PNBC
Research & Information
PNBC
Articles & Information
The Herinated Disc: New Concepts
and Treatments
She was a typical middle
aged woman, maybe a bit overweight but unremarkable
nonetheless. Two days
earlier she had seen a neurologist who said she would
need surgery for her “ruptured disk.” She
was a personal friend of my partner and he asked me to
see her for a second opinion.
Her history was similar to ones I
had heard hundreds of times and to ones heard frequently
by all primary
care physicians. Three weeks earlier she “slept
wrong” and woke up with pain in her back and left
leg radiating down to the foot. She had had some previous
minor problems with her back but nothing dramatic. She
had experienced no weakness, paresthesias, or bowel/bladder
disturbance but her leg pain was severe. She started
with her family practitioner. NSAIDS and rest did not
relieve the pain and after a week she was referred to
a neurologist. He ordered an MRI that showed a left lateral
herniation at L5-S1. She was told to rest and given heavy
pain medication. At follow-up a week later she still
had significant leg pain and was told she would likely
need surgery.
Does this case seem reasonable to you? It certainly
is not unusual. Medical practice has an inertia all its
own and despite new research change often occurs slowly.
This article will outline some new concepts in the treatment
of disc herniations that may give the reader a different
perspective on cases like the one above.
RESEARCH
I have selected a few pertinent studies which should
be of interest to physicians treating patients with back
or neck disease.
Weber H., "Lumbar Disc Herniation:
A controlled, prospective study with ten years of observation." Spine 1983.
280 patients with HNP verified by myelography were divided
into three groups, 87 with definite non-surgical indications,
67 with definite surgical indications, and 126 with uncertain
indications. The 126 patient group was randomized to
surgery or conservative care. Follow-up was done at one,
four and ten years. At one year the surgical group showed
a statistically significant better result. But at the
four and ten year follow-ups there was no significant
difference in outcome.
Saal, JA and Saal, "Non-operative
Treatment of Herniated Lumbar Intervertebral Disc with
Radiculopathy:
An Outcome Study." JS. Spine 1989.
Sixty-four patients with confirmed disc herniation were
included in this study.
Inclusion criteria are listed
below:
-
Chief complaint of leg
pain
-
+Straight leg raise <60° reproducing
leg pain
-
CT or MRI showing herniated
disc (HNP)
-
+EMG
All
patients were treated with aggressive rehabilitation. Follow-up
was done at an average of 31 months. 90% had
good or excellent results. 92% returned
to work. Only 6% needed surgery.
Capicotto, PN et al., "Operative Treatment
of Recurrent Lumbar Disc Herniation
with Mid-Term Follow-Up." Presented
at the North American Spine Society annual
meeting Oct
1994.
20 patients with recurrent
HNP at same level and severe sciatica were retrospectively
studied. The rehernaition
occurred at an average of 29 months after
the first surgery. The authors concluded that the rate
of recurrent disc
hernaition (usually estimated at 10-15%)
is seriously underestimated in the literature because virtually
all
the studies have a follow-up period much
less than 29 months. Would a physician be less likely to
recommend
surgery if the recurrence rate was 30-35%?
Weiner, BK., "Contained
Vs Extruded Lumbar Disc Herniations: MRI Readings Vs
Intra-Operative Findings." Presented at
the North American Spine Society annual meeting
Oct 1994.
Thirty patients were deemed
to be candidates for lumbar microdiscectomy.
Pre-op MRI’s were read by spine
fellows and/or radiologists specializing in Lumbar MRI.
MRI pre-op readings matched the operative findings only
50% of the time. The newer less invasive spine surgery
assumes that we can use MRI’s to differentiate “extruded” discs
from “contained” discs which
are presumably more amenable to techniques
such as
percutaneous
discectomy. Maybe our assumptions are faulty.
Saal, JS and Saal, JA., "Non-Operative
Treatment of Cervical Herniated Discs:
An Outcome Study." Presented at the North
American Spine Society annual meeting Oct 1994.
Twenty-four consecutive patients
with cervical disc herniations were studied prospectively.
Inclusion criteria
were:
All patients were treated with aggressive rehabilitation.
22 of the 24 had good or excellent outcomes and two needed
surgery. 19 of 22 returned to work at the same job. 22
of 24 reported complete or near complete satisfaction
with their result.
In other recent studies,
sequential MRI scans done at six month intervals
have shown that
disc herniations
more often than not are resorbed by the
body. The studies found that larger disc herniations DO
NOT correlate
with
a poor prognosis. They go away. As Ian
McNab,
MD said of disc herniations in his book Backache “90%
of patients will get better and stay better
with conservative care.”
Official Clinical
Guidelines
Some major organizations have
weighed in on this topic. The American Academy of Orthopedic
Surgeons recommends
at least three months of non-operative
care for disc herniations unless there is a progressive
neurological
deficit. This is an important distinction.
It is not enough to simply have an ankle jerk out or
loss of dermatomal
sensation or weakness. The vast majority
of the time these deficits will improve or resolve with
time. Only
if the deficits can be accurately documented
to deteriorate is surgery indicated. In my experiences
neurological
deficits are common but progressive deficits are
rare.
The Agency for Health Care Policy and Research guidelines
for
acute back pain
have gotten
a lot of press lately
after publication in Dec 1994.
The Agency specifically addressed patients with acute
sciatica.
They
state that sciatica may recover more
slowly than isolated back pain
but they go on to say that only
patients with severe, debilitating symptoms of sciatica
and exam
evidence of
nerve root compromise corroborated
on imaging
studies can be expected to benefit from
surgery. They recommend
reserving expensive imaging for
those patients not spontaneously improving. Translation:
You
don’t
need to get an immediate MRI on a patient
with a two week history of
back and leg pain and a neurological
deficit. Try to keep the patient comfortable while the
body
heals itself
but do not rush into the surgical
pathway. That innocuous little laminectomy may not be
as predictable
as we would
like.
The Federally funded study
also was skeptical towards our spinal vocabulary. They
pose this question: What
do the following popular diagnostic terms have in common?
-
Annular
tear
- Fibromyalgia
- Spondylosis
- Degenerative joint disease
- Internal disc derangement
- Disc disruption
- Adult Spondylolysis
- Myofascial pain syndrome
- Lumbar disc disease
- Lumbar sprain
- Facet syndrome
- Subluxation
According to the panel
of experts, “...none of
these diagnoses are scientifically validated. Scientific
studies haven’t proven any of them to have a connection
to back symptoms...”.
This
is not to say none of them are real, just that none are
proven and until they are we should be careful
about basing decisions on theses diagnoses.
Conclusions
There is a lot of information
here to digest. And it may conflict with what many doctors
consider to be proper
treatment for disc herniations. But such
information cannot be ignored. Given the costs and potential
complications
from what in many cases may be unnecessary
surgical intervention, caution is certainly indicated.
In
summary, when faced with a disc herniation the following
points are useful:
-
Don’t
panic. As long as neurological deficits are not
deteriorating, observation
is warranted.
-
Consider an epidural block for nerve
root related leg pain. These injections are not proven
for back pain but
are often successful for leg pain
- Consider exercise a treatment for acute disc syndrome.
- Most patients get well on their own and many disc herniations
disappear.
|
