She was a typical middle aged woman, maybe a bit overweight but unremarkable nonetheless. Two days earlier she had seen a neurologist who said she would need surgery for her "ruptured disk." She was a personal friend of my partner and he asked me to see her for a second opinion.
Her history was similar to ones I had heard hundreds of times and to ones heard frequently by all primary care physicians. Three weeks earlier she "slept wrong" and woke up with pain in her back and left leg radiating down to the foot. She had had some previous minor problems with her back but nothing dramatic. She had experienced no weakness, paresthesias, or bowel/bladder disturbance but her leg pain was severe. She started with her family practitioner. NSAIDS and rest did not relieve the pain and after a week she was referred to a neurologist. He ordered an MRI that showed a left lateral herniation at L5-S1. She was told to rest and given heavy pain medication. At follow-up a week later she still had significant leg pain and was told she would likely need surgery.
Does this case seem reasonable to you? It certainly is not unusual. Medical practice has an inertia all its own and despite new research change often occurs slowly. This article will outline some new concepts in the treatment of disc herniations that may give the reader a different perspective on cases like the one above.
I have selected a few pertinent studies which should be of interest to physicians treating patients with back or neck disease.
Weber H., "Lumbar Disc Herniation: A controlled, prospective study with ten years of observation." Spine 1983.
280 patients with HNP verified by myelography were divided into three groups, 87 with definite non-surgical indications, 67 with definite surgical indications, and 126 with uncertain indications. The 126 patient group was randomized to surgery or conservative care. Follow-up was done at one, four and ten years. At one year the surgical group showed a statistically significant better result. But at the four and ten year follow-ups there was no significant difference in outcome.
Saal, JA and Saal, "Non-operative Treatment of Herniated Lumbar Intervertebral Disc with Radiculopathy: An Outcome Study." JS.
Sixty-four patients with confirmed disc herniation were included in this study.
Inclusion criteria are listed below:
- Chief complaint of leg pain
- +Straight leg raise <60° reproducing leg pain
- CT or MRI showing herniated disc (HNP)
All patients were treated with aggressive rehabilitation. Follow-up was done at an average of 31 months. 90% had good or excellent results. 92% returned to work. Only 6% needed surgery.
Capicotto, PN et al., "Operative Treatment of Recurrent Lumbar Disc Herniation with Mid-Term Follow-Up." Presented at the North American Spine Society annual meeting Oct 1994.
20 patients with recurrent HNP at same level and severe sciatica were retrospectively studied. The rehernaition occurred at an average of 29 months after the first surgery. The authors concluded that the rate of recurrent disc hernaition (usually estimated at 10-15%) is seriously underestimated in the literature because virtually all the studies have a follow-up period much less than 29 months. Would a physician be less likely to recommend surgery if the recurrence rate was 30-35%?
Weiner, BK., "Contained Vs Extruded Lumbar Disc Herniations: MRI Readings Vs Intra-Operative Findings." Presented at the North American Spine Society annual meeting Oct 1994.
Thirty patients were deemed to be candidates for lumbar microdiscectomy. Pre-op MRI's were read by spine fellows and/or radiologists specializing in Lumbar MRI. MRI pre-op readings matched the operative findings only 50% of the time. The newer less invasive spine surgery assumes that we can use MRI's to differentiate "extruded" discs from "contained" discs which are presumably more amenable to techniques such as percutaneous discectomy. Maybe our assumptions are faulty.
Saal, JS and Saal, JA., "Non-Operative Treatment of Cervical Herniated Discs: An Outcome Study." Presented at the North American Spine Society annual meeting Oct 1994.
Twenty-four consecutive patients with cervical disc herniations were studied prospectively. Inclusion criteria were:
- MRI confirmed HNP >4mm in size
- Chief complaint of arm pain in a dermatomal distribution
- The majority had neurological deficits
All patients were treated with aggressive rehabilitation. 22 of the 24 had good or excellent outcomes and two needed surgery. 19 of 22 returned to work at the same job. 22 of 24 reported complete or near complete satisfaction with their result.
In other recent studies, sequential MRI scans done at six month intervals have shown that disc herniations more often than not are resorbed by the body. The studies found that larger disc herniations DO NOT correlate with a poor prognosis. They go away. As Ian McNab, MD said of disc herniations in his book Backache "90% of patients will get better and stay better with conservative care."
Official Clinical Guidelines
Some major organizations have weighed in on this topic. The American Academy of Orthopedic Surgeons recommends at least three months of non-operative care for disc herniations unless there is a progressive neurological deficit. This is an important distinction. It is not enough to simply have an ankle jerk out or loss of dermatomal sensation or weakness. The vast majority of the time these deficits will improve or resolve with time. Only if the deficits can be accurately documented to deteriorate is surgery indicated. In my experiences neurological deficits are common but progressive deficits are rare.
The Agency for Health Care Policy and Research guidelines for acute back pain have gotten a lot of press after publication in Dec 1994. The Agency specifically addressed patients with acute sciatica. They state that sciatica may recover more slowly than isolated back pain but they go on to say that only patients with severe, debilitating symptoms of sciatica and exam evidence of nerve root compromise corroborated on imaging studies can be expected to benefit from surgery. They recommend reserving expensive imaging for those patients not spontaneously improving. Translation: You don't need to get an immediate MRI on a patient with a two week history of back and leg pain and a neurological deficit. Try to keep the patient comfortable while the body heals itself but do not rush into the surgical pathway. That innocuous little laminectomy may not be as predictable as we would like.
The Federally funded study also was skeptical towards our spinal vocabulary. They pose this question: What do the following popular diagnostic terms have in common?
- Annular tear
- Degenerative joint disease
- Internal disc derangement
- Disc disruption
- Adult Spondylolysis
- Myofascial pain syndrome
- Lumbar disc disease
- Lumbar sprain
- Facet syndrome
According to the panel of experts, "...none of these diagnoses are scientifically validated. Scientific studies haven't proven any of them to have a connection to back symptoms...".
This is not to say none of them are real, just that none are proven and until they are we should be careful about basing decisions on theses diagnoses.
There is a lot of information here to digest. And it may conflict with what many doctors consider to be proper treatment for disc herniations. But such information cannot be ignored. Given the costs and potential complications from what in many cases may be unnecessary surgical intervention, caution is certainly indicated.
In summary, when faced with a disc herniation the following points are useful:
- Don't panic. As long as neurological deficits are not deteriorating, observation is warranted.
- Consider an epidural block for nerve root related leg pain. These injections are not proven for back pain but are often successful for leg pain.
- Consider exercise a treatment for acute disc syndrome.
- Most patients get well on their own and many disc herniations disappear.
Brian W. Nelson, MD
Physicians Neck & Back Clinics