THE VERTEBRAL SEGMENT LESION, A NEW OSTEOPATHIC APPROACH TO THE SPINE

When we began applying the Mechanical Link (Lien Mécanique Ostéopathique or LMO)[2] to the spine, the idea was simply to:

replace classical mobility tests with tissue tension tests,

replace vertebral manipulation with the recoil.

This approach, completely new at that time, allowed us to reconsider the way to test and treat the vertebral lesion as it is classically described[3].

In practice, we would proceed with a global test applying pressure to the spinous process to determine which of the vertebrae are in lesion and analytical tests in flexion, extension, rotation, side bending, translation and decompression to determine the parameters of the lesion to be treated[4].

This procedure worked well for years since it allowed us to efficiently correct articular vertebral lesions without the disadvantages or contraindications of structural osteopathy.

Over time, we observed a number of vertebral lesions that were not compatible with the model of articular dysfunctions as classically described.

What is the value of Fryette’s laws when presented with severe facet osteoarthritis, transitional lumbosacral anomalies, anterolisthesis, vertebral fracture, or major scoliosis?

In the case of a vertebral rotation, how can we treat specifically and therefore, differently, the posterior aspect of a vertebra on one side and the anterior aspect on the other?

How to manage vertebral instability?

What to do with an intraosseous lesion such as vertebral torsion[5] or the rigidity of a vertebral line of force?

How to treat a disc lesion in a specific way?

How to manage the spine in the presence of surgical hardware [6]? Etc.

The answer to all these questions was found when we no longer reproduced classical tests but rather began to search with precision for the part of the vertebral segment to which we apply the recoil.  We then realized that it is more important to determine the point of blockage (lesion) rather than test the possibilities of movement of the vertebra (dysfunction).

 

In practice, the blockage of a vertebral segment may be located:

- either on the vertebra (articular or intraosseous lesion),

- or in the intervertebral space inferior to that vertebra (muscular, ligamentous, neural or disc lesion).

 

[1] We present here the process that took us progressively from a classical biomechanical point of view (articular dysfunction) to a model of tissue lesion affecting an element of the vertebral segment. This is not only a tactical change (the technique) but a change in strategy (the method).  

[2] See the article Mechanical Link: Foundations

[3] At this stage, the technical approach changes but the biomechanical model remains the same.  We still talk about a vertebra in flexion, extension, rotation, side bending  or translation.

[4] Several studies have shown the reliability and reproducibility of LMO tests on vertebrae:

- Reliabilitätsstudie über der Befunderhebung der Wirbelsäule nach der Methode der Lien Mécanique Ostéopathique, Master Thesis zur Erlangung des Grade “Master of Science” in Osteopathie an der Donau Universität Krems – Zentrum für chin. Medizin & Komplementärmedizin. By Claudia Hafen-Bardella, 10.2009. -- Follow-up-Studie über die Reliabilität der Befunderhebung der Wirbelsäule nach der Methode des Mechanical Link. By Laura Kühn, 01.2018

[5] See the article: Skoliose: Neue osteopathische Annäherung Die Lien Mécanique Ostéopathique (LMO) in der Anwendung,Dezember  2020 CO.med (or see blog article:  Scoliosis: a new osteopathic approach)

[6] Osteosynthesis, disc prosthesis, laminectomy, etc.

 

From these observations, we developed a new procedure which, although simpler, offers many more possibilities for the diagnosis and treatment of the vertebral osteopathic lesion.

 

General examination of the spine

 

Basic test using pressure-circumduction in the axis of the spinous process to diagnose the potential lesion of a vertebral segment.

Inhibitory balance tests to prioritize the different lesions found and find the dominant vertebral lesion.

This general examination is applied systematically with all patients[1] in every consultation.  The basic test sequence is quick, non-invasive (no mobilisation of the spine) and very comfortable.  In practice, the complete examination of the spine (from the occiput to the coccyx inclusively) with the diagnosis of the dominant lesion and the secondary lesions only requires 2 to 3 minutes.

 

 

[1] From babies to the elderly, the protocol remains the same.

Basic test of the vertebral segment

Treatment of the vertebral segment in lesion.

 

a) Specific tests of the 6 key points of the vertebral segment including:

- 3 key points for the vertebra (spinous process and transverse processes)  

- 3 key points for the inferior intervertebral space (interspinous and intertransverse).

The objective of the specific tests is to determine the point of blockage of the vertebral segment that may be located either on the vertebra as such, or in the intervertebral space tissue.

Vertebral segment: vertebra and intervertebral space

b) Analytical tests on the point of blockage to direct the recoil.

The recoil is always applied to the major point of blockage.

In some cases, such as the intraosseous torsion or vertebral compaction, it is useful to combine two distinct points of contact in the correction (combined treatment).

Take note that, in the cervical spine, only an anterior approach allows intervention on the uncinate processes.  Similarly, to correct a lumbar anterolisthesis, an anterior (abdominal) approach must be used.

 

Since it is not possible within the limited scope of this article to describe all the possible lesional patterns of the vertebral segment, the following are two particular osteopathic lesions: the spinal line of force and the disc protrusion.  These two lesions are both common and difficult to treat.  They are a clear illustration of the difference between the articular dysfunction model and that of the osteopathic lesion of the vertebral segment.

Spinal line of force

We empirically discovered the existence of this very particular osteopathic lesion during a consultation. The patient presented a clear vertebral blockage (positive basic test) but the systematic adjustment of all the articular restrictions achieved nothing: despite all our attempts at correction, the vertebral remained desperately blocked.  Intuitively, we then came up with the idea of applying a recoil to the spinous process, in the direction of the vertebral body.  And to our great surprise, the vertebra immediately released!

As is the case with any bony piece, the vertebra is subjected to constraints that orient its fibrillary network into lines of force.  These lines run throughout the spinal axis in a continuous manner.  By crossing, they allow the shock absorption and distribution of constraints on the vertebral tripod.

Abnormal rigidity in a spinal line of force is generally accompanied by a “lack of springiness” in the entire vertebral axis.  As a matter of fact, it is quite spectacular to witness how much straighter a patient may spontaneously be following the simple adjustment of a spinal line of force.

 

How to correct a spinal line of force lesion?

For the recoil, the practitioner is positioned on the spinous process then, using pressure in the direction of the vertebral body, seeks active resistance opposing his pressure.  From this point, the practitioner applies a short and dynamic impulse along the axis of the spinous process.  The specific test is then used to verify that the vertebra has indeed recovered normal intraosseous elasticity.

Spinal lines of force

Disc protrusion

We often see in practice patients suffering from disc herniations.  The disc protrusion, whether posteromedial or posterolateral, is part of several clinical presentations such as cervicobrachial neuralgia, lumbar pain, sciatica, spinal stenosis, etc.

Disc herniations give a clear illustration of the difference between articular dysfunction and osteopathic lesion.  Indeed, when the disc material protrudes posteriorly, it naturally results in vertebral dysfunction in flexion.  It would be an error here to correct the vertebral dysfunction (the consequence) rather than treat the disc protrusion (the cause)[1].

 

 

[1] Hence certain aggravations reported by patients following vertebral manipulations or even functional techniques although reputed for being inoffensive.  In fact, it is not so much the way to treat than the osteopathic diagnosis that must be reconsidered.  No matter what technique is used, the adjustment must be applied specifically to the disc lesion rather than to the articular dysfunction.

Disc protrusion

How to correct a disc lesion?

Here, the recoil offers a simple and efficient solution, without contraindications.  For safety and comfort, particularly in the acute phase and/or with nerve pain radiation, it is preferable to treat the patient in prone position[1]. We proceed the same way for the lumbar spine and the cervical spine[2].

Specific tests of the intervertebral space allow us to find the exact point of blockage corresponding to the disc herniation[3]. A positive test is generally confirmed by the loss of physiological lordosis at the level involved, patient feedback (increase mechanosensitivy of that point) and medical imaging (when available).

For the recoil, the practitioner positions his thumb in the intervertebral space, over the point of resistance diagnosed with the specific test.  Tension is applied by following the respiration of the patient and according to a well-defined procedure[4]. The resulting effect is usually immediate: the spine regains a more supple lordosis, and the patient feels rapid relief.  Rest and, if necessary, anti-inflammatory treatment may complete the osteopathic treatment. Beyond the clinical results, albeit compelling, it would of course be interesting to objectivate the reduction of a disc herniation using medical imaging[5]. Unfortunately, unlike scoliosis where we can follow the evolution with different X-rays, it is difficult to obtain new MRI scans once the patient is better!

 

To conclude this brief overview of the new possibilities offered by the LMO treatment of the spine, it is worth repeated that the lesion of the vertebral segment must be addressed in the context of the total lesion.  The dominant vertebral lesion must always be balanced against other dominant lesions (peripheral, visceral, cranial, vascular, etc.) to determine the primary lesion of the patient.  Normalisation of a vertebral segment is not always (or not only) achieved through vertebral adjustment!

 

The first course of the Mechanical Link basic course series,  LMO1: Introduction to Mechanical Link in practice with the spine and thorax, presents the Osteopathic Mechanical Link methodology and its practical application to the occipito-vertebro-pelvic axis and the thorax. 

 

 

[1] If this is not possible, the patient may be in side lying position, on the side found most comfortable (generally the side opposite to the pain).

[2] At the thoracic level, disc lesions are less frequent.  They are not approached directly, but rather through the head of the rib in contact with the corresponding vertebral disc.

[3] Depending on the type of disc protrusion, posteromedial or posterolateral, the point of blockage in the intervertebral space will be more or less close to the interspinous line.

[4] The modalities of recoil and the precautions to take in the case of disc lesion partly depend on the clinical picture. Even if the recoil seems to be a simple and inoffensive technique, its application needs to be well mastered.

[5] We have treated a patient suffering from low back pain with acute radiations to the lower extremity.  Despite a strict resting regime, the medical treatment hadn't provided any improvement and the MRI showed a major disc herniation at L1-L2. The osteopathic treatment gave a rapid and perfect result with only one session. After several months, the control MRI objectified a complete resorption of the hernia.

 

 

Eric Prat DO