Dear gummerson-ga,
I am sorry to hear about your back problems. I am a surgery resident
(MD), but don?t feel that I have a bias toward pursuing surgery.
Actually, most surgeons I?ve worked with try to avoid surgery until
absolutely necessary.
I must preface my answer by stating that it is no substitute for
medical advice from someone who can examine you and physically look at
your MRI scan.
Your herniated / bulging disc at the L4/L5 level is the most common
type of herniated disc. This is also known as HNP (herniated nucleus
pulposis). The disc between the vertebral bodies is composed of a
spongy material surrounded by a tough fibrous ring that holds the
spongy material in place. With wear and tear or trauma, the fibrous
ring can be breached, and the spongy portion can bulge (herniated)
out. Sometimes, this causes no symptoms, but in other cases, such as
yours, the disc can cause pressure on the nerve root at that level.
The nerve roots are connected to the spinal cord and carry the sensory
and motor nerves that travel to the legs, buttocks, etc., at that
level.
You can see some good diagrams of the anatomy at this web site if you like:
http://www.merck.com/mmhe/sec06/ch076/ch076c.html#fg076_2
More specifically, the L4/L5 nerve root (known as the L5 level)
contains nerves that carry sensation from a strip of skin along the
lower back, the outside of the thigh, the inside of the lower leg, and
the heel. These sensations are carried in the sciatic nerve to the
fifth lumbar vertebra (L5). Pain caused by pressure on the nerve root
near the spinal cord, next to the disc that is bulging, is perceived
as pain (often like an electrical shock) shooting down the leg on the
side where the disc is bulging. This is commonly known as
?sciatica.?
You can see the patterns of innervation (called dermatomes for sensory
innervation) at this web site:
http://www.merck.com/mmhe/sec06/ch093/ch093a.html
Now, thinking about treatment options ? As you know, because lower
back pain is such a common problem, there are many ?treatments? out
there. Honestly, if any of them worked well, the medical community
and drug companies would be all over them immediately. That being
said, for back pain caused by muscle spasm, or arthritis of the
articular joints (the joints between the vertebral bodies), many
anti-inflammatory and analgesic medications will provide some relief.
It is in this condition that back strengthening exercises, abdominal
exercises, and weight loss are most beneficial.
Once the disc physically bulges or herniates, putting pressure on the
nerve root, these exercises and medications will help to some degree,
but will really only alleviate the pain caused secondarily by muscle
spasms that occur subsequent to the pain one feels from the nerve root
compression. In other words, the disc presses on the nerve root,
causing pain (called radiculopathy), and you tighten your lower back
muscles in response, which can be improved by muscle relaxants, pain
medications, and exercises, but the main source of the pain will still
remain.
So, how to treat the primary source of your pain. Several options
exist: After nerve root compression is documented by MRI that
corresponds to your symptoms (in other words, the compression from the
disc isn?t just an incidental finding), then surgery is the most
common treatment recommended. This usually involves performing a
laminectomy (removing a small piece of the vertebral body surrounding
the spinal cord), to relieve the pressure on the nerve root. This
procedure is performed by either a neurosurgeon or orthopedic surgeon
and takes approximately 2-3 hours.
A possible alternative form of therapy involves having steroid
injections into the epidural space. This is done by a pain specialist
(usually an anesthesiologist with special training) and helps to
reduce the inflammation around the compressed nerve root. These
specialists also do injections for relief of trigger points and pain
originating in ligaments.
Here?s a website from the NIH that talks about these injections, as
well as nearly every other form of treatment out there. The NIH also
summarizes the evidence from studies that have evaluated how well each
of these treatments work (or don?t), and weighs the risks and benefits
of each.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Search&db=books&doptcmdl=GenBookHL&term=lower+back+pain+AND+hstat%5Bbook%5D+AND+342437%5Buid%5D&rid=hstat6.section.26067#26178
Here is their summary on back manipulation (done by chiropractors):
?The evidence for effectiveness of manipulation varies depending on
the duration and nature of the patient's presenting symptoms. For
patients with acute low back symptoms without radiculopathy, the
scientific evidence suggests spinal manipulation is effective in
reducing pain and perhaps speeding recovery within the first month of
symptoms. For patients whose low back problems persist beyond 1 month,
the scientific evidence on effectiveness of manipulation was found to
be inconclusive. For patients with radiculopathy, the scientific
evidence was also inconclusive about either the effectiveness or the
potential harms of manipulation. Finally, the panel offered the
opinion that, for patients with acute low back problems and findings
of possible progressive or severe neurologic deficits, assessment to
rule out serious neurologic conditions is indicated before initiating
manipulation therapy?
Here?s a summary regarding epidural injections for temporary relief to
avoid surgery:
?Limited research evidence indicates that epidural injections using
any type of medication lack proven efficacy for treating patients with
acute low back pain without radiculopathy. Epidural injections are
invasive and pose rare but serious potential risks. There was no
evidence that epidural steroids are effective in treating acute
radiculopathy, but the panel's opinion was that epidural steroid
injections may be useful as an attempt to avoid surgery.?
Lastly, a summary regarding acupuncture:
?No studies were found evaluating efficacy of acupuncture in patients
with acute low back problems. In three of the six RCTs evaluating
efficacy for chronic low back problems, outcomes were better for the
acupuncture group than for nontreatment control groups. All studies
had methodologic flaws. Acupuncture was also found to have risks of
significant complications.?
The same NIH website also has a very good discussion of the surgery
for herniated disc:
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Search&db=books&doptcmdl=GenBookHL&term=lower+back+pain+AND+hstat%5Bbook%5D+AND+342515%5Buid%5D&rid=hstat6.section.26230#26311
This site discusses the procedure, as well as risks and benefits and
how well the surgery works. The surgery is not a 100% guarantee of
fixing the problem ? a condition known as ?failed back syndrome.?
Approximately 90% of patients had good symptom control after one year
of follow-up. Only ~67% of the non-surgical patients were symptom
free at one year. After 4 years and 10 years, both surgery and
non-surgery groups were 90% symptom-free. This relief of symptoms is
likely because the herniated disc can begin to dry and shrink,
relieving the pressure over time.
Summaries of other treatment modalities are discussed on the above website as well.
Here are some other useful websites:
The American Association of Family Physicians has a nice article on
diagnosis and causes of lower back pain here:
http://www.aafp.org/afp/991115ap/2299.html
The Merck Manual is a superb, free online resource. Here?s a link to
the article on lower back pain. It includes a very nice diagram of a
herniated disc and shows the relationships between the disc and the
nerve root particularly well. The article goes on to discuss sciatica
and how it arises from pressure on the nerve root. Near the end of
the article, there are some exercises to improve muscle strength.
http://www.merck.com/mmhe/sec06/ch094/ch094a.html?qt=herniated%20nucleus%20pulposis&alt=sh
I hope this answer was helpful. Please feel free to ask for clarification.
-welte-ga |
