Herniated Disc and Recovery

Introduction

A herniated disc is when a disc extrudes into the spinal canal and often referred to as a prolapse disc, ruptured disc or sometimes a slipped disc [1-2]. In this health news article I will briefly discuss the following;

 

  1. Pathophysiological Causes

  2. Misconceptions

  3. Healing Process

  4. Non-Operative Management vs Surgical Intervention

  5. The Science

  6. Final Thoughts

 

1. Pathophysiological Causes

There are many intrinsic, extrinsic and traumatic pathophysiological influences that may cause a disc herniation.  For example although not exhaustive some may be caused by; poor mechanics, improper technique lifting or twisting with load, sport-specific training errors or in people with a previous history of a disc herniation. It can also occur in sedentary life particularly in people aged between 30-40 years due to the elasticity and water content of the nucleus pulposus reducing with age [1-6].  

 

2. Misconceptions

Patients who suffer a disc extrusion often wonder what happens to the material from the inside of the disc once it has prolapsed (pushed outward) and is pressing on the nearby sensitive tissue structures. A misconception I hear regularly is that people assume that this material will permanently remain there, this is simply not true! [7-13]

 

3. Healing process

Studies clearly suggest that the body’s natural immune system will eventually clean up the extruded disc material. However the healing process will entirely depend on the person’s systemic health, genetics and rehabilitation Intervention. For example a musculoskeletal injury specialist such as a sports therapist will not only be able to rehabilitate the injury but will also be able to assess the patient’s movement patterns and whether a patient’s movement patterns provoke the disc extrusion. For patients that have a disc extrusion and smoke it may be a good time to stop. Smoking has been suggested to affect the rate of the reliability of resorption [1,3-5,14-17].

 

4. Non-Operative Management vs Surgical Intervention

For patients that experience a disc extrusion, occasionally accompanied with sciatica (leg pain) that has been presented to a surgeon to remove the disc material from the nerve root. The current scientific literature recommends that surgical intervention following a disc extrusion should only be considered if;

 

  • Pain is not manageable under non-operative conservative care

  • Persistent occurring symptoms of weakness in the muscles e.g. the leg

  • Difficulty in standing and walking

  • Evidence of severe nerve compression

  • Proficiency to defecate or urinate is compromised caused by the pressure of disc material on the nerves that manage these structures

  • If a serious pathology is suspected

[5-6,15-18]

 

Arguably despite the above considerations whether patients should opt for non-operative or surgical intervention is still very much questionable. The medical literature reviewed suggests that both outcomes had similar mixed results when comparing both groups of patients throughout a 2 year follow up period. Therefore we must now consider some of the advantages and disadvantages associated with both interventions. 

 

Advantages of Non-operative management

Over a period of time the body will resorb and heal the herniated disc extrusion (see the science). Risks of sustaining further complications through conservative management is small.

 

Disadvantages of Non-operative management

A patient may not respond well to conservative management due to additional complications such as medical abnormalities or poor management. 

 

Advantages of Surgical Management

Patients with a disc herniation combined with leg pain symptoms (such as sciatica) surgery will often help manage both leg and back pain symptoms sooner rather than later [3,19-20].

 

A 2016 published study suggests that patients that didn't respond well to conservative management or had further complications associated with their disc herniation post 0-2+ years responded well in both pain reduction and improved function following micro-discectomy surgery [21]. 

 

Disadvantages of Surgical Management 

There's always a potential risk in surgical procedures of post-operative infections. This is due to the possibility over increasing concerns over antibiotic resistant pathogens [22]. 

 

Post-operative concerns over future risks of sustaining a herniated disc reoccurrence [23].

 

Patients may have misconceptions if they opt for non-operative management they may miss out on the opportunity of surgical intervention. This is simply not true!

 

5. The Science

Below is a brief overview of the literature on how your body can heal an extruded disc often referred to as resorption,

 

MRI interventions following a 6-12 month time period suggests approximately 50% of patients had a reduction of 70% in size of extruded material since their initial MRI [8-13].

 

Research suggests that 90% of patients with a disc herniation accompanied with radiculopathy symptoms can be successfully treated using non-operative conservative management [16].

 

MRI findings failed to keep up with patients improved leg symptoms [7].

 

Research suggests that larger extrusions and sequestrations are more likely to resorb [9-11].

 

6. Final Thoughts 

Both non-operative and surgical interventions have similar mixed outcome results. Both interventions can be beneficial to the patient. However the route of intervention would entirely depend on patients medical history, diagnosis and medical requirements. It is imperative that patients understand the cause and mechanics of injury to prevent reoccurrence of injury through patient education and adherence. Furthermore it is imperative that patients be informed of the risks associated with both interventions. Whether a patient opts for surgical or non surgical intervention we provide our patients with a safe, professional evidence-based service to both athletes and non-athletes alike. Our aim is to restore optimum levels of function, occupational and sports specific, regardless of age and ability, as quickly as is practicable possible, without reoccurrence of injury. 

 

As always thanks for reading this article, enjoy your sport. For more information on how I may be able to help you with your back pain click here.

         His knowledge of anatomy was incredible. ...The pain I experienced disappeared almost instantly after I left the treatment room and has been a lot better since... Thanks Nick!

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References

  1. Buttermann GR. (2004) Treatment of lumbar disc herniation: Epidural steroid injection compared with discectomy. A prospective randomised study . J Bone Joint Surg Am 86:670-679 2004.

  2. Edelson, Stewart. (2002) Save Your Aching Back & Neck: A Patients Guide. 2nd ed., San Diego. CA: SYA Press and Research 2002.

  3. Peul WC, van Houwelingen HC. (2007) Surgery versus prolonged conservative treatment for sciatica N Engl J Med 31;356(22)-2245-2256, 2007.

  4. Weber, H. (1983) Lumbar disc herniation: A controlled prospective study with ten years of observation. Spine 8:131-140, 1983.

  5. Weinstein J,N. (2006) Surgical vs non-operative management for lumbar disc herniation: The Spine Patient Outcomes Research Trials (SPORT). A randomised trial JAMA 296:2441-2450, 2006

  6. Reider, B. (2014) Orthopaedic Rehabilitation of The Athlete ISBN 9781455727803 Elsevier Saunders publishing 2014. 

  7. Ito T, Yamada. M, IkutaF. (1996) Histologic evidence of absorption of sequestration-type herniated disc. Spine 1996; 21:230–4.

  8. Fagerlund, MK. Thelander, U. Friberg, S. (1990) Size of lumbar disc hernias measured using computed tomography and related to sciatic symptoms. Acta Radiol 1990; 31(6):555–8.

  9. Maigne, JY. Rime, B. Deligne, B. Computed tomographic follow-up study of forty-eight cases of non-operatively treated lumbar intervertebral disc herniation. Spine (Phila Pa 1976) 1992;17(9):1071–4.

  10. Bush; K. Cowan, N, Katz, DE. The natural history of sciatica associated with disc pathology. A prospective study with clinical and independent radiologic follow-up. Spine (Phila Pa 1976) 1992; 17(10):1205–12.

  11. Jensen TS, Albert HB, Soerensen JS. (2006) Natural course of disc morphology in patients with sciatica: an MRI study using a standardized qualitative classification system. Spine (Phila Pa 1976) 2006; 31(14): 1605–12 [discussion: 1613].

  12. Autio, RA. Karppinen, J. Niinimaki, J. (2006) Determinants of spontaneous resorption of intervertebral disc herniations. Spine (Phila Pa 1976) 2006; 31(11):1247–52.

  13. Monument, MJ. Salo, PT. (2011) Spontaneous regression of a lumbar disk herniation. CMAJ 2011; 183(7):823.

  14. Henmi T, Sairyo K, Nakano S, Kanematsu Y, Kajikawa T, Katoh S, Goel VK. (2002) Natural history of extruded lumbar intervertebral disc herniation. J Med Invest. 2002 Feb, 49 (1-2):40-3.

  15. Komori H, Shinomiya K, Nakai O, Yamaura I, Takeda S, Furuya K (1996) : The natural history of herniated nucleus pulposus with radiculopathy. Spine 21 : 225 – 229, 1996.

  16. Saal JA. (1996) Natural history and non-operative treatment of lumbar disc herniation.Spine (Phila Pa 1976). 1996 Dec 15;21(24 Suppl):2S-9S.

  17. Liu, JT. Li, XF. Yu, PF. Li, XC. Qian, Q. Liu, GH. Yu, ZH. Ma, QH. Tang, DZ. Jiang, H. (2014) Spontaneous resorption of a large lumbar disc herniation within 4 months. Pain Physician. 2014 Nov-Dec;17(6):E803-6.

  18. Refshauge K,M. Maher C,G. (2006) Low back pain Investigations and prognosis: a review: Br J Sports Med 2006;40:494-498.

  19. Lurie JD, Tosteson TD, Tosteson AN, Zhao W, Morgan TS, Abdu WA, Herkowitz H, Weinstein JN. Surgical versus nonoperative treatment for lumbar disc herniation: eight-year results for the spine patient outcomes research trial. Spine (Phila Pa 1976). 2014 Jan 1;39(1):3-16.

  20. Atlas SJ, Keller RB, Wu YA, Deyo RA, Singer DE. Long-term outcomes of surgical and nonsurgical management of sciatica secondary to a lumbar disc herniation: 10 year results from the maine lumbar spine study. Spine (Phila Pa 1976). 2005 Apr 15;30(8):927-35.

  21. Pitsika M, Thomas E, Shaheen S, Sharma H. (2016) Does the duration of symptoms influence outcome in patients with sciatica undergoing micro-discectomy and decompressions? Spine J. 2016. 

  22. Accessed theatlantic.com March (2006) http://www.theatlantic.com/health/archive/2015/10/how-antibiotic-resistance-could-make-common-surgeries-more-dangerous/410782/

  23. Watters WC 3rd, McGirt MJ. (2009) An evidence-based review of the literature on the consequences of conservative versus aggressive discectomy for the treatment of primary disc herniation with radiculopathy. Spine J. 2009 Mar;9(3):240-57.

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