Distraction Techniques for Lumbar Pain
At the dawn of the 21st century there are still a great many patients still suffering from common lumbar pain syndromes. Fortunately, unlike just a few decades ago, we now have many treatments to help these patients. These treatments run the gamut from doing “nothing” (eg. bed rest or passive modalities only) to doing “everything” (for example, open spinal surgery, discectomy, laminectomy, and/or interbody fusion). Choosing an appropriate treatment for a particular patient, however, is a complex process.
Unfortunately for all concerned, the exact diagnosis is rarely clear cut. Using only the anatomical information found on imaging studies such as MRI and CT, the physician typically has a very low probability of making the proper etiological diagnosis for lumbar pain. The physician must also consider the patient’s complaint, abnormalities on neurological examination, limitations in activities of daily living, functional limitations, objective studies such as magnetic resonance imaging, EMG and nerve conduction studies, and other special studies that may be needed.
On top of all this, the physician must factor in the patient’s preferences. The patient’s lifestyle, personal preferences, prejudices, and philosophy toward medical interventions are the key final factors in determining which treatment will ultimately be given. Evaluation of any large group of patients—all having the same symptoms, findings, test results, diagnoses, and the same objective degree of disability—will reveal a wide range of prejudice in regards to suitable treatments. Some patients do not wish to take any medications whatsoever, while other patients may wish to use medications exclusively and not consider any other therapy. Still other patients will wish to have whatever therapy is available—no matter how aggressive and risky the treatment may be—as soon as possible. These patients are not unreasonable, they simply desire to do whatever may be necessary to get them back to “normal” as quickly as possible.
We now have the benefit of many years of research to demonstrate that old treatments that we once thought were beneficial (for example passive physical therapy modalities and lumbar traction) are no longer believed to be useful or beneficial to patients suffering from serious lumbar spinal or neurological injuries. It has also become more widely appreciated that traditional lumbar surgery—with or without discectomy, laminectomy or interbody fusion, with or without installation of surgical hardware—can help some severely injured and disabled patients. However, surgery is not a panacea for most spinal problems. We now understand that there are great limitations to what surgery can accomplish. For example, open surgery performed for relief of pain alone rarely has a successful outcome. Surgeries performed for reasons of progressive neurological deficit, on the other hand, are more often successful. Recent years have seen a decrease in the percentage of patients undergoing these types of surgery as a result of more stringent selection criteria. As a result, a much higher proportion of these surgically treated patients now enjoy good outcomes.
Many of our patients that only a decade or two ago would have undergone open spinal surgery can now be helped by treatments that are far less invasive. These treatments include procedures performed through a small incision less than one inch long such as microscopic discectomy. There are also many “less invasive” procedures performed with only the insertion of a large needle or catheter into the spine or perispinal tissues. These treatments include using a laser, rotors, clips, suction devices, or application of heat energy or radiofrequency energy to remove or alter part of the annulus or of the nucleus pulposus. Injection of agents that dissolve or chemically alter the nucleus or other spinal tissues have been used in this country and abroad for over two decades. These treatments have been well described in this and other publications.
...interventional but noninvasive therap(ies)... actively intervene in the disease process and help to bring about improvement in the patient’s symptoms, and the disease itself—but do so without penetrating the patient’s body.
Over the past decade a new procedure category has arisen: that of interventional but noninvasive therapy. Fortunately for today’s patients, therapies in this class actively intervene in the disease process and help to bring about improvement in the patient’s symptoms, and the disease itself—but do so without penetrating the patient’s body. The most useful of these— and the most widely used at present—are the lumbar distraction techniques.
Pioneering Lumbar Distraction
The first lumbar distraction technique to enjoy widespread use was the vertebral axial decompression technology (VAX-D®) developed in 1991 by Alan E. Dyer, PhD, MD, formerly a Deputy Minister of Health in Ontario, Canada. This VAX-D® device was shown to actually improve lumbar disk injuries and neurological symptoms in some patients. Despite a significant incidence of side effects, the procedure gained rapidly in popularity throughout Canada and the United States over the past decade because it could do what no other procedure had done before. This procedure could actually decrease the disability due to a herniated disk and actually affect the herniated disk without the need to physically invade the body.
A study conducted by Ramos and Martin in 1995 directly measured the effects of vertebral axial decompression on intradiscal pressure utilizing the VAX-D® and recorded significant reduction in pressure—up to -100 mm Hg—with applied tension in the upper range.1
VAX-D® began its use in the United States in the early 1990s and was quite widespread by the late 1990s. However, many physicians became disenchanted with several of the drawbacks of the VAX-D®. The device transmitted a general force to the lumbar spine and could not individually select a vertebral level. The device required a patient’s cooperation, and was dependent upon relaxation of the lumbar paravertebral muscles to allow distraction to take place while, at the same time, the therapy required the patient to maintain contraction of the shoulder girdles and cervical paraspinal muscles. Physiologically, this is a very difficult task to accomplish.
Despite some complications, VAX-D® therapy has remained popular throughout the United States due to the continuing benefit to many people with disabling spinal injuries—without the risks and costs associated with almost any surgical procedure. There are still many VAX-D® units in clinical practice.