Non-surgical treatment of a herniated – bulging disc
What is the successful treatment of a herniated, ruptured or bulging disc? For many patients who move onto surgery their definition of success for discogenic pain (pain from the disc) may be based on the following questions: “How long is my recovery time following herniated disc surgery?”, “What is the rate of success in herniated disc surgery?,” “Will I be able to return to work quickly?”
Conflicting evidence suggests that these may be difficult questions to answer prior to surgery. Or that the patient and the doctor may have two different definitions of success and what should be the goals of treatment. This one concluding statement from a new research study spells out likely outcomes of herniated disc surgery.
“In the majority of disc surgery patients, a long-term reduction in pain was observed. However, the cervical neck surgery patients seemed to profit less from surgery than the lumbar surgery patients. In the long-term a considerable number of patients still reported high levels of pain.”1
The surgery was successful for some, did not work better for herniated discs in neck than lumbar disc herniation, and for a “considerable” number of patients long-term high levels of pain remained after surgery.
For working people, one study tried to give a better predictive value for returning to work. In this research 153 patients were followed and doctors found the most decisive risk factors in prolongation of work absence were: psychosocial factors, mobility of the spine and structural changes of facet joints and the patient’s ability to perform the physical demands that their work required.2 Please see our articles that address these factors: Treating back pain in patients with depression and anxiety, Ligament laxity and spinal instability, Facet joint instability.
Is the Disc the cause of pain? Is discograms the only evaluation tool?
A recent study from doctors in Australia questioned the prevalence of back pain caused by the discs. In their research the doctors noted the widespread belief that up to 42% of chronic low back pain is attributed to a problem lumbar disc(s). BUT, these estimates on the number of pain causing discs largely originated from research conducted 20 years ago and that the estimates may be too high, something else may be causing the pain.
- The doctors tested 223 patients and 644 discs. Positive discograms (a controversial injection procedure to determine if pain is coming from the discs) were recorded in 74% of patients, with 22.9% negative and 3.1% assessed as indeterminate.
- Among patients receiving both discography and diagnostic blocks, 63% had proven discogenic pain, 18% had pain of mixed pain causes and 14% remained undiagnosed.
Taking into account all low back pain cases during this study, discogenic pain prevalence was 21.8%. The researchers concluded that while lower than believed the research supported the clinical use of discography.3
Is Discography Useful?
The Discography or discogram procedure usefulness a test and evaluation tool is controversial. Like an MRI it may show things that are not the root cause of the problem. In the procedure a dye is injected into the discs to look for cracks or other abnormalities. Sometimes several discs are injected. Like an MRI, the discogram may show damage that are not causing symptoms, so the discogram may be leading doctors to treat something that is not the problem.
For the purpose of this article bulging, ruptured and herniated disc will be referred to a “herniated disc.”
A disc is like a jelly-filled donut. The hole where the jelly comes out is the herniation. The jelly part is the nucleus pulposus and is the part that is herniated. A ring of ligament tissue called the annulus fibrosis surrounds this area.
Herniated discs are caused by the degeneration of the disc, aging or injury to the spine. Degeneration may result from tiny tears or cracks in the outer shell of the disc. The jellylike material inside the disc may be forced out through the tears or cracks, causing the disc to bulge, break open or break into fragments.
Injury can occur from a sudden, heavy strain or increased pressure to the lower back. Repetitive activities, as well as prolonged exposure to vibration or sports-related injuries also increase the risk of disc herniation.
Symptoms of a herniated disc depend on its position. A herniated disc itself does not cause pain; the pain is a result of pressure on the nerve roots or spinal cord. If the disc is not pressing on the nerve, an individual may experience a low backache or no symptoms at all. If the disc presses on a nerve, pain or numbness may occur in the part of the body associated with the nerve. If the herniated disc is in the lower back, sciatica may occur, which involves leg pain and other nerve-related symptoms.
A patient may also receive a diagnosis of disc desiccation. This is a common degenerative change of intervertebral discs over time caused by “aging.”
The incidence climbs with age, and to a large degree a gradual desiccation is a ‘normal’ part of disc aging. It results from replacement of the jelly like nucleus polposus with fibrocartilage. It should be pointed out that the body is acting in this way to stabilize the spine. See our companion article on Degenerative Disc Disease.
Prolotherapy strengthens the annulus fibrosis and other ligaments that support the disc, helping the condition resolve without surgical intervention. If the disc material is pressing on the nerve, then other treatments in addition to Prolotherapy may be indicated, including nerve blocks or epidural injections to decrease the inflammation on the nerve.
Discectomy or Microdiscectomy
Back surgery for herniated discs can cause significant damage to muscles and ligaments, this is a topic we discuss in both our articles Failed Back Surgery Risks and Failed back surgery syndrome treatment options.
Complications from this surgery are explained better by the surgeons who perform this procedure – this is from the American Academy of Orthopaedic Surgeons website:
“One of the major drawbacks of open surgery is that the pulling or “retraction” of the muscle can damage the soft tissue. Although the goal of muscle retraction is to help the surgeon see the problem area, it typically affects more anatomy than the surgeon requires. As a result, there is greater potential for muscle injury, and patients may have pain after surgery that is different from the back pain felt before surgery.”
A discectomy is the surgical removal of the disc material (nucleus pulposus) bulging out onto the nerve root or the spinal cord. This is an “open back surgery.” The procedure often involves a laminotomy, removing a small piece of bone (the lamina) to allow the surgeon access to the herniated disc.
Lumbar microdiscectomy is a less invasive technique and procedure and even then is delayed in patients who present radicular pain, paresthesias, and in extreme cases weakness or foot drop. As noted in one paper typically patients are treated conservatively for 6-8 weeks with a combination of steroids, nonsteroidal anti-inflammatory drugs, physical therapy, epidural steroid injections, and rest.
In the absence of symptom improvement, microdisectomy is recommended to patients who are not improving after 6 weeks of non-operative treatment.
Percutaneous Disc Decompression for Herniated Discs
Decompression is a term used to describe the treatment of a “compressed” disc that is causing bulging or herniation. Percutaneous disc decompression involves dissolving or removing parts of a herniated disc to alleviate back pain. This therapy is used for patients who present with low back pain and numbness with pain radiating down one or both legs. Most patients who undergo this procedure have an MRI that shows a modest herniated disc. In other words, this treatment is not for people with “severely” herniated discs.
The treatment involves placing a needle into the herniated disc using X-ray guidance. Depending on the type of decompression therapy, excess disc tissue is either dissolved through radio waves or removed by a revolving needle. The result is decreased pressure on the disc and adjacent nerves. Although some studies show effective pain relief, we believe the long-term effects of removing tissue are not worth the short-term pain relief.
Prolotherapy vs. Disc Decompression for Herniated Discs
Prolotherapy treats low back pain by addressing the root cause of pain: ligament laxity. Very few cases of low back pain actually stem from a herniated disc. Rather, the herniated disc is proof that ligament laxity exists. Prolotherapy is an injection technique that induces a mild inflammation to stimulate the body’s immune system to heal the injured area. When compared to Prolotherapy, percutaneous disc decompression raises some red flags in the case of low back pain:
Prolotherapy is safe, effective, and cost-friendly. It is a low-risk procedure that treats a whole host of back pain symptoms.
1 Dorow M, Löbner M, Stein J, et al. The Course of Pain Intensity in Patients Undergoing Herniated Disc Surgery: A 5-Year Longitudinal Observational Study. Sherman JH, ed. PLoS ONE. 2016;11(5):e0156647. doi:10.1371/journal.pone.0156647.
2 Papić M, Brdar S, Papić V, Lončar-Turukalo T. Return to Work After Lumbar Microdiscectomy – Personalizing Approach Through Predictive Modeling. Stud Health Technol Inform. 2016;224:181-3.
3 Verrills P, Nowesenitz G, Barnard A. Prevalence and Characteristics of Discogenic Pain in Tertiary Practice: 223 Consecutive Cases Utilizing Lumbar Discography. Pain Med. 2015 Aug;16(8):1490-9. doi: 10.1111/pme.12809. Epub 2015 Jul 27.