Lower Back Pain and Sciatica: When Chiropractic Care Isn't Enough
- Dr. Lucas Marchand
- 4 days ago
- 5 min read
He came to me in a Ford Transit van parked outside his house, the way most of my patients do. He was 55, walked slowly to the door, and had been waking up at 3 a.m. for three months. The pain had started deep in his lower back and burned straight down his left leg. He'd tried ibuprofen. A heating pad. YouTube stretches. Nothing had touched it.
He sat carefully in the chair I keep near the van's rear doors, and when I asked him to describe the pain, he used three words without hesitation: sharp, burning, aching. All at once.
That should have been my first signal to slow down.
What sciatica usually is — and what it isn't
Most people who come to me with lower back pain radiating into the leg have some version of the same problem: the sciatic nerve — the longest nerve in the body, running from the lumbar spine all the way to the feet — is getting compressed or irritated. The usual culprits are a herniated disc pushing into the nerve root, or spinal stenosis, where the canal narrows and crowds the cord. Less commonly, a tight piriformis muscle can mimic the same symptoms, as can sacroiliac joint dysfunction or spondylolisthesis (a vertebra sliding forward on the one below it).
The vast majority of sciatica cases respond well to conservative care: chiropractic adjustments, targeted stretching, physical therapy, time. The prognosis is generally good. Most people get better.
But sometimes the pain is a signal for something else entirely.
The part of his history that changed everything
After I'd gone through the basics — location, duration, quality of pain — I asked the question I ask every patient: tell me about your medical history.
He'd had a kidney transplant several years earlier. He was on immunosuppressants to keep his body from rejecting the organ. He had type 2 diabetes and hypertension. And for a separate inflammatory condition, he'd been taking prednisone, a corticosteroid, for an extended period.
I paused my exam and sat with that for a moment.
Four things were true simultaneously, and each one complicated the picture:
First, the prednisone. Long-term corticosteroid use is one of the leading causes of secondary osteoporosis. It disrupts the way bone remodels itself, quietly hollowing out vertebral bodies over time. In severe cases, this leads to vertebral compression fractures — the vertebra simply collapses under normal load. These fractures don't always announce themselves dramatically. Sometimes the patient just has back pain that won't quit, especially at night, when the spine is unloaded and the fracture settles.
Second, the immunosuppression. Because his immune system was pharmacologically suppressed to protect his transplanted kidney, he was at significantly elevated risk for infections that a healthy immune system would normally contain — including infections in unusual places. Spinal epidural abscess is a rare but catastrophic condition: bacteria seed the space surrounding the spinal cord, causing severe back pain, fever, and eventually neurological compromise. It is routinely misdiagnosed as a musculoskeletal problem in its early stages. In immunocompromised patients, the presentation can be even more subtle — the fever may be blunted, the white count may not spike the way it normally would.
Third, the diabetes. Chronic hyperglycemia damages small nerve fibers throughout the body — a condition called diabetic peripheral neuropathy. The symptoms? Burning pain. Weakness. Numbness in the lower extremities. They can look almost identical to compressive sciatica. The critical distinction is that diabetic neuropathy doesn't get better with spinal manipulation. It requires a different diagnosis, and potentially different treatment entirely — glycemic control, neuropathic pain medications, neurology involvement.
Fourth, and most urgently: his leg weakness. He mentioned it almost as an aside. He'd been having trouble on stairs lately. His left leg felt unreliable. In a straightforward disc herniation, weakness is possible but not typical early on. Progressive lower-extremity weakness, especially combined with pain that wakes a patient from sleep, is a red flag. It can indicate significant nerve compression — or something worse.
One of the most feared emergencies in spinal medicine is cauda equina syndrome, a condition where the bundle of nerve roots at the base of the spinal cord is severely compressed. The hallmarks are saddle anesthesia (numbness in the groin and inner thighs), bowel or bladder dysfunction, and bilateral leg weakness. It requires emergency surgery. He didn't have all of those findings — but he had some of them, and I had no imaging.
The limits of what I could offer
My practice is built on what I can carry into a home or out of the mobile clinic. I do full orthopedic and neurological exams. I can assess range of motion, deep tendon reflexes, dermatomal sensation, and provocation tests for the lumbar spine. What I don't have is an MRI, a CT scanner, or the ability to draw labs and culture blood. For most patients, I don't need them.
For this patient, I did.
The honest truth about mobile chiropractic — the truth about any chiropractic, in a clinic or otherwise — is that our tools are calibrated for a specific kind of problem. Mechanical lower back pain. Disc irritation. Facet joint dysfunction. Joint restriction. Those are the problems we're trained to address, and we address them well. But we are not equipped to rule out spinal infection, pathologic fracture, or progressive neurological compromise. That requires imaging. That requires labs. That requires a specialist.
Continuing to treat this man as though he had a mechanical problem — without ruling out the other possibilities — would have been a disservice to him. Maybe a dangerous one.
When to stop and refer
This is the part of the conversation most patients don't hear from their chiropractor, so I want to be direct about it: chiropractic care is not always the right first step. There are symptoms that should send you to a physician or emergency department before you book a spinal adjustment. They include:
Pain that wakes you from sleep and doesn't improve with position changes. Progressive weakness in one or both legs. Saddle anesthesia or any change in bowel or bladder function. Unexplained fever, chills, or recent infection. Unexplained weight loss. A history of cancer. A history of long-term corticosteroid use. A significantly immunocompromised state.
If you have any of these — especially in combination — the appropriate next step is imaging and a medical workup, not manipulation.
I referred him that day. I explained what I was seeing and why I wasn't comfortable treating him without further workup. He saw a spine specialist and got an MRI within the week.
What this case is really about
There's a version of this story I could tell that positions the referral as a failure — I couldn't help him, so I passed him off. I don't see it that way. Recognizing the edges of your competence and acting on that recognition is the job. A chiropractor who treats every back pain patient the same way isn't practicing good chiropractic. They're practicing a pattern.
The work is in the history. The work is in slowing down long enough to ask why this patient, at this time, is having this symptom. Sometimes the answer is a herniated disc. Sometimes it's something that will kill them if you miss it.
This patient's case was a reminder that the spine doesn't exist in isolation. It's embedded in a body with a history — kidneys and immune systems and blood sugar and bones that have been quietly changing for years. Good care starts with understanding that whole picture, and knowing honestly what you can and cannot see from where you're standing.
If any of this sounds familiar, reach out. I'd rather spend ten minutes talking through your situation than have you wonder if your back pain is something more.
Have a wonderful week,
Dr. Lucas Marchand
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