Learning More: Cutting-Edge Treatment For Back Pain

This week I decided to check out other blogs to see what more I could learn about treatment of lower back pain. I was pleased to find that there are many blogs dedicated to this very subject. One such blog described a new spinal decompression machine that looks to be a good step forward in limiting the role of surgery in back pain treatment. I read the post concerning this machine and found that I had a few questions to ask the author, Dr. Eben Davis. Dr. Davis is a chiropractor in San Francisco who specializes in non-surgical methods of back and wrist pain treatment. I left a comment on his blog asking for help understanding the benefits of the new decompression machine, and I hope to hear back from him soon. For your convenience, I am also including the full text of my comment below. As I continued searching through the blogosphere, I came upon another excellent blog dealing with orthopedics, aptly titled "Orthopedic." One post on this blog was dedicated to the discussion of spinal surgical techniques. As I had a few questions about these procedures, I also left a comment there. As with my first post, it is also available in full text below.

"What is Degenerative Disc Disease? Can the DRX9000 Help?"
Comment:
"Hi Dr. Davis, I’m a student at the University of Southern California and I have a great interest in spinal therapy for a couple of reasons. First of all, I suffer from sciatica due to a herniated disc. Secondly, I plan to go to med school after graduation and I’m currently looking at orthopedics as a specialty.

I think that this new machine looks like a great treatment method for people with back pain. Surgery should be kept as a last resort, and innovative ideas like this will surely help reinforce that. How long does one session on the DRX machine provide relief for a patient? I saw on the DRX website that the treatment effectively relieves pressure on lumbar discs that are bulging or even ruptured. What I don’t understand is how the disc returns to normal after the pressure is relieved. If a disc has ruptured, how does it pull itself back together all of a sudden during this treatment? I can imagine that a herniated disc might be able to reassume a normal shape, but is there really any way that a patient with a ruptured disc can get an effective resolution of pain non-surgically?

Additionally, how do you feel about this new article published in the British Medical Journal last week (http://www.sciencedaily.com/releases/2008/01/080131214541.htm) saying that stretching does not effectively decrease back pain? I personally disagree with these results, as I have achieved almost complete success through stretching and exercising my back over the last 18 months since my injury. Basic yoga has done worlds of good for me. When my back tightens up, whether as a result of stress or bad posture, I always find the most relief from stretching on the floor in the Cobra Pose. I also have worked to strengthen my lower back with the Full Locust Pose. Of course, my personal success with this kind of treatment does not necessarily prove its validity in general.

I am looking forward to learning more about this field, so any insights you could offer would be greatly appreciated."

"What are the Spinal Orthopedic Procedures?"
Comment:
"Great post – it’s hard to find good information on these techniques online. I hadn’t realized that some surgeons operate from the front of the patient when operating on the spine. What is the benefit of this approach? I had thought that herniations occurred on the posterior side of lumbar and/or cervical discs.

What are your thoughts on non-surgical treatments for disc herniations? I have been researching this for a while, and it seems like many people have personal success stories with alternative treatments like yoga and spinal decompression with a chiropractor, but the medical community at large seems to disagree. What, in your opinion, is the best treatment plan from injury to full resolution of pain? I suffered a herniated lumbar disc about 18 months ago, and I have always kept surgery as a last resort. I have instead taken the non-invasive route and tried my best at yoga, with some dramatic success. As of now, I am almost 100% pain free.

I think that the idea of minimally invasive spinal surgery is a great one. It’s amazing that the same goal can be met either with a hazardous open procedure or a relatively benign laparoscopic one. How long have minimally invasive surgeries been around for the spine? I have read on numerous sites that they are new, but I haven’t seen any actual dates.

Once again, thank you for posting this here – a good resource is invaluable for someone looking for information on back pain treatments. Surgery, especially, is never really discussed in any sense other than outcomes. Plenty of people write about their own experiences with surgery, but you are the first I have seen to write in detail about each of the different options."

Lower Back Pain Treatment: Are Orthopedic Surgeons Hiding Something From Their Patients?

There are several key areas of orthopedic surgery that are current and developing enough to warrant timely blog posts. One of these is the treatment of lower back pain. This is of particular interest to me, as I have herniated a lumbar disc myself. I am not in a rare situation though. Lower back pain is a major financial burden for Americans, as a Duke University study found that the annual cost of lower back pain treatment in America exceeded $25 billion, or 2.5% of all national healthcare expenses.

Lower back pain manifests itself in two forms: axial and radicular. Axial pain is concentrated in the lower back and can be caused by aggravation of the soft tissue surrounding the spine. Improper lifting technique, for example, can put strain on the tendons and ligaments that support the spine, and thus allow more severe damages to take place. These can lead to radicular pain, or pain that is no longer confined to the lower back. Radicular pain is often referred to as sciatica. A patient typically suffers from pain that shoots down one or both legs, either intermittently or chronically. At its worst, this pain can be accompanied by numbness or loss of strength in the affected limb or limbs.

The anatomy of a sciatica-stricken lower back is fairly simple. Each vertebra in the spine is separated from its neighbor by a lumbar disc. The primary function of this disc is shock absorption. Lumbar discs are shaped like a jelly doughnut. They have a tough outer layer, known as the annulus fibrosus, and a softer inner layer, called the nucleus pulposus. See diagram below for clarification. When a disc ruptures or becomes herniated, the nucleus pulposus pushes out into the space normally contained by the annulus fibrosus. This makes the disc as a whole bulge out into the surrounding space. A bulging disc can impinge on nerve roots that exit the spine next to the discs, and in doing so cause pain to be experienced all along the path of that nerve. When the bulging disc is in the lower back, the impinged nerve tends to run to one of the legs.

For many years, the gold standard treatment for radial lower back pain was surgery. There are several different procedures that are in common practice today, and each one has pros and cons for a given patient’s situation. In each procedure, the basic goal is the same: to relieve pain caused by nerve root impingement. One method involves shaving down the herniated portion of the disc, thus returning the outer shape of the disc to its natural curve. This releases pressure on the nerve, but permanently weakens the annulus fibrosus. Another method, known as a discectomy, involves either the removal or dissolution of the herniated disc. The two vertebrae are then fused together to prevent any motion between them. This method can be a great relief for some patients, but it decreases flexibility in and permanently weakens the lower back. One of the more recent developments is called a total disc replacement. An interactive video detailing this procedure can be seen here.

In contrast to this newest procedure, over the past few years surgical techniques have generally become less and less invasive. Orthopedic surgeons are now commonly performing laparoscopic microdiscectomies rather than open surgeries to speed up recovery time and lessen any chance of infection. Treatment plans have similarly taken a step away from the traditional surgery route. Many surgeons now advise that surgery is not necessary for any patients but those with the most serious disc herniations. Each of the twenty-four orthopedic surgeons who gave their opinions on back.com felt that the best course of action is to start with rest and non-steriodal anti-inflammatory drugs (NSAIDs), then advance to exercise and stretching, then try cortisone injections around the affected area, and finally to proceed to surgery if nothing else has given the patient relief. It is amazing how uniform this treatment plan is from doctor to doctor. It is not by any means the only method prescribed by doctors around the country, but it evidently has a pretty strong following.

There are a few issues with this treatment plan. Several recently published studies contradict the idea that following this protocol will lead to resolution of lower back pain. The first, a recent review of 65 studies comprising over 11,000 subjects with lower back pain, has concluded that NSAIDs like ibuprofen are no more effective at treating symptoms from radial pain than simple painkillers such as Tylenol. It also concluded that NSAIDs were only slightly effective at relieving pain for these subjects. Another study published by the British Medical Journal has shown that exercises and lifting technique education are not effective at relieving back pain. As written in Science Daily, “a group receiving both training and an assistive device was compared to a group receiving training only and another control group which received nothing -- there was no difference in back pain [after one year].”

I find it very odd that orthopedic surgeons would be advocating a treatment plan that calls for NSAIDs, education on posture and lifting, and stretching and exercises for the back considering that these elements of the treatment have been shown to be ineffective. Is it possible that these surgeons know that eventually their patients will come crawling back for surgery after months of ineffective exercise and stretching? Many people are averse to the idea of having surgery on their back and will only consent when they feel it is their only option for relief. If surgeons were only promoting alternative therapies to add credence to their own surgical specialty, then what a wicked game that would be.

I cannot believe that any medical professional would knowingly give out bad information to a patient simply to make surgery seem like a better option. Instead, I think that these surgeons believe that many back pain sufferers can simply get better on their own. Given time, many (some estimate up to 80%) patients will regain most of their strength and learn to live with whatever pain lingers. I believe that what the common treatment plan does is give the majority of patients the time that is necessary to begin to heal themselves without surgery. After all, this has been my own personal experience with back pain. I herniated a disc in my lower back almost 18 months ago, and I am finally to the point where I could declare myself as being 90% better. I was given the standard treatment plan – first rest and painkillers, then stretching and exercise, and I was told that surgery would be held as a last resort. I ended up not taking that last resort because my pain went away quickly enough. The stretching and exercise involved with this treatment plan worked well for me because it gave me something to do while I waited for my pain to go away. Whether it went away because of what I was doing or simply on its own does not matter because in either case, I recovered. And when it comes to lower back pain, that’s really what counts.