Can you realistically avoid lumbar surgery for bulging or herniated disc?

Ross Hauser, MD

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 caregiver 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.

Summary topics of this article:

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.

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 was told 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 that 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 are 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.

The annulus fibrosus

When someone has a contained herniated disc herniation, maybe like yourself, the center of the disc or “nucleus pulposus” is contained within the annulus fibrosis (the stronger outer layers of the disc). The annulus fibrosus is very sensitive to pain. A person with a degenerated, bulging, or the herniated disc must realize that this may be a coincidental finding and unrelated to the actual pain he or she is experiencing. A degenerated disc is one that is losing water and flattening. This is a usual phenomenon that occurs with age. It is also normal for a disc to bulge with bending. A herniated disc occurs when the annulus fibrosus no longer holds the gelatinous solution in the disc. The result is a weakened disc. The annulus fibrosus is basically a ring of ligament tissue. 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. Visits to a chiropractor or medical doctor typically begin at this time. 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.

“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 the 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).

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)

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.

“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:

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:

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.

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:

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:

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 recommended 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 2022 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 are 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.

Transforaminal Endoscopic Lumbar Discectomy

Some of you exploring treatment options may have been made aware of Transforaminal Endoscopic Lumbar Discectomy. This is a minimally invasive surgical technique akin to arthroscopic surgery. Instead of an incision, the surgery is performed through a needle puncture and an endoscope. Much has been made of this technique recently both good and not so good. The not-so-good surrounds the challenge of the surgeon making this a successful surgery. Two very recent studies point us in that direction of concern.

A December 2021 paper in the International Journal of Spine Surgery (6) writes: “Open microdiscectomy is the gold standard surgical technique for radiculopathy with lumbar disc herniation. Transforaminal endoscopic lumbar discectomy (TELD) has been developed as an effective and minimally invasive alternative to open surgery. As a result of these remarkable technical evolutions, the clinical outcomes of Transforaminal endoscopic lumbar discectomy (TELD) have become comparable to those of conventional open surgery. However, considerable learning curves and endoscopy-related adverse events may emerge as critical problems.”

A January 2022 paper (7) from Korean doctors adds this: “Percutaneous transforaminal endoscopic discectomy (PTED) has been widely used in the treatment of lumbar degenerative diseases. Epidural injection of steroids can reduce the incidence and duration of postoperative pain in a short period of time. Although steroids are widely believed to reduce the effect of surgical trauma, the observation indicators are not uniform, especially the long-term effects, so the problem remains controversial.”

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.

Rebound pain after surgery?

Surgeons writing in December 2021 in the journal Orthopedic Surgery (8) expressed concern with the phenomena of “rebound pain” after percutaneous endoscopic lumbar discectomy. Here is what they wrote:

“After percutaneous endoscopic lumbar discectomy, most patients with lumbar disc herniation experience relief from the typical symptoms of low back and leg pain. However, for a small number of patients, these symptoms are relieved immediately after surgery but aggravated soon after, and then relieved after short-term full rest or conservative treatment. The aim of the study was to demonstrate this short-term recurrent phenomenon, termed rebound pain.”

To assess this problem the surgeons of this study examined post-surgical patients with and without rebound pain. What they found was “(the) typical feature was pain that usually began within one month after surgery and lasted for less than one month. The symptoms were mainly leg pain with or without low back pain. The range of pain was equal to or less than that before surgery. The symptoms were relieved after conservative treatment. Although rebound pain with multiple characteristics and a short duration had no significant effect on long-term postoperative efficacy, its high incidence often caused unnecessary concern in both patients and doctors. As a result, careful differentiation of rebound pain from other postoperative complications is needed.”

What were the conservative treatments that helped? “Patients were asked to restrict activities for 4–6 weeks and wear waist braces for 6 weeks after surgery. A good habit of sitting up sideways must be established within 3–6 months. In addition, a straight leg lifting exercise was performed daily within 3 weeks, and the “five-point support exercise” was required after 3 weeks (a method of lumbodorsal muscle exercise where the patient, while in the supine position, bends the knees and hips with five support points of the feet, elbows, and head and holds the back in an arch shape with the strength of the lumbodorsal muscles for 3–5 seconds each time).”

One more note: Patients who were excluded from this study who had post-surgical pain had other lumbar instability, spondylolisthesis, or scoliosis that could still be causing pain or if the surgery itself caused the pain such as “incomplete removal or recurrence of a herniated disc”

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:

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 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:

Patient expectations of what spinal; surgery can do for them are rarely met

In July 2022, Canadian physicians found an odd paradox among their patients who had a lumbar surgery: (14) This is the paradox as published in the journal Neurosurgery: “Patients undergoing elective spine surgery in Canada have high expectations with variability as to what they deemed as the most important expectation. Generally, their expectations were higher than what they achieved: Only half of our patient population fulfilled their most important expectation and 17% reported that none of their expectations were fulfilled. Those with higher preoperative expectations of spine surgery were less likely to have their expectations fulfilled independent of their functional outcomes improvement. Despite this disparity, most patients (85%) were satisfied with the results of the surgery. Furthermore, preoperative expectations, disability, and pain improvement as well as fulfillment of expectation were positively associated with satisfaction with surgery. Fulfillment of preoperative expectations globally, and what patients deemed as the most important expectation, was the strongest predictor of higher satisfaction with surgery.”

In other words, the surgery did not meet expectation, but it helped. It should also be noted that “there is a large discrepancy between surgeons’ and patients’ expectation across different expectation dimensions.” In other words the surgeon may pronounce a very successful surgery but their assessment did not meet  the patient’s idea of what successful surgery was.

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.

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. (10)

Is Discography Useful?

The Discography or discogram procedure’s usefulness as 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 the damage that is not causing symptoms, so the discogram may be leading doctors to treat something that is not the problem.

Disc desiccation

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 pulpous 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 Injections

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, (11) 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:

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).

A December 2021 paper in the Journal of Back and Musculoskeletal Rehabilitation (12) performed Prolotherapy on six hundred fifty-four patients with chronic low back pain and lumbar disc herniation at four to six-week intervals. The results were:

The Visual Analogue Scale (0-10 0 = no pain 10 = severe, unbearable pain) scores decreased from very severe pain of 7.2  to a mild to almost no pain score of 0.9 after 52 weeks of the treatment. Thirty-four patients’ treatments resulted in poor clinical results (5.2%), and 620 of the patients’ pain improved (94.8%).

Conclusion: “Prolotherapy can be regarded as a safe way of providing a meaningful improvement in pain and musculoskeletal function compared to the initial status. The diagnostic injection is an easy way to eliminate patients and may become a favorite treatment modality. 5% dextrose is a more simple and painless solution for Prolotherapy and also has a high success.”

Summary and Learning Points of Prolotherapy to the low back

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 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.

 

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References
1 Lilly DT, Davison MA, Eldridge CM, Singh R, Montgomery EY, Bagley C, Adogwa O. An Assessment of Nonoperative Management Strategies in a Herniated Lumbar Disc Population: Successes Versus Failures. Global Spine Journal. 2020 Jul 7:2192568220936217. [Google Scholar]
2 Heider FC, Mayer HM. Surgical treatment of lumbar disc herniation. Oper Orthop Traumatol. 2017 Feb;29(1):59-85. doi: 10.1007/s00064-016-0467-3. [Google Scholar]
3 Gupta A, Upadhyaya S, Yeung CM, Ostergaard PJ, Fogel HA, Cha T, Schwab J, Bono C, Hershman S. Does size matter? An analysis of the effect of lumbar disc herniation size on the success of nonoperative treatment. Global Spine Journal. 2020 Oct;10(7):881-7. [Google Scholar]
4 Wong JJ, Cote P, Sutton DA, Randhawa K, Yu H, Varatharajan S, Goldgrub R, Nordin M, Gross DP, Shearer HM, Carroll LJ. Clinical practice guidelines for the noninvasive management of low back pain: A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. European Journal of Pain. 2016 Oct 1. [Google Scholar]
5 Castellini G, Iannicelli V, Briguglio M, Corbetta D, Sconfienza LM, Banfi G, Gianola S. Are clinical practice guidelines for low back pain interventions of high quality and updated? A systematic review using the AGREE II instrument. BMC health services research. 2020 Dec;20(1):1-0. [Google Scholar]
6 Lee SG, Ahn Y. Transforaminal Endoscopic Lumbar Discectomy: Basic Concepts and Technical Keys to Clinical Success. International Journal of Spine Surgery. 2021 Dec 1;15(suppl 3):S38-46. [Google Scholar]
7 Song Y, Li C, Guan J, Li C, Wu H, Cheng X, Ling B, Zhang J. Outcomes of epidural steroids following percutaneous transforaminal endoscopic discectomy: a meta-analysis and systematic review. The Korean journal of pain. 2022 Jan 1;35(1):97-105. [Google Scholar]
8 Zhang C, Li Z, Yu K, Wang Y. A Postoperative Phenomenon of Percutaneous Endoscopic Lumbar Discectomy: Rebound Pain. Orthopaedic Surgery. 2021 Dec 1. [Google Scholar]
9 Dorow M, Löbner M, Stein J, Pabst A, Konnopka A, Meisel HJ, Günther L, Meixensberger J, Stengler K, König HH, Riedel-Heller SG. The course of pain intensity in patients undergoing herniated disc surgery: a 5-year longitudinal observational study. PloS one. 2016 May 31;11(5):e0156647. PLoS ONE. 2016;11(5):e0156647. [Google Scholar]
10 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. [Google Scholar]
11 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. [Google Scholar]
12 Hauser RA, Hauser MA. Dextrose Prolotherapy for unresolved low back pain: a retrospective case series study. Journal of Prolotherapy. 2009;1:145-155.
13 Solmaz I, Orscelik A, Koroglu O. Modified prolotherapy by 5% dextrose: Two years experiences of a traditional and complementary medicine practice center in Turkey. Journal of Back and Musculoskeletal Rehabilitation. 2021(Preprint):1-8. [Google Scholar]
14 Rampersaud YR, Canizares M, Perruccio AV, Abraham E, Bailey CS, Christie SD, Evaniew N, Finkelstein JA, Glennie RA, Johnson MG, Nataraj A. Fulfillment of Patient Expectations After Spine Surgery is Critical to Patient Satisfaction: A Cohort Study of Spine Surgery Patients. Neurosurgery. 2022 May 17:10-227. [Google Scholar]

This page was updated January 4, 2022

 

 

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