SIMPLE PELVIC TRACTION GIVES INCONSISTENT RELIEF
TO HERNIATED LUMBAR DISC SUFFERERS.
EDWARD L. EYERMAN, MD
Journal of Neuroimaging June 1998
A new decompression table system applying fifteen
60 second tractions of just over one half body weight in twenty one-half
hour sessions was reported to give good or excellent relief of sciatic and
back pain in 86% of 14 patients with herniated discs and 75% of patients
with facet joint arthrosis. (Shealy, C.N.,Borgmeyer, V., AMJ. Pain Management
Herniated and degenerated discs can be shown at
discography-discomanometry to have elevated intradiscal pressures made even
worse by sitting and standing, thus preventing proper disc nutrition. Therefore
decompressing the over pressurized disc should allow for healing and repair
of disc prolapse, herniation and annulus tears. Serial MRI of 20 patients
treated with the decompression table shows in our study up to 90% reduction
of subligamentous nucleus herniation in 10 of 14. Some rehydration occurs
detected by T2 and proton density signal increase. Torn annulus repair is
seen in all. Transligamentous ruptures show lesser repair. Facet arthrosis
can be shown to improve chiefly by pain relief. Follow up studies for permanency
or relapses are in progress.
The DRS Mechanical Decompression Distraction System
was described by Shealy and Borgmeyer (1) to give relief of lumbar herniated
disc and facet joint arthrosis superior by 50% to conventional pelvic traction.
Twenty DRS treatments produced on midsagittal MRI a 50% reduction in one
case, and a 7mm distraction of 1.5 on SI was shown on lateral x-ray. (2)
Clinical improvement in 75 to 85% of subjects was reported. Does clinical
betterment correlate directly to improvement in MRI image and can MRI shed
any light on the mechanism of improvement?
That the abnormal disc has an elevated pressure
can be appreciated at discogram. It is postulated that this elevated pressure
interferes both with diffusion of nutrients from surrounding vessels into
the nucleus and with adequate patching or repair of the tom annulus. Nachemson's
group has emphasized lowering intradiscal pressure for 30 years. (3) &
(4) Neurosurgeons Rainon and Martin (5) at operation on a similar decompression
table measured in an L45 herniated disc a lowering of intradiscal pressure
from 30 to 50 mm above the normal 90 to 100 mmHg into the negative range
of minus 100 to 150 mmHg during 90 to 95 LB traction. Will such negative
pressures heal the annulus, rehydrate the nucleus?
The aim of the present study was to do before and
after MRI to correlate clinical improvement with any MM evidence of disc
repair in annulus, nucleus, facet joint or foramen as a result of DRS treatment.
A course of 20 DRS Lumbar De-compression treatments were given in 4 to 5
weeks to 18 patients, and a double course of 40 in 10 weeks to 2 more. Pull
of distraction was adjusted to one half-body weight plus IO lbs. Each session
consisted of 20 repetitions in 30 minutes of full distraction for 60 seconds
and 30 seconds of relaxation to 50 lbs. Distraction angle on pelvic harness
was varied from 10% for L5-S I to 20 to 25% for L4-5 herniations and above.
Subjects comprised 12 males and 8 females from age
26 to 74. Radiculopathy in 14 patients was from herniated discs of varying
sizes. (L5-S I level in 6, L4-5 in 6, and 1 each at L3-4 and L2-3). Radiculopathy
without disc herniation was present in 6 patients from foraminal stenosis
facet arthropathy and lateral spinal stenosis. EMGs confirmed radiculopathy
in all. MRI's before and after were obtained on high and mid field units.
Clinical status was assessed before, during, and after treatment with standard
analog pain rating scale of 0- I0 and a neuro exam.
Range of motion for spinal mobility (initially impaired
in all), myotomal weakness reflex and dermatomal sensory loss were tested.
A) MRI OUTCOMES
a) Disc Herniation: 10 of 14 improved significantly,
some globally, some at least local at the site of the nerve root compression.
Measured improvement in local or general disc herniation size varied in range
of 0% in 2 patients, 20% in 4 patients, 30 to 50% in 4 patients and a remarkable
90 % in 2 patients who had the number of treatments at 40 sessions in 8 weeks.
b) Facet joint arthropathy and foraminal compression cases showed no demonstrable
change save 2 cases with slight increase in height but not in
B) CLINICAL OUTCOMES
Irrespective of MRI status all but 3 patients had
very significant pain relief, complete relief of weakness when present, and
of immobility and of all numbness (save in 1 patient with herniation and
2 with foraminal stenosis without herniation). With disc herniation, 10 patients
of 14 had 10 to 90% improvement in pain and disability. Two had 40 to 50%,
one had only 20% with foraminal syndrome without herniation, 4 had 70 to
100 % improvement, one had 40 to 50 %, one with severe spinal stenosis had
only 25% and was sent for surgery. Degree of clinical improvement roughly
followed MRI changes but not totally with full correlation.
Improvement from DRS treatment clinical outcome
of radiculopathy whether from disc herniation or foraminal syndromes is more
impressive than most improvement shown consistently by MRI, at least with
today's techniques and short time of follow-up. Relief of pain and disability
by reduction of disc size is easy to argue in a small majority of this series.
A few patients have dramatic anatomic improvement. The others with minimal
or no significant MRI improvements are harder to explain. Also, many patients
improved very early in treatment, probably before MRI change could be seen.
Nutrient diffusion increase and tom annulus healing
resulting from lowering intradiscal pressures are likely causes of clinical
improvement when MRI anatomy is not much altered by distraction. Leaking
of important sulfates and carboxylates from the nucleus and posterior annulus
have been shown in recent studies. (6) and (7) lowering of intradiscal pressure
by DRS treatment likely can start to reverse these processes by allowing
fibroblast repair of the annulus outer layers and some nutrition to the nucleus.
Also penetration of nerves into inner annulus and nucleus of degenerated
prolapsed discs has been recently demonstrated and could play a role in pain
production. (8) Mechanical intradiscal pressure relief may help this feature
as well as giving structural stability.
(1) DRS distraction treatments afforded good or
excellent relief of pain and disability whether from herniated disc or foraminal
or lateral spinal stenosis.
(2) MRI showed imperfect correlation with degree
of clinical improvement but 10 to 90% reduction in disc herniation size could
be seen at least at the critical point of nerve root impingement in 10 of
(3) Two patients with extended courses of treatment
showed 90% disc reduction and one of these had early rehydration of the
degenerated disc at L4-5. An "empty pouch" sign on MRI at the site of previous
herniation was seen in these 2 patients.
(4) Foraminal and lateral spinal or facet arthrosis
cases causing radiculopathy without herniation also improved but without
(5) Annulus healing or patching in the herniated
disc can be shown by MRI and is postulated to be a primary factor in clinical
and MRI improvement.