Non-surgical treatment of a herniated – bulging disc
In our opinion there are two ways to treat a herniated disc non-surgically.
The first is to manage the disc pain until it can no longer be non-surgically managed and then go to surgery.
The second way is to repair the problems causing back pain and help patients avoid spinal surgery.
Let’s look at the first choice through the eyes of a Canadian research team who reviewed the current concepts and clinical guidelines for the management of low back pain to assess their quality of care.
In this soon to be published (February 2017) study., doctors and researchers found according to high-quality guidelines:
- All patients with acute or chronic low back pain should receive education, reassurance and instruction on self-management options;
- Patients with acute low back pain should be encouraged to return to activity and may benefit from paracetamol, nonsteroidal anti-inflammatory drugs (NSAIDs), or spinal manipulation;
- the management of chronic low back pain may include exercise, paracetamol or NSAIDs, manual therapy, acupuncture, and multimodal rehabilitation (combined physical and psychological treatment); and
- Patients with lumbar disc herniation with radiculopathy may benefit from spinal manipulation.
This new study found some of these guidelines to still be in practice but outdated, specifically the use of paracetamol for acute low back pain.
The other problem they found was the recommend education, staying active/exercise, manual therapy, and paracetamol or NSAIDs as first-line treatments., were guidelines targeted to nonspecific low back pain.1
If you are reading this article, there is very good chance you were not helped by these guidelines and have been recommended to surgery and you are exploring alternatives.
- The use of NSAIDs we have shown can cause more pain, see our article When NSAIDs make pain worse, and how NSAIDs inhibits healing.
- Please read our article on long-term problems of spinal and over-manipulation
- If you have lumbar disc herniation with radiculopathy please see our article on non-surgical treatment of lumbar radiculopathy.
Following this course of treatment and continued pain a patient will be referred on to a surgical consultation
What is a successful surgery for herniated, ruptured or bulging disc? For many patients who move onto surgery their definition of success may be based on the following questions and the answers they get from their surgeon:
- “What is the rate of success in herniated disc surgery?,”
- “How long will my recovery time be?,”
- “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 from the University of Leipzig in Germany spells out likely outcomes of herniated disc surgery.
- “In the majority of disc surgery patients, a long-term reduction in pain was observed. Cervical 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.2
In recap: 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 in the medical journal Health technology and informatics, in 153 patients doctors found the most decisive risk factors in prolongation of work absence were:
- psychosocial factors,
- mobility of the spine and structural changes of the facet joint and the patient’s ability to perform the physical demands that their work required.3
For treatment of a herniated disc to be successful – the disc must be the problem
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.4
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.
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 and Ligament laxity and spinal instability,
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.
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 Wong, J.J., Côté, P., Sutton, D.A., et al. (2017), Clinical practice guidelines for the noninvasive management of low back pain: A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Eur J Pain, 21: 201–216. doi:10.1002/ejp.931 Citation
2 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.
3 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.
4 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.