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Back Facts for Those In Pain
Back Facts for Those In
Pain (part two)
by Dr. Steve Opersteny of Professional
Back Solutions
III. Disc Pain
Damaged discs do not all require surgery. In fact, the majority can improve without surgery. Research supports that 78-90% of patient with disrupted discs (herniated or bulging) can heal without surgery. Non-operative or non-surgical treatment can work even in the cases where numbness or weakness is present.
A cauda equina syndrome is where the spinal nerves are compressed to the point that loss of control of bowel and/or bladder occurs. If a cauda equina syndrome exists this is considered a surgical emergency. Unless a cauda equina syndrome exists non-surgical treatment is an option. Non-surgical treatment does require a commitment from the patient to exercise appropriately and to use proper body mechanics. Surgery for back pain without numbness or weakness often has a poor outcome. Many surgeons are reluctant to operate for back pain alone. After surgery, the body's natural response is to form scar tissue. There is a direct relationship between the amount of scar tissue formed after surgery and remaining symptoms. After surgical removal of a disc herniation 22-48% of patients experience residual back pain. Almost half of all people with surgical procedures to correct disc problems will have pain after the surgery. Expectations must be realistic. If surgery is undertaken a post-surgical rehabilitation program is recommended.
The decision to pursue surgery is a difficult one to make. Both surgical and non-surgical options require active participation to improve. The question remains "is it better to surgically remove the pressure from the nerve by removing the disc and contend with scar tissue formation, or, follow a non-surgical approach relying on physical means to reduce the disc herniation along with inflammation control and nerve regeneration?" Whichever decision you make is an individual one, and it would benefit you to discuss your options with your doctor.
In summary, disc disruptions can be managed without surgery even in the presence of leg numbness or weakness. A cauda equina syndrome is the only surgical emergency. Methods to treat disc disruptions without surgery include anti-inflammatory medications, limitation of activity, proper body mechanics, exercises to reduce the disc bulging (McKenzie or disc reductions programs), gravitational traction and strengthening exercises.
IV. Invasive or Surgical Options
Invasive or surgical options for a disc disruption include Epidural Steroid Injections (ESI's), Chemonucleolysis, Intradiscal Electro-Thermal Therapy (IDET ä), Radiofrequency denervation of the disc, Percutaneous removal of disc material through percutaneous discectomy, arthroscopic discectomy or laser discectomy, macro-discectomy, and fusion surgery. Open surgical procedures include the micro-discectomy and macro-discectomy, and finally fusion surgery. Open procedures are more invasive surgical techniques to open the surrounding area. This is important because the more cutting and invasive a surgery is, the higher the likelihood of scar tissue forming.
A. Epidural Steroid Injections
Epidural Steroid Injections (ESI's) have proven effective in treating disc disruptions. The concept of ESI's is similar to that of injecting cortisone into any other joint such as a knee or shoulder that is swollen and painful. The cortisone or steroid reduces inflammation or swelling. Steroid injected into the epidural space will help reduce disc swelling and inflammation. Epidural Steroid Injections are best performed with the assistance of X-Ray guidance (Flouroscopy). ESI's are best combined with exercises to help mechanically reduce the disc such as McKenzie or Disc Reduction Exercises.
B. Chemonucleolysis
Chemonucleolysis was used in a large number of patients from 1969 to 1975. The procedure involves injecting an enzyme into the disc that dissolves damaged or herniated disc material. The FDA for safety concerns then removed it. The enzyme if injected into the wrong area could damage normal tissue, which could cause damage to the nerves and spinal cord resulting in paralysis. The FDA then re-released the enzyme for use in the lumbar region in 1982. Severe allergic reactions to the enzyme can occur and can cause serious complications. It is recommended that each patient considering injection of Chymopapain (the enzyme most commonly used) be administered a skin test to determine if they are allergic. There are numerous studies that show that Chymopapain is relatively safe and produces results. Chymopapain is used sparingly in the United States probably because of negative publicity associated with its history. New generation enzymes are being tested that may have less potential side effects.
C. Intradiscal Electro-Thermal Therapy
Intradiscal Electro-Thermal Therapy (IDETä) involves using a special probe guided into the disc. The probe is then heated to cause a "burn". This induces scarring and hope is the scar tissue can repair the torn disc.
After this procedure the patient is required to follow a specific post procedural program of 4 - 6 months in duration. This program involves using a brace, limitations of activity for 4-6 months, and specific exercises. These precautions are necessary to allow the disc to adequately heal before subjecting the disc to stress again. This is a newly developed technique. Initial studies using this method to "repair" the disc disruption appears promising, but the research with larger numbers or participants over a longer follow-up time from is still needed.
D. Radiofrequency Denervation
Radiofrequency denervation of the disc involved placing a needle with a wire attached inside the disc. The wires are then attached to a Radiofrequency alternating current, which burns the tissue around the needle tip. The Radiofrequency burn made in the disc is thought to cause some scarring and destroy the pain fibers in the disc. The scarring may allow the disc to begin to heal. Burning of the pain fibers may help eliminate some of the pain from the disc.
E. Percutaneous Procedures
Involves removing some of the disc material through a small puncture hole made in the back. Percutaneous procedures include percutaneous discectomy, arthroscopic micro-discectomy, and laser discectomy. These procedures are similar in that a probe or cannula (long probe that is hollow) is inserted into the disc and the disc material is removed through the cannula, or in the case of laser surgery burned through the
cannula.
An arthroscopic discectomy involves using modified arthroscopic instruments with a scope so that the disc can be seen on a TV screen. Suction, pinchers, and cutters are then used to remove part of the nucleus. In the case of laser discectomy a laser beam is used through the cannula to vaporize part of the nucleus. Results of the percutaneous procedures are not clear. Some outcome studies that look at the results show success rates as high as 80% and as low as 29%. One author reviewing the literature on percutaneous discectomies indicated, "justification for percutaneous discectomies and arthroscopic discectomies is not found in published studies."
Micro-discectomies involves using a small ncision 1-2 cm long. With the use of an operating microscope, the disc is exposed and removed. Macro or micro-discectomies involve removing some of the bone (lamina) from the spine.
Macro-discectomy uses a larger incision. The bone (lamina) is either partially or totally removed and the herniated disc is surgically removed.
The success rate for macro-discectomies or micro-discectomies for patient with a herniated disc and neurological symptoms is about 85%. There are no studies that micro-discectomies are superior to macro-discectomies. However, intuitively it would seem that the procedure of choice would be a micro-discectomy as there is less tissue disruption and less scar tissue formation.
F. Discectomy and Fusion
A final surgical option available for disc disruption is discectomy and fusion. After the disc is removed a plug of bone is inserted where the disc was located. Usually hardware (plates and screws) is applied. The bone eventually grows together or "fuses". In my own practice I have only seen about a 50% success rate of fusion surgeries done for disc disruptions. It would seem wise to try the less invasive surgeries first and save a fusion as a procedure of last resort.
In summary, if surgery is chosen as a treatment there are several options to consider. After surgery active rehabilitation is important to advance to a good outcome.
V. Facet Joint Pain
Facet joint pain is another cause of back pain. Our spine has actual joints called "facet" joints. They are similar to most other joints in our body. A combination of axial compression (pressure from head to toe), and backward bending can cause a jamming type of injury to the facet joints (similar to jamming your finger).
Common accidents that can cause injury to the facet joints are motor vehicle accidents, slipping and falling, or having something fall on you. Arthritis can develop in these joints as well and can be a source of pain.
An acute facet joint injury should be treated the same as any other injury. Use the RICE (Rest, Ice, Compression, and Elevation) principle to address the initial injury. After 1 -2 days a program of ice, use of a back brace, restricted activities, and gradual stretching should be initiated. One study showed that patients with back pain due to a facet syndrome improved with correction of postural abnormalities, stretching, and strengthening of the back. After the initial 24-48 hours either ice or heat may be used (whichever feels better). Manipulation, such as that performed by a chiropractor or Doctor of Osteopathy (D.O.) may have a place in treating a facet joint problem. One study that looked at manipulation for back pain summarized that "manipulation is a passive process that can initiate spinal movement but must be combined with other forms of treatment and exercise." Traction and strengthening exercises for a facet joint problem can help as well. The facet joints can also be injected with cortisone or steroids. The facet joint injections are most useful when combined with a rehabilitation program designed for a facet joint problem.
In summary, a facet joint can be injured like any other joint in the body. Treatment options include initially rest, ice, and possibly back braces followed by stretching, anti-inflammatory drugs, manipulation and strengthening of the muscles that stabilize the spine.
VI. Sacroiliac Joint Pain
The Sacroiliac joint (SI joint) is another potential pain generator in the back.
The SI joint can become painful and inflamed if the joint has shifted or becomes unstable due to stretched ligaments as a result of an accident.
Persons at risk for developing pain from a SI joint problem are pregnant women, people with excessive hypermobile joints (lax joints or "double jointed") or persons involved in a trauma such as a motor vehicle accident or a bad fall.
Treatment for the SI joint problem is the same as for any other acute injury RICE. After the first 24-48 hours of RICE, stretching of the tightened muscles combined with strengthening exercises for the muscles that cross the SI joint and help stabilize it.
Other treatment options for an SI joint problem include using an SI stabilization belt. ( Manipulation or Muscle Energy Techniques (self mobilization) may also be helpful, as can SI joint injections with cortisone or steroids. All of these are most effectively used with combination of a SI specific strengthening and stretching program.
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