Can you realistically avoid lumbar surgery for bulging or herniated disc?
Many people will undergo very successful spinal surgeries. While there is a good success rate with lumbar surgery, some people will opt out of surgery for various reasons. If you are reading this article you know what these reasons are. You can’t take time off from work, you are a care giver or primary wage earner, the thought of surgery frightens you, you have your good days and your bad days and you only need some help getting through the bad days. Maybe you did a lot of research online and this convinced you to try anything to help you manage your back pain short of surgery.
What makes a person show up at our center?
A patient will be sitting in one of our examination rooms. They have low back pain and a diagnosis of a herniated disc or discs be it L1 through L5 and or the lumbosacral joint at L5/S1. The patient will then tell us that they did all the traditional conservative care treatments for their herniated disc. They went to physical therapy which did not help (please see our article: Why physical therapy and yoga did not help your low back pain), they alternated ice and heat and got little comfort. They went to the chiropractor and had short-term relief. On very bad days the patient says they take NSAIDs which are becoming less and less effective and worse, the pills need to be taken in greater frequency, please see our article When NSAIDs make the pain worse.
They tell us that their visits with their back pain specialists are now moving in the direction of cortisone, epidurals, then finally and ultimately, some type of surgery to relieve their pain and symptoms. The patient tells us that their doctor wants to try the injections first before the surgery to see if the surgery can be put off for a while, or, at least help the patient until surgery can be scheduled.
“The worst MRI ever. I must get surgery.”
Some patients tell us that they started losing patience with this hit or miss treatment method and that they need surgery. Their doctors sometimes disagree. Others tell us that their doctors have told them that they have a “terrible MRI” and that they should get online for surgery. Some of these “terrible MRI” people are the ones who contact us. They want an option other than surgery and one with a realistic chance of providing some type of long-term relief, or enough relief that they can go about their routine daily business without making a game plan in the morning to decide if they need their back brace, anti-inflammatories, or other remedies to get them through the day and into bed at night feeling no worse.
You may be reading this article convinced you have “the worst MRI ever,” and based on this, you must have surgery. You may be a business owner, a physical laborer, someone on their feet all day, someone sitting in front of a computer all day, or a caregiver. If your pain is so significant, your MRI confirms that you have significant disc degeneration and you have constant, radiating pain into your legs with numb neurologic problems, you can’t walk for example, then yes, surgery should be explored and you should follow recommendations from your surgeon. Again, this is not the patient we usually see. We see the patient who despite a terrible MRI, still manages to get along in their daily activities and responsibilities but not without moments of severe pain.
The patient in our examination room will start talking about the highs and lows of getting surgery. The high is that the surgery will finally fix their years of back pain. The lows are the surgery will fail and of course, there is the fear and concern and recovery time worries that are the natural drawbacks to surgery. Many people do very well with surgery for their problem of herniated discs. These are the people that we do not see in our office. We see the people for whom it has been suggested that surgery may or may not help, that recovery times are not realistic for the resumption of their work or job, or, worse, the patient had the surgery and they got worse.
We have an extensive article on our website, Is your MRI or CT Scan sending you to a back surgery you do not need? In that article, we seek to offer one simple piece of information, that indeed, your MRI may be sending you to unnecessary surgery. We support this simple idea with a lot of research and our observations in the many patients we have seen after failed back surgery syndrome.
“Oh, by the way, you have a herniated disc, we are not sure that is the problem, but to make sure, let’s try disc surgery.”
In our many years of treating patients with lumbar or low back pain, we came across patients who had continued back pain after spinal surgery. The reason? A coincidental finding on MRI of a herniated disc. Coincidental means, “oh, by the way, you have a herniated disc, we are not sure that is the problem, but to make sure, let’s try disc surgery.” The outcomes of this medical strategy did not go as well as hoped for, in many patients we have seen.
A person with a degenerated, bulging, prolapsed, or herniated disc must realize that this may be a coincidental finding and unrelated to the actual pain he or she is experiencing. In other words, you can walk around with a herniated disc that is not causing you pain.
The question remains: Do you really need that surgery? In some instances, yes. In some instances, no.
If you have been using epidural steroid injections and painkillers to manage your back pain, more likely yes, you will need that surgery.
We have a very extensive article on epidural steroid injection. In this article, we compare various treatments to epidural steroid injections and we demonstrate the research which suggests that while some people will benefit from epidural steroid injection, others will not. There is also evidence suggesting prolonged use of these injections may actually accelerate the need for surgery.
A July 2020 study published in the Global Spine Journal (1) from researchers at the Cleveland Clinic, and the University of Texas Southwestern Medical Center compared conservative treatments in patients with lumbar intervertebral disc herniations who were successfully managed nonoperatively versus patients who failed conservative therapies and elected to undergo surgery (microdiscectomy).
- The study examined the clinical records of more than one-quarter million (277,941 patients) with lumbar intervertebral disc herniations. Of these, 269 713 (97.0%) were successfully managed with nonoperative treatments, while 8228 (3.0%) failed maximal nonoperative therapy and underwent a lumbar microdiscectomy.
- Maximal nonoperative therapy failures occurred more frequently in males (3.7%), and patients with a history of lumbar epidural steroid injections (4.5%) or preoperative opioid use (3.6%).
In other words, men, getting epidural steroid injections or using painkillers will eventually need surgery. These two pain treatments do not stop progression to surgery.
But nothing has helped you, you NEED the surgery. Maybe you don’t. According to these doctors, when should a patient have disc surgery?
People who get epidural steroid injections understand that these injections come with risks. But many people we talk to will tell us, “I know the steroid injections are bad for me, but I needed something, I was in pain.” The reason they are at our center is that they still need something, and it is something else.
What we want to suggest here is that it can be difficult for people to understand that the MRI of a herniated disc can show something “bad,” but that is really not what is causing the problem for them. Getting on a waiting list for surgery may not be the answer. In a recent study, doctors at the University of Salzburg presented these findings on the surgical and conservative care of herniated discs.(2)
- When the conservative treatments did not improve clinical symptoms.
- Persisting pain alters the quality of the patient`s life.
The researchers however also warn, “Results of surgery are strongly dependent on the preoperative duration of symptoms. Paramount is the “timing” of surgery: poorer surgical results associated with increasing preoperative duration of symptoms.”
The longer the patient waits for surgery, the more difficult it gets.
Finally, the above-cited researchers suggested that surgery should be the LAST CHOICE and that all conservative treatment methods must be FIRST exhausted.
- It is important to note again that the above paper from spinal surgeons recommended strongly, that surgery be the last choice, BUT, treatments of any kind should not be delayed.
“I have a massive disc herniation”
This is from an October 2020 study in the Global Spine Journal (3). It comes from Harvard Medical School. What the researchers did in this study was to examine whether the size of a lumbar disc herniation is predictive of the need for surgical intervention within two years after obtaining an initial magnetic resonance imaging (MRI) scan.
In other words, does size matter when it comes to disc herniations?
The thinking or hypothesis of these researchers was that the size of the herniation would not matter, that the portion of the disc that occupied a larger percentage of the spinal canal would not predict which patients failed conservative management.
In other words, looking at an MRI and seeing a moderate or large disc herniation, doctors may automatically assume that the only way to fix this problem would be with surgery. Therefore the description of the herniated disc that we hear from some patients that they have a “large,” “massive,” bulging disc that must have surgery, may not actually need surgery based on the fact that surgery or conservative care option outcomes may be the same. Let’s get back to this study:
- In this study, the patients had received a diagnosis of primary lumbar radicular pain, had MRI showing a disc herniation, and underwent at least 6 weeks of nonoperative management.
- Patients experiencing symptoms suggesting cauda equina syndrome and those with progressive motor neurological deficits were excluded from analysis, as were patients exhibiting “hard” disc herniations (infiltration of bone spurs).
- A total of 368 patients
- 14 patients (3.8%) had L3-L4 herniations,
- 185 patients had L4-L5 herniations (50.3%),
- 169 patients had L5-S1 herniations (45.9%).
- Overall, 336 (91.3%) patients did not undergo surgery within 1 year of the lumbar disc herniation diagnosis.
- Patients who did not receive surgery had an average herniation size that occupied 31.2% of the canal, whereas patients who received surgery had disc herniations that occupied 31.5% of the canal on average. (The size of the herniation was virtually the same).
Conclusions: The percentage of the spinal canal occupied by a herniated disc does not predict which patients will fail nonoperative treatment and require surgery within 2 years after undergoing a lumbar spine MRI scan.
Herniated disc symptoms
These are the problems we see in our patients. They are probably many of the problems that you are suffering from now:
- leg pain (sciatica) that is often severe;
- weakness and/or tingling in the leg;
- low back pain and/or pain in the buttock;
- and loss of bladder or bowel control, the latter of which is rare and warrants medical attention because it may indicate a more serious condition called caudal equina syndrome.
Most disc herniations occur in the lower portion of the spine at the L4-L5 or L5-S1 level, either of which can lead to additional symptoms.
- L5 nerve impingement at L4-L5 can cause weakness in extending the big toe and potential weakness in the ankle (foot drop), as well as numbness and pain on top of the foot, with the pain radiating into the buttock.
- S1 nerve impingement at L5-S1 can cause loss of the ankle reflex and/or weakness in the ankle to push off (inability to do toe rises), as well as numbness and pain that can radiate down to the outside of the foot or underneath to the sole.
A herniated disc causing spinal radiculopathy is relatively easy to diagnose. Based on history and neurologic examination alone, a physician may expect to be correct 60% of the time. With the addition of certain test procedures, accuracy is cumulative: with a straight leg raising test positive, accuracy increases to 70%; with a positive electromyogram, to 80%; and with a positive water-soluble contrast myelogram, to 90%. MRI is able to show internal disc morphology.
Conservative care for a herniated disc – why it may not work for you.
This is why many doctors will recommend many and varied courses of conservative care before recommended spinal surgery.
Here are our articles on conservative care for herniated disc:
- epidural steroid injection. In this article, back pain treated with epidural steroid injections and Prolotherapy is compared. We will answer common patient questions such as: Do epidural injections help herniated, slipped, bulging discs?
- Narcotic painkillers can increase chronic pain.
- Non-steroidal anti-inflammatory drug (NSAIDs) usage can also make the pain worse.
- Chiropractic care, physical therapy, and various spinal and muscle stimulators.
Research: Latest information on conservative care for herniated discs OUTDATED
While many people will find great pain relief from the above conservative care measures, some will not. Some doctors feel that conservative care failures are based on outdated information about what will work, for whom it will work, and when it will work for these people indicating as we did above that there is a window of opportunity when these treatments or any treatment will be most effective in helping the patient avoid surgery.
Let’s look at the first choice of herniated disc treatment 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 February 2017 study published in the European Pain Journal, (4) doctors and researchers found according to high-quality guidelines:
- All patients with acute or chronic low back pain should receive:
- and instruction on self-management options;
- Patients with acute low back pain should be encouraged to return to activity and may benefit from:
- nonsteroidal anti-inflammatory drugs (NSAIDs),
- or spinal manipulation;
- Patient with chronic low back pain may include:
- paracetamol or NSAIDs,
- manual therapy,
- 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 and other herniated disc symptoms.
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.
That was 2017, this is 2021 is the information still outdated? Yes.
An October 2020 study (5) citing this research says “Clinical practice guidelines provide recommendations for practice, but the proliferation of Clinical practice guidelines issued by multiple organizations in recent years has raised concern about their quality. The aim of this study was to systematically appraise Clinical practice guidelines quality for low back pain interventions.”
The study’s outcome: Yes, they are still outdated:
“Conclusions: We found methodological limitations that affect Clinical practice guidelines quality. In our opinion, a universal database is needed in which guidelines can be registered and recommendations dynamically developed through a living systematic reviews approach to ensure that guidelines are based on updated evidence.”
When these conservative care options fail, when the spinal MRI shows enough damage, the surgical recommendation can now be made
Up until this point in this article, we took you through a familiar journey of MRI to conservative care, treatments that did not work, and perhaps just like in your life, the only thing that seems to be left is surgery. We will briefly go through some of the surgical options and provide links to more comprehensive articles on our site about spinal surgery. Then below we will present our non-surgical treatment options.
Discectomy or Microdiscectomy
We have a more comprehensive article on the subject, benefits, and complications of minimally invasive spinal surgery. In this section we will briefly discuss these surgical options.
There is a belief among many patients that same day surgery means that everything is repaired in one day. In essence it is. But the main difference in minimally invasive surgery compared to conventional surgery is the size of the incision. The benefit of Minimally invasive surgery is less damage to supportive tissue. The surgery is the same.
The benefits of microdiscectomy is better explained 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 nonsteroidal anti-inflammatory drugs, physical therapy, epidural steroid injections, and rest. Let’s point out, that even when you have a “superior surgery,” the best treatment is still non-surgical. However, In the absence of symptom improvement, microdiscectomy is recommended for 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.
What is a successful surgery for a 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 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.(6)
In recap: The surgery was successful for some, did not work better for herniated discs in the 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.(7)
For herniated disc treatment to be successful – the disc must be the problem
A study from doctors in Australia published in the medical journal Pain Medicine 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 the 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 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.(8)
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 is 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.”
Why did the disc degenerate in the first place?
Degeneration of a disc begins as soon as the lumbar ligaments become loose and cause spinal instability, allowing the vertebral segments to move excessively and cause pain. The body attempts to correct this by tensing the back muscles. The hypermobile vertebral segments add strain to the vertebral discs. Eventually, these discs cannot sustain the added pressure and begin to flatten and/or herniate.
The incidence climbs with age, and to a large degree, gradual desiccation is a ‘normal’ part of disc aging. It results from the 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.
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:
In Caring Medical published research in the Journal of Prolotherapy, (9) we cited our own research and that of others in demonstrating the effectiveness of Prolotherapy for back pain.
In our research, we reported on 145 patients who experienced low back pain for an average of 58 months, who were treated on average with four sessions of dextrose (12.5%) Prolotherapy, quarterly, at a charity clinic.
The patients were contacted on average 12 months after their last Prolotherapy session. In these patients:
- pain levels decreased from 5.6 to 2.7 (numerical rating scale NRS, 1-10 scale);
- 89% experienced more than 50% pain relief
Results were similar in the patients who were told by at least one medical doctor that there was no other treatment option (55 patients) or that surgery was the only option (26 patients).
When steroids and Prolotherapy are needed
When disc material prolapses or herniates through the annulus, a severe inflammatory reaction occurs, which affects the lumbar nerves and causes excruciating pain. This is one time when steroids are needed to resolve the pain. With appropriate treatment using steroids injections onto the nerve(s) and Prolotherapy treatment to the lower back, it is possible to strengthen the ligaments through which the disc herniated. Anyone this debilitated by pain would likely need to come into the office in a wheelchair or be in obvious discomfort but after treatment often would be able to leave walking out much happier.
If you have been diagnosed with a bulging disc, slipped disc, herniated disc, Prolotherapy is safe, effective, and cost-friendly. It is a low-risk procedure that treats a herniated disc symptoms.
Questions about our treatments?
If you have questions about Spinal fusion surgery complications and how we may be able to help you, please contact us and get help and information from our Caring Medical staff.
Brian Hutcheson, DC | Ross Hauser, MD | Danielle Steilen-Matias, PA-C
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This page was updated February 18, 2021