Non-surgical treatment of a bulging or herniated disc in the lumbar spine
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.
The visits with their back pain specialists are now moving in the direction of cortisone, epidurals and 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 a surgery can be scheduled.
MRI suggests surgery. Do you really need it?
The patient in our examination room will then 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.
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 go to 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.
Before you continue with this article, if you have questions about herniated discs and back pain, you can get help and information from our Caring Medical staff.
Do you really need that surgery? If you have been using epidural steroid injections and painkillers to manage your back pain. More likely yes, you will need that surgery.
A July 2020 study published in the Global spine journal (x) 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
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.(1)
According to these doctors, when should a patient have disc surgery?
- When the conservative treatments did not improve clinical symptoms.
- When progressive or persisting neurological deficits, as well as for persisting pain which 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.
Herniated disc symptoms
Indications of a herniated disc include one or more of these symptoms:
- 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
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 pain-killers can increase chronic pain.
- Non-steroidal anti-inflammatory drug (NSAIDs) usage which 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
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, 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.(2)
If you are reading this article, there is a very good chance you were not helped by these herniated disc treatment guidelines, you have been recommended to herniated disc surgery, and you are exploring alternatives.
- As mentioned above, the use of NSAIDs have been shown to be a culprit in causing greater 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
Discectomy or Microdiscectomy
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 nonsteroidal anti-inflammatory drugs, physical therapy, epidural steroid injections, and rest.
In the absence of symptom improvement, microdisectomy is recommended for patients who are not improving after 6 weeks of non-operative treatment.
In discussing revision lumbar discectomy, surgeons say the procedure can be a more technically complicated operation.
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.(3)
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.(4)
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.(5)
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, a 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, 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).6
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 for 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 your back pain? You can get help and information from our Caring Medical staff.
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