A Triumvirate of Treatments

Editor's note: This is a compilation of three short articles from Dr. Joseph Kurnik, a practitioner from Torrance, California and frequent contributor to the California Forum.

• Undetected Thoracolumbar Problems • Lumbar Traction and Sacroiliac Joint Function • Right-Sided Lumbosacral Pain

Thoracolumbar problems here refers to lower thoracic and upper lumbar problems. More specifically, when examining this area in the seated position and placing the spine into extension, the upper lumbar or lower thoracic spine may appear to be normal or hypermobile. If you leave it this way and go to other areas, you may miss a great opportunity of discovering a hidden problem.

You should place the patient, which should include low back pain sufferers, in the prone position unless antalgic and unable to lie prone. You need to examine the lumbar and lower thoracic spine by testing in two main directions. These two directions are tested in the prone position:

1. testing posterior to anterior;

    

2. testing P to A and inferior to superior, at an upward angle, so as to induce slight traction simultaneous with P to A pressure.

Extension problems are easier to detect when tested in the prone position. The "seated screen" test used in motion palpation is a good overall test, and I use it on every patient. I can however refine my accuracy by double-checking in the prone position all regions from L-5 to T-1, with special emphasis at the upper lumbar and lower thoracic regions.

I have found that this region can be most difficult to analyze and treat. Seated palpation may show an overall flexible lumbar spine, but when placed in the prone position; the spine is stabilized and individual extension restrictions can be detected. Previously, these extension restrictions were hidden by the overall flexibility of the lumbar and lower thoracic spine region.

I have also found that the correction of this region by adjustment is most easily achieved with an incline table. I use a table which is similar to the Pettibon style, but with some modifications which make adjusting easier for me (see DC, October 11, page C-4). Patients with very long and flexible arms, or very short and stocky arms, may not be suitable to this type of adjustment; Seated rotation and extension, or prone or supine adjusting, may be more effective.

Most of my patients, however, are easily treated in the incline position.

Of particular interest are the numbers of sacroiliac dysfunctions that clear or improve after treating the extension fixation at the thoracolumbar region. Motion palpating the SI joints before and after thoracolumbar adjusting will indicate the amount of SI functional restoration achieved.

Lumbar Traction and Sacroiliac Joint Function

The sacroiliac joints have an important function with regard to stabilization of the lumbar spine. Through the process of nutation or counter-nutation, the sacrum can be re-angulated. This re-angulation, even though minor, can affect the stress and stability of the lumbar spine, especially at the L-5/S-1 level.

During palpation examination and visual analysis, what one finds often is sacroiliac compensation for lumbar disorders in the form of AS (anterior superior) and PI (posterior inferior) hypomobile fixations (dysfunctions). Sacroiliac compensation also exists for thoracic kyphosis, dysfunction, and other problems. With relationship to the lumbar spine, L-4/5 and L-5/S-1 facet and lumbar disorders can exist, that cause frequent ilium AS fixation patterns, and less frequent PI ilium fixation patterns. As previously described in other DC articles, the lower lumbar segments exhibit rotation patterns which cause sacroiliac compensatory AS and PI ilium fixation patterns. In addition to lumbar rotation patterns, lumbar facet imbrication (facet compression) patterns can exist, especially in the L-4 and L-5 levels, which cause further sacroiliac compensations.

With regard to AS ilium fixation compensation reactions to lower lumbar facet compression, the most frequent and usual reaction is the bilateral AS ilium fixations, and less frequently the left or right AS fixation compensation. If lower lumbar rotation is not a concern, but lumbar posterior compartment compression is the concern (such as an L-5/S-1 facet syndrome with L-5/S-1 disc thinning); then segmental traction of L-5/S-1 can be done. Typically, a contact on the L-5 spinous process is made, and the L-5 segment is tractioned superior. If the AS fixations are monitored before and throughout prior to and after traction, you can frequently witness a partial or complete release of the AS ilium fixation patterns. This is a useful diagnostic tool. If no AS ilium fixation release is noticed; the procedure is not what is needed. If the AS fixation pattern is compensatory, then you will usually see a change in the SI patterning with the proper treatment. There may be other contributing factors, such as:

1. thoracic kyphosis;
2. lumbar rotation dysfunction;
3. thoracic dysfunction.

Several such factors may be simultaneously contributing to the SI compensatory patterning. If so, and if each of these are treated, SI functioning should improve as determined by motion palpation.

With regard to the tractioning of the lumbar segments with spinous contacts, frequently there will be too much tenderness at the site of the pain, and you are unable to traction comfortably the compressed lumbar or lumbosacral joint. A deviation from normal procedure may solve this problem. Instead of tractioning by contact on the spinous process, contact the mid-sacral region with one palm. With the other hand, depress the traction table so that the caudal end flexes anteriorly towards the floor while the contact hand tractions the sacrum inferiorly and anteriorly. Frequently, the lumbar tenderness will be absent or reduced, symptoms will improve, and sacroiliac fixation compensation will be reduced (i.e., the AS ilium pattern will be absent or decreased).

In summary, the analysis of sacroiliac functioning often supplies information about the effectiveness of your treatment.

Right-Sided Lumbosacral Pain

This is a unique, yet common disorder. Right-sided lumbosacral pain can be more difficult to control than left-sided pain. Excluding significant lumbar disc injury and transition elements, a few situations emerge most commonly:

1. unilateral right sacroiliac AS (anterior superior) fixation dysfunction;

    

2. L-5 rotation, in the form of an LP-type listing. This means that the spinous process has deviated right, and the left mammillary process has deviated left posterior. In motion analysis, the left side of L-5 resists P-to-A motion and favors right-sided P-to-A motion. That is, the left side of L-5 is posterior, and the right side is anterior. There is right-sided facet compression at L-5/5-1. This can create pain on the right side. It can also create pain on the left side as a result of distraction at the left L-5/5-1 facet interface.

    

3. L-5 rotation, combined with a compensatory right AS ilium compensation, which has turned into an articular fixation. This is the most intense form of right-sided, nonpathological, functional right-sided lumbo-sacral pain.

What are the solutions to this type of situation? There are common solutions and complicated solutions. Sometimes, these complexes are combined with upper lumbar extention and lower thoracic extention dysfunctions. Most of the time, however, this right-sided lumbosacral pain is related to situations #2 and #3 above. With #2 (L-5 LP listing), the right-sided L/S pain can be alleviated with an L-5 LP adjustment. In case #3, the right-sided L/S pain can be alleviated with an L-5 LP adjustment, followed by a right AS ilium adjustment. An LP L-5 adjustment is accomplished with a left-sided L-5 contact and thrust situation. Example #3 above elicits the deepest and most severe pain and dysfunction. Ultimately, examples #2 and #3 may lead to hip joint pain and pathology, groin pain, anterior thigh pain, anterior knee compartment pain or disorders, ischial tuberosity pain, and hamstring disorders.

Joseph Kurnik DC
Torrance, California