- Dr. Jason Rountree
Do you HAVE to have surgery for a disc herniation?
Welcome back! Today, I would like to speak with you about low back pain - specifically, low back disc herniations.
What is a Disc Herniation?
First, let's talk about what a disc herniation is and what it really means. To understand this, we need to look at the anatomy of the lower back. In this region you have the spine which is the backbone of your support for the entire body. The spine is made up of separate joined bones called vertebrae and, in between each of them, there is a somewhat squishy disc that is designed to provide support, mobility, and cushioning for the lower back.
Now, the discs themselves are actually quite tough as they provide a lot of support while also providing mobility. However, over time and with injuries, they can develop little cracks or fissures and they can start to leak. Inside of the disc is a jelly like substance and, when that substance gets to the point where it can leak out of the disc, it can start to push against the nerves. More importantly, the specific nerves that travel from and out of the spine and then down the leg. From there, they go to sensory and motor nerves that control your muscles. They also go through a section of the spine that is quite narrow and, if a disc herniates and leaks it's insides onto that nerve or near that nerve, it can produce enormous amounts of pain and even weakness or drop foot (where you cannot elevate or lift up your foot). Additionally, it can interfere with your sense of balance, your reaction speed, and it increases your fall risk.
So, on top of being incredibly painful, there are additional effects that can really impact your quality of life. However, it is the pain that is the leading instigator sending people to the doctor saying, "hey, my back hurts" or "this pain is running down the back of my leg, I can feel it down into my calf and, sometimes, even down all the way into the foot." Unfortunately, the pain typically gets worse. Whenever you lean forward, sometimes lean off to the side, or whenever you cough or sneeze, it can be very painful because it increases the pressure on the disc. As mentioned above, when you increase the pressure on the disc it pushes more of that jelly substance to the outside.
The technical term here is 'disc herniation' because the insides of the disc has herniated or come outwards to the outside of the disc. It is not the more commonly known herniation that happens in the abdomen, such as an umbilical herniation or an inguinal herniation where some of the intestines have actually pushed out into the outer wall of the abdominal muscles or through the muscles of the groin. This is talking about the insides of the spinal disc going to the outside of the disc, but it is still very much contained in the body. You cannot feel this type of herniation from the outside because it is very deep.
The previously mentioned motions will bother a disc herniation quite a bit:
This type of injury can be sneaky as it may start gradually with just a little bit of lower back pain but, then, one small motion such as bending forward to tie your shoe can really set this whole process in motion. Disc herniations oftentimes start with little cracks, little injuries, or little fissures to the outside edge of this disc that steadily allows that disc to bulge and for the insides to end up herniating through.
Surgical Intervention for Disc Herniation: Right or Wrong?
You may be wondering, what do most of us do when something like this happens? We usually go to the doctor. There is typically a lot of pain in the lower back, pain running down the leg, or maybe even weakness like stumbling or having trouble sitting for a longer period of time while driving. The doctor will most likely say, "oh, well this looks like it may be a disc issue. Let's get an MRI." The MRI will show them how big this disc herniation is. Now, whether it is big or small, your doctor will most likely say you need - drum roll please - SURGERY. From there, you are referred to a surgeon, they review your MRI results, and agree that you have a painful issue requiring this form of intervention. What I just gave you was the typical progression of care with this type of injury. However, there are more factors at work here than that.
The rate of spinal surgery in the United States is the highest in the world. Approximately five times that of England, Scotland, and other developed countries. That is a direct statistic from the article I am presenting to you today. It is new research published just this year in the Global Spine Journal. The title of the study is 'Does Size Matter? An Analysis of the Effect of Lumbar Disc Herniation Size on the Success of Non-Operative Treatment.' The focus being: do large disc herniations always require surgery?
Does Size Matter (for disc herniations)?
Clearly something is going on here in the United States. We have a five times higher rate of spine surgery than everyone else. Why is that? Let me quote you what the surgeons from this study found. "Some surgeons use the size of a lumbar disc herniation to determine whether or not a patient will ultimately fail non-operative management and require surgery. Perhaps this practice is the result of an underlying belief that spontaneous resolution of large herniations is rare and will ultimately require surgical intervention. Regardless, the literature is controversial at best in its support of utilizing disc size to inform surgical management of lumbar disc herniations. Unless patients are suffering from exigent conditions, such as cauda, equina syndrome, or a profound or progressive neurological deficit necessitating immediate surgery, most patients’ symptoms resolve without significant intervention." A more simplified version of this statement: Despite what your doctors might think, it does not matter how big the disc herniation is. Many times, there is not any evidence to suggest that a large disc herniation always needs surgery. Unless you are experiencing an actual emergency like loss of bowel or bladder control or severe weakness, most of those symptoms will resolve without significant intervention like surgery.
As a matter of fact, these doctors go on to say that even massive disc herniations can be successfully treated conservatively. Meaning that, patients without those red flags of the loss of bowel or bladder controller or the major weakness should always undergo six weeks of non-operative management before surgery is even considered. Over 90% of lumbar disc herniations will resolve on their own - especially if it is coupled with good, conservative care. What do we mean by conservative care? That means non-surgical care such as:
These Harvard doctors go on to say that, in their study, only 8.7% of the patients analyzed actually required surgery. That included even enormous disc herniations, some of which were so big they almost completely filled the area where the nerve goes through. That is amazing! We are talking just six weeks of conservative care that can make all the difference between having invasive surgery which carries risks, side effects, and potentially ongoing problems afterward. Six weeks of some form of conservative care should be considered for almost all lumbar disc herniation patients.
Let me give you a couple of examples. In the last year or two, I have had two specific cases of lumbar disc herniation patients with significant, large herniations that ended up having their MRIs and were sent to a surgeon. The surgeon agreed that they needed surgery and that they probably needed a fusion of the spine. A fusion is where they remove the unhealthy tissue and use permanent hardware to prevent that section of the spine from even moving. Now, these patients were very hesitant to undergo that, especially due to the fact that they were fairly young and healthy otherwise (one is around 35 and the other one is about 55). Besides the one disc herniation, the rest of the spine on both of these patients looked good. Therefore, jumping right into a fusion type surgery was something that they realized was probably not the best for their situation. Now, neither one of them were in this emergency category where they had a loss of bowel or bladder function. They both had some weakness in the affected leg and were in significant amounts of pain when they came to see me. For both patients, we started a six-week conservative care plan that included exercise, chiropractic, and laser therapy. Each of them had rapid improvements within a week! They were feeling better and have continued to get better since and are no longer considering surgery. As a matter of fact, they are rapidly regaining strength and doing great with the ability to do the things they want to do. No downtime, no surgical risks, no medications.
Friends Don't Let Friends Get Unnecessary Surgeries
If you or someone you know has just discovered that you have a lumbar disc problem, are in a lot of pain, and will be going straight into surgery - stop! It may be worth a trial of conservative care, whether that is physical therapy, chiropractic, or even massage therapy coupled with exercises. Laser therapy has been shown, in many cases, to be very helpful with and resolving low back pain and disc injuries. In some cases, even helping to repair the disc itself!
If you are saying, "but doc, what about my really big disc herniation?" Well, the researchers say that there is no correlation between the size of a disc herniation and the likelihood that a patient will require surgery after they have had their six weeks of non-operative management. The vast majority of patients experienced a resolution of their symptoms with conservative management and non-operative care. Additionally, while we all want to feel better as quickly as possible, these doctors say that "this should be a reminder for clinicians and patients to exhibit patience in the treatment of lumbar disc herniations." This cannot be done overnight. Even if you have surgery, there are many times where people are left with ongoing pain and every time that there is some kind of surgical process, you run the risk of having ongoing problems with arthritis and degenerative changes.
I would highly encourage you to get evaluated by our medical professionals at Montana Laser and Medical Center as an alternative intervention for your herniation. We do no-charge consultations with our case manager and usually have openings within one to two weeks! Call us today!