J Manipulative Physiol Ther 2011 (Jul); 34 (6): 408–412 ~ FULL TEXT
Ralph A. Kruse, DC, and Jerrilyn Cambron, DC, PhD
Ralph A. Kruse, DC,
2417 W. 183rd Street, Homewood, IL 60430
Every practicing chiropractor has had the experience of helping patients who suffered from failed back surgery. Treating these patients, although common, is only sparsely documented in the scientific literature. This study was a retrospective study of 32 patients who had postsurgical low back pain. Cox flexion distraction technique was used with an average of 14 treatments over a two month period. There were marked reductions in pre post pain scores and no adverse effects were noted.
OBJECTIVE: Although chiropractic manipulation is commonly used for low back pain, applying this procedure to the patient with postlumbar spine surgery has not been adequately studied. The purpose of this retrospective chart review is to report on the results of chiropractic management (including Cox flexion distraction technique) of patients with postsurgical lumbar spine pain to determine the change in reported pain based on surgical type.
METHODS: Ten years of patient files from one chiropractic practice were electronically screened for lumbar spine surgery occurring before presenting for chiropractic care. Of the 58 patients with a postsurgical diagnosis, 32 files contained all pertinent components for this study including treatment with Cox flexion distraction manipulation (in addition to adjunct procedures) for at least 2 weeks and pretreatment and posttreatment pain measures using the Numeric Pain Scale (NPS) that ranged from 0 (no pain) to 10 (worst pain imaginable).
RESULTS: A change was observed in the mean pretreatment and posttreatment NPS pain scores of 6.4 to 2.3, a reduction of 4.1 of 10. The mean number of treatments was 14, with a range of 6 to 31. When stratified by surgical type, the mean change in pain was most remarkable in patients who underwent a surgery that combined lumbar discectomy, fusion, and/or laminectomy, with an average NPS pain reduction of 5.7 of 10. No adverse events were reported for any of these postsurgical patients.
CONCLUSIONS: The results of this study showed improvement for patients with low back pain subsequent to lumbar spine surgery who were managed with chiropractic care.
From the FULL TEXT Article
The rates of lumbar spine surgery have steadily increased over the past 2 decades1 even though the prevalence of low back pain remains approximately the same. In one recent study, Weinstein et al  performed an assessment of Medicare claims and enrollment data between 1992 and 2003 regarding rates of lumbar laminectomy/discectomy and lumbar fusion in beneficiaries older than 65 years. The results of this analysis revealed that regional rates correlated well over time. However, there was an almost 20-fold difference in rates between facilities, demonstrating a marked variation in surgical decision making and representing the largest coefficient of variation seen with any surgical procedure. These differences in opinion regarding the indication for lumbar surgery call to question the evidence and guidelines supporting such surgeries. In addition, the reoperation rates 11 years after lumbar surgery are between 17% and 28%, depending on the type of surgery (fusion vs decompression, respectively)  and failed back surgery syndrome, meaning persistent or recurrent pain after low back surgery, occurs in 10% to 40% of patients.  A recent study points out that there may be other options for low back pain aside from surgery, such as chiropractic management.  However, some people require surgery, and it is not clear if chiropractic may be able to assist these postsurgical patients.
As the rates of spinal surgery increase, the number of patients with failed back surgery syndrome will also increase. Rather than reoperation, chiropractic care may be beneficial for the treatment of postspine surgery pain. For patients who have experience surgery, it is theorized that after periods of hypomobility, as seen with surgical cases, manipulation may be able to assist with breaking up spinal joint intra-articular adhesions to promote increased range of motion.  At present, there is little published documentation of spinal manipulation on postsurgical patients in regard to both effectiveness and safety. Also, flexion distraction as a type of manipulation has only been documented in 4 case studies. [6-9] Gluck  reported on a 41-year-old man who had previously undergone 2 lumbar spinal surgeries for an L4/L5 herniated disk and had residual severe pain. Flexion distraction adjustments combined with passive modalities and active rehabilitative exercises over 16 weeks improved his pain, walking dysfunction, and sleep patterns. Estadt  describes a case of a 54-year-old man with a postlumbar microdiscectomy treated with flexion distraction, side-posture manipulation, passive modalities, and active rehabilitation. The patient's pain and disability diminished, and his ranges of motion and initially abnormal orthopedic tests returned to normal. In a prospective case series with 8 patients who underwent lumbar total disk replacement surgery and had residual, persistent low back pain, O'Shaughnessy et al  treated all patients with side-posture lumbar manipulation. After 1 to 10 treatments, all patients improved in at least one outcome measure (pain intensity, Oswestry Disability Index, or Fear Avoidance Beliefs Questionnaire). Although some postmanipulation soreness was documented, it was considered benign with no major or irreversible complications. Finally, in a recent case report by Kruse and Cambron,  a 55-year-old postal clerk with an L5/S1 posterior surgical fusion presented to a chiropractic clinic with subsequent low back and leg pain and was successfully treated with 13 sessions of Cox decompression manipulation. The patient had complete resolution of his symptoms with a reduction of his pain score from 5 to 0 of 10 and of his Oswestry score from 18% to 2%.
With the rates of spinal surgery continuing to increase, the incidence of pain subsequent to lumbar spine surgery is anticipated to rise as well. The purpose of this retrospective chart review is to report on the effects of chiropractic care (including Cox flexion distraction) on patients with postsurgical lumbar spine pain attending one chiropractic practice over the course of 10 years to determine the change in reported pain based on surgical type.
Little has been published on the effects of Cox flexion distraction manipulation (Figure 1) on pain experienced in patients who previously underwent lumbar spinal surgery. The results of this study demonstrate that postsurgical patients with subsequent low back pain seem to respond positively to Cox flexion distraction manipulation treatments. These results are similar to previous case reports in terms of their positive outcomes; however, the data included in this article stratify treatment results based on surgical type and include a much larger sample size than previously documented.
The group of patients in this study that had the greatest reduction in pain scores was the group that previously underwent “combination” surgery, meaning discectomy, laminectomy, and/or fusion surgery. These results may have been due to the fact that the combination surgery group had the highest average pretreatment NPS (7.7 of 10). The group that improved the least was the fusion group with an average change in pain of only 2 of 10. However, this group was the oldest (average age, 67.5 years) had the longest average number of years since surgery (24 years) and had the shortest treatment duration to maximum medical improvement. Likewise, 1 of the 2 patients in the fusion group was 46 years old postsurgical and did not improve over treatment time. More research is needed before conclusive results can be determined. The discectomy and laminectomy groups were somewhat similar in age, years since surgery, pre- and post-NPS scores, number of treatments, and duration of treatment. No postsurgical patients included in these results reported experiencing adverse effects from the flexion distraction treatment. This finding will need confirmation in larger studies.
First, because this is a descriptive study, these results may be biased by inclusion of only patients who chose to receive this form of care and who met the study criteria. Patients who withdrew from care, who did not choose this form of care, or who were not eligible for inclusion in this chart review may not have developed such positive results. Second, because this chart review is retrospective and all data were gathered by the clinician, there may have been some reporting bias. We attempted to minimize this bias through oversight by an IRB, but we cannot rule this out as a possibility. Third, the files were gathered based on the patient diagnoses used for billing. There is a possibility that not all patients were included due to data entry errors or a lack of diagnostic code for lumbar spine surgery in the patient's electronic file. Fourth, we report no adverse effects in this retrospective review; however, no follow-up calls were made to determine if there were any unreported postcare adverse effects. Finally, there were relatively small numbers in each of the surgical groups possibly leading to an over or underestimation of results.
The results of this study showed that patients with low back pain subsequent to lumbar spine surgery improved with chiropractic care. No adverse events were reported for any of these postsurgical patients.
Cox flexion distraction manipulation may successfully treat low back pain subsequent to lumbar spine surgery.
An average of 14 treatments for 2 months was used for postsurgical patients with low back pain.
No adverse effects occurred during treatment of the patients with postsurgical low back pain.