By Thomas V. Giordano, D.C.
This case deals with the Chiropractic Management of a 12 year-old
girl who showed a marked improvement in a chronic Autonomous Neurogenic
Bladder (ANB) secondary to a surgically re-positioned myelomeningocele
caused by Spina Bifida Manifesta while being treated for a functional
This was one of the most satisfying cases I have handled. I believe
it exemplifies what we, as Chiropractors, can accomplish with
interprofessional cooperation for the benefit of our patients.
On August 20, 1991, Valentina C. and her father, presented themselves
to my chiropractic office for a consultation for scoliosis. They
were referred to me by Dr. Antonio M., a staff neurosurgeon at
a local hospital.
Valentina had recently had an orthopedic consultation for the
spinal complaint and pain with weakness in dorsiflexion of the
right foot when walking. When the orthopedist requested an EMG
of the sciatic nerve and prescribed a L'NARD boot, Dr. M. raised
an objection, intervened and requested they try a chiropractic
approach to the problem (for complications which will become obvious
Valentina, a twelve year-old student, was born with Spina Bifida
Manifesta (L5-S3) and a myelomeningocele. At the age of four years,
she underwent neurosurgery (by the same Dr. M.) to re-position
the escaped contents of the spinal canal. The surgery was successful,
but she developed a "clubfoot" and a spastic urethral
sphincter, necessitating two surgical catheterizations following
enteric bacterial infections of the urinary bladder with vesiculoureteral
Although hydronephrosis was evidenced prior to the surgeries,
no kidney damage occurred because of the timely interventions
of Dr. L., the young girl's urologist.
The patient's father reported that, for the last eight years,
Valentina had lost the "stimulation" to urinate and
had to catheterize four times per day to void her bladder. She
was able to void 20cc of urine with light pressure, but about
180cc had to be catheterized. Unfortunately, she was under constant
observation due to recurrent bladder infections - the last one
being on the 29th of June (1991) from Klebsiella pneumoniae.
(N.B.: as a sidenote, intraureteral water pressures are between
10 to 12 cm, but can increase to between 50 and 200 cm w.p. with
forced voiding of the bladder. Bladder obstruction, therefore,
can result in a vesiculoureteral reflux, increasing the possibility
of progressive, hydrostatic damage to the kidney. Patients are
advised not to force urination against a spastic sphincter for
this reason. Unless absolutely sterile procedures are followed,
the catheter can provide a direct route of entry for bacterial
- both staphylococcus sp. and enteric - infections. Its a sad,
but necessary, trade-off!)
Valentina had entered menarche. Her mother became alarmed seeing
her daughter in a swimsuit and noticing a scoliosis. As was their
habit, they took immediate action to try to rectify the situation,
but the orthopedist's approach was, to their minds, "too
aggressive" and they didn't want Valentina to suffer further
"inconveniences with long hospitalizations, tests and radical
treatments" as she had already been through so much.
My notes only indicate the areas which stood out from the norm:
1) A prominent "fat pad" from L5 to the sacral apex.
The area was hyperpigmented and "tufted" with hair.
Of special note was a clean, well marginated and granulated incision
scar running sagittally from L4 to the sacral apex, and; 2) a
global hypotrophy below the right knee which my notes indicate
as "reminiscent of Dejerine-Sota's peroneal nerve atrophy".
The right foot was severely cavus with an eversion and internal
Sacrum: Light palpation around the "fat pad" indicated
"well-defined margins" and produced no discomfort for
Right leg and foot: The Tibialis Anterior muscle was "taught"
and "band-like". The area of the insertion of the Achilles'
Tendin was indurated and "hyperkeratinized". Passive
dorsiflexion and plantar flexion were present to normal ranges,
but there was no discernible movement of the tarsals, metatarsals
nor the phalanges. The plantar aponeurosis was also recorded as
"in extreme tension" in my notes.
Right everted and internally-rotated pes cavus, genu valgum, right
leg dismetria with attendant PI Ilium and "s" italic,
functional (Adam's POS), scoliosis (right convex lumbar; left
GAIT: Foot drop on the right noted with claudication.
Lasegue's complex, Valsalva's, Naffziger's, Sotto-Hall's all NEGATIVE;
Ober's (bilat.) - Negative; Ely's Test and Sign (bilat.) - Negative;
Knee evaluation - negative bilaterally for pathology, dislocation
DTRs - (L4-S1) P&N bilaterally; Superficial Reflexes (T10-L2)
- Present bilaterally; No loss of sensation at all levels.
MUSCLE TESTING - Right Ext. Hallicus Longus - Weak (4 of 5) on
the right; Dorsiflexors 5/5 bilaterally (This was an odd finding
to me!); Babinsky's reflex was negative bilaterally.
PI Right Ilium; AS Left, PIR Sacrum, L5 (indecipherable due to
the anomalous formation), T12 - Anterior; T8 - PLS; T1 - PL; C2
- BPSL; C1 - ASRP.
This first visit ended with my ordering orthostatic, full spine
films in AP and LL for scoliosis - something the orthopedist hadn't
ordered only days before after his visit. The next day, the patient's
father returned the films to my office and I reviewed them in
his presence. The initial, clinical observations were confirmed.
(08/21/91): AP & LL C/D/L/S and Pelvis in Orthostasis:
AP View: SBM of L5 - S3 noted. 16 deg. right convex, non-rotatory
lumbar scoliosis with compensatory dorsal deviation (left). Dismetria
on the right of 7mm at the level of the femoral heads; 14mm at
the iliac crests. Pelvic obliquity noted - PI right; AS left.
LL View: Ant. rotation of the pelvii. SB Angle = 48 deg.; L5 Disc
Angle = 15 deg.; GWL lies midway through the sacral base.
No other evidence of fracture, tumor, or dislocation noted.
My treatment plan was directed toward addressing the pedal fault
and reducing the functional scoliosis by means of pedal orthotics
and exercise and, when the opportunity presented itself, correction
of the subluxations. The patient reported to the office the next
day (the 22nd) for a temporary heel lift on the right
and a podometric study to quantify the pedal defect.
By the 29th, Valentina was already out of pain simply
using the orthotics. Her functional scoliosis was noticeably reduced
and her deambulation was near-normal with no "wobbling"
secondary to the pelvic obliquity. It was nearing the time for
me to start adjusting, after this brief period of adaptation to
The first time on the table, the PIR sacrum, the PI right Ilium
and C2 were adjusted. The patient reported feeling a "warm"
sensation in her right foot. The visit ended, and they left.
An hour and a half later, a very excited Sig. C. returned to the
office to tell me that Valentina, one-half hour after the adjustment,
had the "urge" to urinate - a sensation she had forgotten
in eight years - and that one hour post-adjustment, urinate she
did - a full 200cc (and 20cc with the catheter). She was used
to urinating 20cc and 180-200cc with the catheter, so this alteration
relieved, but frightened her.
I told her father to tell her not to force the urination, to contact
the urologist and report the event and to keep me informed. Over
the course of the next two weeks, her stimulation to urinate normalized
and the non-forced volume of urine gradually increased without
the catheter in progression 20cc-40cc-60cc to eventually 180cc.
The urologist became alarmed at this and ordered testing for reflux.
With forced urination, no reflux was evidenced to the ureters,
but he gave orders to continue with the catheterizations. He called
my office to see what I was doing with the patient and what had
caused the changes. He admitted not knowing anything about chiropractic
procedures, but listened attentively as I described Valentina's
protocol. I explained to him that I was in no way "treating"
Valentina for her spastic sphincter, but rather, for her functional
scoliosis and foot drop (which had already greatly improved).
He then told me he had already talked to Dr. M. about the case
and was seeking information as to the possible mechanism behind
the release of the spastic sphincter, to which the neurosurgeon
only told him," ... it's just another chiropractic marvel;
obviously, Giordano reduced a lumbosacral subluxation that freed
the nerve roots." My explanation was a bit more precise,
and we began to coordinate our activities to follow Valentina
toward a very good outcome.
Over a period of a few months, she was freed from the catheterizations
and the recurrent bladder infections. Although her pes cavus persists
to this day, there is movement and no eversion nor internal rotation.
She came in PRN until 1993, but I haven't seen her in a bit.
The loss of "stimulation", the spastic sphincter muscles
and the low urinary volumes was actually what is referred to as
an "Autonomous Neurogenic Bladder"(ANB).
This is one of four types of "Neurogenic Bladder", which
is distinguished from the others by involving the sacral cord
or cauda equina, resulting in an interruption of afferent baroreception
and efferent stimulation to the urethral sphincter muscles in
the reflex arc. The overall effect of this is that sensation is
abolished, both reflex micturition and voluntary control are lost
and the bladder empties in reduced contractions by local myoneural
In Valentina's case, however, some interesting things were noted,
it was not the "classic" ANB: 1) she had voluntary control,
but no stimulation (meaning the afferent stimulation from the
bladder-wall baroreceptors was blocked (or not interpreted); 2)
there was no evidence of a flaccid paralysis of the bladder (the
detrissor muscles were not atonic), and; 3) there was evidence
of sciatic nerve involvement - the "clubfoot".
It occurred to me, upon reflection afterwards, that I was actually
looking at an afferent input block at one segmental level (the
lost stimulation) and an efferent output block at a higher segmental
level - resulting in clonus of the plantar aponeurosis, tibialis
anterior, gastrocnemius and flexor digitori of the right foot.
Since these events demonstrated themselves as an immediate sequelae
of the surgical repositioning of the myelomeningocele, it couldn't
have been the result of cicatrical formation (fibrous adhesions).
One may argue that Valentina's reaction was secondary to the reduction
of the pelvic obliquity, as well. It must be remembered that the
intrapelvic organs are all positioned by ligamentous attachment
to the sacrum and pelvii and that the reduced "torsion"
allowed function to normalize, but I consider this unlikely. She
was "aligned", as it were, by the orthotics, which reduced
the genu valgum attendant to the pes cavus. The functional scoliosis
I specifically waited to begin adjusting, as it has been my experience
that these orthotics aid in the adjustment and reduce the repetitive
subluxation patterns often seen in patients with functional scolioses,
and, quite frankly, I was frightened as hell to adjust these wide-open
segments! I usually give the patient two days to a week to "adapt"
to the stress of the orthotics before thrusting at the spine.
As far as the immediate "warm" feeling of the foot post-adjustment,
there are two possibilities, to my mind: 1) reflex arterial vasodilation
- the sciatic nerve also serves the tunica media (muscularis)
of the arteries serving the leg, and; 2) the muscular relaxation
of the clonus, which reduced the intramuscular pressure, permitting
capillary filling. Spasms produce an intramuscular pressure more
positive than the capillary pressure trying to serve them.
Further, research has recently shown the effects of Nitric Oxide
(NO) in both vasodilation and muscle relaxation. Nitric Oxide
Synthase (NOS), which governs the production of NO, is produced
in every cell of the body. NO is a potent neurotransmitter and
has been implicated in EVERY DISEASE STATE! This may also be tied
in to the phenomena of both the sphincter release and the vasodilation
It is a possibility that NOS activity and, hence, NO production,
is hindered at the terminal ends of entrapped nerves; thus no
vasodilation, no muscle relaxation, etc. (I'm still collecting
data on the tie in with the cytokines and NO, but that's for another
post on a possible model of VS which may be over-looked by our
It must be stated here that only after the adjustment did the
changes begin to take place! To my mind, and also to the neurosurgeon's,
the urologist's and the girl's pediatric GP's, there is only one
way to account for the events she experienced - the sacral subluxation
was reduced (in their terms); adjusted (in ours). The subsequent
decompression of direct, nerve root impingement was obtained and
the normalized, physiologic manifestations ensued.
I am a firm believer in the concept that there is a nervous component
in every aspect of the processes of health and disease - from
beginning to end. In this particular case, I can find no other
way to explain the reaction experienced by Valentina.