The Treatment of Chronic Refractive Radiculopathy

with High Power Laser Therapy

Authored by Joseph A. Costello Jr. DC

HISTORY:

A 47 year old eastern European male patient presented with a long term history of back and left leg pain of 10 years duration. He denied any bowel and bladder signs. He had failed all forms of conservative care which was available to him in his country. He refused surgical intervention. Traditional treatment options for this patient would typically have included a series of epidural steroid injections, pain medication, acupuncture, physiotherapy, and spinal manipulative therapy.

CLINICAL PRESENTATION:

Weight: 197 lbs.

Neurological:

DTR: 2/2, left achilles was 1+ with reinforcement. Dermatomes reveled left S1 hypesthesia. Myotomes showed EHL_s 5/5 and symmetrical. Circumferential mensuration reveled no atrophy of either calf. Heel/toe walking was also 5/5.

Orthopedic:

SLR was classic on the left for radiation into the foot @ 30 degrees, 70 degrees on the right. The left sciatic notch was exquisitely tender on the left. Springing maneuver was painful at L5/S1. Sitting SLR combined with long axis traction and popliteal compression were classic for extreme leg/buttock pain. ROM reveled that his leg pain was exacerbated by flexion and alleviated by extension.

Orthokinetic weight-bearing:

Bilateral subtalar pronation was noted more so on the right which resulted in slight inferiority of the right hemipelvis. No tibial or Femoral torsion was noted.

Diagnosis:

Chronic left S1 radiculopathy complicated by kinetic chain dysfunction.

Treatment Plan:

Prior to initiating therapy, the patient was prescribed custom fabricate orthotics which were posted as follows: Rearfoot posting: 5 degrees varus, forefoot posting 6 degrees varus in order to correct the kinetic chain dysfunction and to create an "optimal healing environment". The patient then underwent flexion/extension provocation testing. It was noted that he had dramatic centralization of his left leg pain with hyperextension coupled with right side bending. The patient began High Power Laser Therapy (12 watts, for 10 minutes) to the following locations: L5/S1 disc, Left Sciatic notch, and left common Peroneal nerve. He was treated daily, 5 days a week, for 2 weeks. At the end of the 10 treatment sessions, the patient indicated a reduction in pain and activity intolerance of between 60-70 %. His supine and sitting root tension signs had also dramatically improved.

Discussion:

Laser therapy is classified as an Actinotherapy which results in biostimulation of the

Chromophores inside the mitochondria of each cell (1,8). This photo-stimulation results in increased cellular metabolism. Although the High Power Laser is warm, the results are photochemical and not thermal (8). Biostimulation translates into reduction of inflammation, increased blood flow, nerve regeneration and lymphatic drainage(5,6). Regarding patients suffering from back and leg pain, the High Power Laser is thought to decrease inflammation of the disc and nerve root as well as aid in nerve regeneration. Healing of annular defects in the outer 1/3 of the disc (which is vascularized) have the ability to heal(9). In order to achieve optimal healing and long term results, it has been found in a clinical setting that all biomechanical abnormal forces need to be removed so healing is not interrupted or compromised during gait.

Summary:

High Power Laser Therapy has the ability to reach deep within the body when compared to Low Level Laser Therapy(8). When used in a patient whose biomechanical abnormalities have been corrected, the results achieved seem to be long term in nature. This may also be due to the fact that laser energy appears to also biostimulate collagen and fibroblast growth which would enhance the tensile strength of the annular fibers of the degenerative disc patient (1,2,3,4). Clearly, further investigation regarding a blinded study with pre and post MRI evaluations is necessary to help further visualize the anatomical effects of photo-stimulation with High Power Laser Therapy.

References:

1. Effects of infrared laser exposure in a cellular model of wound healing.Skopin M and Molitor S, Dept. of Bioengineering, University of toledo, Toledo OH.
2. Mester E, Mester AF, Mester A (1985) The Biomedical effects of laser application. Lasers Surg. Med. 5.31-39.
3. The influence of low level infra red laser therapy on the regeneration of cartilage tissue. P Lievens, Ph. Van der Veen.

4. Therapeutic low energy laser improves the mechanical strength of repairing medial

5. Double-blind randomized study evaluating regeneration of the rat transected sciatic nerve after suturing and postoperative low-power laser treatment. Journal of Reconstructive microsurgery. 2001; 17 (2): 133-137. Shamir MH, Rochkind S, Sandbank J, Alon M.

6. Effects of laser irradiation on the spinal cord for the regeneration of crushed peripheral nerve in rats. Lasers in Surgery and Medicine 2001, 28(3): 216-219. Rochkind S, Nissan M, Alon M et al.

7. Assessment of laser therapy for late postoperative pain after lumbar fusion surgery and for pain and wound healing after acute traumatic injury- preliminary results. Biyani A, Skie M, Goel V, Ciocanel D, University of Toledo School of Medicine.

8. Class IV "High Power" laser therapy in Chiropractic and rehabilitation. Wertz R.,Dynamic Chiropractic- 2006 vol. 24, issue 23.

9. Vascularization of the intervertebral disc in pathological conditions. Moore R,