only 5.5 at the end of therapy. No significant adverse events or safety issues resulted from these treatments.2
Observationally, my outcomes with decompression over the last few years have mirrored the above preliminary research results. The most important factor in achieving a favorable outcome is to have an accurate diagnosis, primarily through MRI results and, again, I urge every doctor utilizing decompression to maintain control over that decision by becoming expert at reading your own MRI’s. To use a computer metaphor; "Garbage in—garbage out."
Robert A. Kenul, D.C., has been in private practice on Long Island, NY, since graduating from Life Chiropractic College, Marietta, Georgia, in 1982. He has specialized in Applied Kinesiology, TMJ, Craniopathy. He began utilizing Non-Surgical Spinal Decompression in 2006.