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March 29, 2008
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Summary
The lumbar region of the human spine is a location that is very susceptible to injury and trauma. A majority of the population experience back pain at some time during their life, and although in most cases the pain subsides after a time of rest, there is an enormous need for treatment of this malady. The various types of treatment for lumbar disc herniations include a more conservative method of rest, physical therapy, and anti-inflammatory or non-steroidal drugs. A more extreme condition would require surgery to try to alleviate the symptoms. The older, more traditional surgery is a posterior laminotomy, however, newer less invasive microscopic and endoscopic surgeries been implemented to increase success and recovery time as well. Although most of these operations are performed on the posterior, anterior surgeries are also performed, depending upon the nature of the injury. While these surgeries partially remove disc material affecting the spinal cord, another type of surgery is used to remove the disc entirely and replace it with prosthetics. Still, there are alternative treatments including chiropractic care, acupuncture, and physical therapy that are increasing in popularity. Due to the sensitivity and vulnerability of the spinal cord, the diagnosis and treatments have a moderate risk of failure, and force a patient to explore numerous options to relieve pain.
Introduction
The vertebral column is composed of seven cervical, twelve thoracic, five lumbar, five sacral, and four coccygeal vertebrae. The lumbar vertebrae are numbered from one through five starting with the highest vertebrae, and preceded by the letter L. (i.e. the lowest vertebral body will be represented as L-5) Between the vertebrae of the cervical, thoracic, and lumbar regions are invertebral discs that serve as shock absorbers that allow the everyday movements of the spine. Discs themselves are represented by naming both of their adjacent vertebral bodies (i.e. a lumbar disc is can be identified as L-4 L-5 or L-4,5). The discs are made up of an outer ring of more dense material called the annulus fibrosus. The annulus fibrosus helps to contain the inner gelatinous material called the nucleus pulposes. Upon a stressful movement of the spine, the nucleus pulposes may rupture through the annulus fibrosus posteriorly toward the spinal cord. Pressure upon the spinal cord, which is the origin of nerves throughout the body, can irritate the nerves exiting through lateral spaces between adjacent vertebrae called the invertebral foramen. These nerves travel to the lower extremities cause a dull ache and sometimes numbness or loss of strength. The nerve most commonly affected by a disc herniation is the sciatic nerve. The sciatic nerve originates between the third sacral(S-3), and fourth lumbar(L-5) vertebrae, is formed in the pelvis and exits through the greater sciatic foramen towards the gluteal region. It then travels laterally underneath the piriformis muscle towards the pudendal nerve, then divides travels anteriorly down the leg until it divides near the knee into the politeal and tibial nerves(Shanahan, 1997).
A term herniated disc is used synonymously with ruptured or prolapsed discs. They describe a protrusion of the nucleous propulsus through the annulus fibrosus upon the spinal cord. Commonly herd terms such as a slipped or a bulging disc refer to the disc being close to herniation, but still remaining intact. In this case, the nucleus propulsus is contained, however, the contortion can still lead to decreased foraminal space, and sciatic nerve irritation. The symptoms for bulging or slipped discs are similar to those for a herniated disc, but are usually milder and less intense, thus requiring more conservative treatments(Shanahan, 1997).
An estimated eighty percent of the population suffers at least one episode of back pain in their life, and in as many as fifty percent of the cases, the problem will recur within the next three years (DiNubile, 1997). The purpose of this paper is to discuss lumbar disc problems that afflict a large portion of the population, and discern between the numerous treatment options available to a patient. It will discuss the wide range of these interventions and attempt to provide a clear view of the success and appropriate applications of the treatments.
Discussion
The cause of a disc rupture can be traced to many events such as a single squat exercise by weight lifter, or the repetitive stressful jumping of a basketball player, or even a violent sneeze. The patient would normally become concerned upon recognizing a dull ache in their gluteal or hamstring muscles. More severe cases would include the pain to continue laterally from the knee to foot, and possibly a loss of strength in these areas. Someone uneducated in the nature of the sciatic nerve would not associate the leg pain with a back problem and would most likely take a few days to rest hoping that the pain would subside. If the persistent dull ache were to continue, the patient would be inclined to seek professional help.
Traditionally, an orthopaedist who diagnosed a patient with sciatica caused by a prolapsed disc, would prescribe bed rest for two weeks with the aid of narcotic drugs to alleviate pain, and leave surgery as the last option. Besides the fact that it is unrealistic to expect a patient to follow this advice to remain in bed, the treatment has been found to be unsuccessful as well as compromising to a possible recovery. The rest and inactivity is believed to decondition the lumbar musculature, and promote chronic pain and increase the chance of future problems. The lack of strength and flexibility can modify spinal mechanics in a way that places greater strain on the lumbar area, thus prolonging pain (DiNubile, 1997). This lack of success with traditional treatments, combined with the common fear of back surgery, has led people to explore the option of alternative medicine. A study done by the American Board of Family Practice showed that twenty eight percent of family practice patients sought some sort of alternative medicine. Back pain was the most common problem for which patients sought alternative care, which shows that patients are unhappy with traditional treatments. One of the most popular forms of modern intervention is chiropractic care. Chiropractic care involves a manipulation of the spine in order to relieve the symptoms of back and neck injuries. Although there is no accepted scientific methodology that supports chiropractic care, studies show that twenty one percent of chiropractic patients received “some” relief from manipulation (Drivdahl,1998).
Another increasingly popular treatment for chronic low back pain is transcutaneous electrical nerve stimulation (TENS). This treatment involves the conduction of electric impulses into the affected area, in attempt to decrease swelling and pain, while increasing range of motion. Evidence shows that TENS does have positive effects on reducing pain and improving functioning of patients. However, the studies show that although ninety five percent of the two hundred and eighty eight patients experienced a decrease in pain, only three percent had relief for more than two hours(Gadsby 1997).
Another form of conservative treatment is physical therapy. Physical therapy includes a wide variety of exercises that attempt to strengthen and mobilize the spine in order to relieve pressure from the discs. Although most would agree that some form of physical activity is preferred over bed rest, the extent and type of excercises performed are not readily agreed upon. The difficulty comes from the sensitivity of each patient and the nature of his injury. For instance, the McKenzie method of therapy incorporates spinal extension exercises that aim to return a bulged or slightly herniated disc into its original space. Since the disc material is herniated posteriorly, usually during a flexion of the spine, a series of extensions will hopefully force the disc to reverse, and free the spinal cord. This method has shown good results in moderate cases, however it has also produced some negative results as well. While seventy percent of patients using the McKenzie method showed a decrease in leg pain associated with sciatica, three percent found an increase in the radicular pain in their leg, and twenty eight percent did not notice a difference (Drivdahl, 1998). Still, those who experienced an increase in radicular pain, were the patients who initially had more severe conditions to begin with. This concludes that the McKenzie method of physical therapy is a viable option for most cases of sciatica, especially moderate ones.
The prescription of anti-inflammatory drugs as a treatment has also gained increased in volume during the past five years. This is due in part to the apprehension doctors have when prescribing narcotic drugs, for fear of addiction. Thus, most intermediate cases of lumbar disc herniations are given the option to take anti-inflammatory drugs, with the hope that they will continue with their daily life activities. Sciatic pain is can be due in part to a perineural inflammatory response to a disc herniation(Hatori, 1999). The goal of the anti-inflammatory would be to reduce the inflammation, thus relieving pressure on the sciatic nerve. These non steroidal anti-inflammatory drugs (NSAID’s) also have their problems, however. With most of these drugs, there is a relatively high rate of gastro-intestinal disturbances. For example, a commonly prescribed drug known as indomethacin has been reported to produce gastro intestinal side effects in up to twenty nine percent of it’s users(Hatori, 1999). Despite these problems, new drugs are constantly being introduced to reduce the side effects. A relatively new NSAID named etoldac has shown good results after testing. In a test done with one hundred and eighty one patients suffering from disc herniations fifty four percent showed a “slight” to “marked”, though short lived, improvement, while only one of these patients complained of gastro intestinal side effects(Hatori, 1999).
A more invasive procedure with similar goals to the NSAID’s is an epidural injection into the exact location of the origin of the pain. The goal is to reduce inflammation in the foramen through direct application of strong anti inflammatory medications. This option is not very popular for the obvious reason that the prospect of injection is intimidating to most people. The overall success of the injections is generally short lived with most symptoms returning within three to four days. Long term relief from epidural injections, for more than three months, is only gained in under five percent of the recipients(Traynellis, 1997).
The persistent nature of lumbar disc injury is such that it affects every aspect of a persons life from tying one’s sneakers to getting in and out of a car, to standing on line at the grocery store. Such constant pain draws people to search for relief in any form they can. When conservative treatments do not provide relief, the only answer is to opt for the surgical repair of the disc. The surgery, however is not guaranteed to be effective due to the many complications of the area, thus there is somewhat of a “taboo” aura associated with back operations.
One of the main problems associated with a disc operation is the inconclusive nature of the diagnostic images. A surgery candidate will undergo a computed tomography scan (CT scan) and a magnetic resonance imaging (MRI) test to help determine the cause of sciatica. Although the images can clearly show disc prolapses, the evidence does not directly correlate to clinical symptoms(Wittenberg1998). The doctor can make a highly educated guess as to the cause of the pain, but he cannot be positive as to where the symptoms arise. This can get increasingly complicated in a case with herniations at more than one level. The pain could possibly arise from all, some, or one of the levels of irregular disc, making surgery more complicated. This idea is reinforced by a study done at Ruhr University in Germany that randomly tested people who had no history of chronic back pain by giving them all evaluative MRI’s. The study showed that sixty eight percent of the people who had no history of chronic back pain showed positive images for at least minimal disc irregularity. This concluded the theory that although MRI’s are a reliable source to determine abnormalities and structural changes, there is no definite correlation between image findings and clinical symptoms.
Still, surgery is a necessary treatment for many severe cases, and is generally successful in at least reducing the amount of pain. The traditional surgery to repair a ruptured disc is referred to as a laminotomy. This procedure included a large posterior incision to expose the spine. The lamina of the vertebrae was shaved and partially removed in attempt to reach the affected area. The surgeon would then manually remove the pieces of disc herniation that were irritating the nerve. This operation was fairly successful, but had a few drawbacks. The surgery was very invasive, and generally required at least two weeks of post operative hospitalization. The possibility of scar tissue forming on the spinal cord itself also proposed a possible explanation for a failed procedure.
Within the last five to ten years, the emergence of a much less invasive micro surgery for disc prolapses has made the laminotomy obsolete as a surgical procedure. The microdiscectomy puts to use the modern technology of arthroscopic and endoscopic techniques to perform disc excisions. This surgery has produced great results in success rates as well as recovery time. A microdiscectomy requires only about a two and a half inch incision posterior to the disc, and only needs minimal shaving of the lamina to reach the affected foraminal space. The surgeon inserts a microscpope into the area, which projects the image onto a screen. He can then operate with much greater precision. A patient of a microdiscectomy needs usually about on or maybe two nights of hospitalization, and is encouraged to return to non stressful normal activities as soon as possible, usually about two weeks(Flagg, 1997).
While a microdiscectomy partially removes the protruding disc, it leaves the rest of the disc intact. In a case where the entire disc must be removed, surgeons opt for a surgery called a fusion. This operation consists of the removal of the disc, and the use of pedicle screws to keep the spine in place, with the goal to have the vertebrae fuse together. This surgery is more involved than a microdiscectomy, and is open to more variation. The discussion continues on the degree of angle at which the screws should be inserted as well as the degree of lordosis and kyphosis at which the spine should be fixated. Research has shown to be contradictory as one study shows that the procedure should be done in kyphosis, or a slight rounding of the back, to prevent foraminal stenosis or narrowing(White et Al, 1999). A second study shows that fusion done in lordosis, or a slight arch in the lumbar region, would prevent flat back problems(Casey et Al, 1999). Despite these claims, still others contend that there is no evidence to support either fusion in kyphosis or lordosis and that there is no overwhelming advantage to either one(Molz, 1999).
The cutting edge of fusion procedures includes the use of inter body fusion cages to replace the disc. Instead of directly fusing the bones together, a prosthetic piece is implanted between the vertebral bodies. The goal here is to provide a stabilizing structure to reduce the pressure of the vertebrae fusing directly together. There have been many different types of cage designs since its initial introduction a few years ago. Some of the different cages are cylindrical in shape, requiring to be screwed into place, while others are cuboid in shape requiring to be placed in the disc space. Studies were done to measure the flexibility and mobility allowed by the inter body devices. The evidence showed that the most effective fusion device is the Stryker cage, which is a ridged bullet shaped polyethetetherketone implant. It had the greatest effect on stabilization and mobility after undergoing many cyclic loading tests, and was concluded as the most effective interbody fusion cage(Kettler et Al).
Fusion surgeries are most often performed posteriorly, but they can also be performed anteriorly as well. Some surgeons are dissatisfied with the long term results of the posterior procedure and favor an anterior operation. The anterior approach shows better results with result to restoring the anterior vertebral column to its normal height, thus creating more foraminal space, and restoring sagital alignment. The negative side of the anterior surgery is the risk of complications of the invasive surgery. The approach is made by a transabdominal incision and is very complicated as result of the many problems that can occur. Any number of problems such as damage to the left iliarlumbar vein can occur, and could possibly produce fatal results. As a result, this procedure is not frequently performed, and requires highly prepared surgeons. Despite the many complications, there have been no deaths associated with the anterior approach, and there is a ninety six percent chance of fusion rate in the patients(Samudrala, 1999).
With all the information present, the picture is not crystal clear as to what the solution to back pain is. Most doctors would agree that surgery should be the last option in most circumstances. In my opinion, the best way to approach a back injury, would be to explore every option possible before surgery. There is a good chance that you will find some form of treatment that would help your pain. If surgery can be avoided it should be, however, I do believe that surgery is a safe option. The main question is the extent of the injury, and the quality of your life because of it. It is not worth avoiding surgery simply because you are afraid of it, especially when everyday activities are agonizing. It is nearly impossible to enjoy life with the constant pain shooting down your leg.
If surgery is the necessary solution to the problem, than the most important part of your decision will be the choice of doctors. In my opinion, someone undergoing any operation would be putting himself at a greater risk, if they did not pursue the most successful doctor. If the financial resources are available, it is well worth the research or travel to put yourself in the most capable hands.
In conclusion, I think that the sufferers of lumbar disc prolapses and sciatica are faced with a tough road, however, I believe that with patience and persistence, their former quality of life can return, and relative normalcy can be restored.
Bibliography
Works Cited
Casey,M et Al: The effect of Harrington Rod Contouring on Lumbar Lordosis. Neorosurgical Focus. v12: p75-83, 1999
Di Nubile, A: Treating Low Back Pain. The Physician and Sportsmedicine v25-8 ,p51, 1997
Drivdahl, Christine: The use of Alternative Health by a Family Practice Population. Journal of the American Board of Family Practice. v19: p54-56, 1998
Flagg, Susan: Bounce Back from Surgery. Prevention. v49 p37-38, 1997
Gadsby, JG: Transcutaneous Electrical Nerve Stimulation for Chronic Low back Pain. Cochrane Review Abstracts. December 1997
Hatori, Masahito: Clinical use of Etoldac for Treatment of Lumbar Disc Herniation. Current Medical Research and Opinion. v15: p193-201, 1999
Ketter, Annette et Al: Stabilizing Effect of Posterior Lumbar Interbody Fusion Cages Before and After Cyclic Loading. Neurosurgical Focus v14:p43-56, 1998
Molz, Fred: Effects of Kyphosis and Lordosis on the Remaining Lumbar Vertebral Levels Within a Thoracolumbar Fusion. Journal of Southern Orthopaedic Association. v26: p60-68, 1999
Samudrala ,Srinath: Complications During Anterior Surgery of the Lumbar Spine. Neurosurgical Focus. v7: p6-18. 1999
Shanahan, Donal: Anatomical Review of the Lumbar Spine. The Lancet. v348: p38-40, 1997
Traynellis, Robert: Epidural Injections for Sciatica. Neurosurgical Focus. v17: p26, a997
White,A et Al: Clinical Biomechanics of the Spine. JB Lippincott Co. August 1997
Wittenberg, RH: The Correlation Between Magnetic Resonance Imaging and the Clinical Findings After Lumbar Microdiscectomy. Int Orthopaedics v22: p241-244, 1998
Word Count: 3055
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