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Q: Spinal cord compression from degeneration ( Answered 5 out of 5 stars,   1 Comment )
Question  
Subject: Spinal cord compression from degeneration
Category: Health > Conditions and Diseases
Asked by: sheilakm-ga
List Price: $50.00
Posted: 29 Jul 2005 23:29 PDT
Expires: 28 Aug 2005 23:29 PDT
Question ID: 549712
The patient is an active 75 year old man with a slightly raised
cholesterol,  high blood pressure (well controlled for many years with
medication) and sleep apnea (under control with a continuous positive
airway pressure at night). The patient, an industrialist working in
his own family business, travels widely between Europe,Africa and
Asia.

He suffers from pain and weakness in one leg, and is unable to walk
for long distances. He has had an MRI scan which has revealed
degenerative disease of the vertebrae, with no fluid remaining in the
disc between L4 - 5.  (He also has some degree of degeneration of the
vertebrae in his neck but this is not causing significant problems)
 
While surgery is an option, he has been told that because of his
existing conditions it may be risky.

I wnat to find out if there are any alternative treatmenst which may
be offered to treat this condition.
Answer  
Subject: Re: Spinal cord compression from degeneration
Answered By: welte-ga on 31 Jul 2005 08:16 PDT
Rated:5 out of 5 stars
 
Hi Sheilakm-ga, and thanks for your question.  First, let me emphasize
that the following information is not a substitute for medical advice
and direct examination of the patient.

While the patient you describe does have a few medical problems, none
of them are absolute contraindications to surgery.  Sleep apnea may
increase the risk for general anesthesia somewhat, but many people
with this condition undergo surgery without any problems.  Risk
accompanies any surgery and one shouldn't make the decision lightly,
but this patient, from the limited description you provided, does not
have any serious medical conditions that would preclude surgery.

The symptoms you describe are somewhat concerning.  Pain and weakness
in one leg constitutes a focal neurological finding that suggest
compression of the spinal cord or nerve root at the level you state -
L4/L5.  This is known as radiculopathy and is typically caused by
herniation of the intervertebral disc, which then pushes against the
exiting nerve root to the leg as it leaves the spinal cord.

The first line of treatment for a herniated lumbar disc is
conservative, with the exception being certain patients who have
severe weakness of one or both legs.  Herniated lumbar discs can be
resorbed spontaneously, which likely explains why some patients have
resolution of their symptoms with only conservative management (pain
control, no primary treatment, aka "watch and wait").

Below I've outlined a number of non-surgical interventions that may
play a role in the treatment of degenerative disc disease for patients
with persistent symptoms.  Several of the articles I quote as
references are not freely available, so I have included the relevant
text for your convenience.  Where articles are freely available, I
have provided the links.  Other articles may be requested directly
from the authors as reprints - for these I have provided the e-mail
addresses of the authors.

=============================================================

Epidural steroid injections:

Dr. Butterman of the Midwest Spine Institute published a study looking
at epidural steroid injections vs. discectomy (surgical removal of the
disc) for patients with large herniated discs that did not respond to
conservative treatment for 6 weeks.  Here is the abstract from the
article:

"Background: Epidural steroid injection is a low-risk alternative to
surgical intervention in the treatment of lumbar disc herniation. The
objective of this study was to determine the efficacy of epidural
steroid injection in the treatment of patients with a large,
symptomatic lumbar herniated nucleus pulposus who are surgical
candidates.

Methods: One hundred and sixty-nine patients with a large herniation
of the lumbar nucleus pulposus (a herniation of >25% of the
cross-sectional area of the spinal canal) were followed over a
three-year period. One hundred patients who had no improvement after a
minimum of six weeks of noninvasive treatment were enrolled in a
prospective, nonblinded study and were randomly assigned to receive
either epidural steroid injection or discectomy. Evaluation was
performed with the use of outcomes scales and neurological
examination.

Results: Patients who had undergone discectomy had the most rapid
decrease in symptoms, with 92% to 98% of the patients reporting that
the treatment had been successful over the various follow-up periods.
Only 42% to 56% of the fifty patients who had undergone the epidural
steroid injection reported that the treatment had been effective.
Those who did not obtain relief from the injection had a subsequent
discectomy, and their outcomes did not appear to have been adversely
affected by the delay in surgery resulting from the trial of epidural
steroid injection.

Conclusions: Epidural steroid injection was not as effective as
discectomy with regard to reducing symptoms and disability associated
with a large herniation of the lumbar disc. However, epidural steroid
injection did have a role: it was found to be effective for up to
three years by nearly one-half of the patients who had not had
improvement with six or more weeks of noninvasive care."


So, while the epidural steroid injections were not as effective
overall as surgical removal of the offending disc, they were not
ineffective (~50% of patients had some improvement) and could play a
role in the treatment of the patient you describe.

____________________________

Physical Therapy may play a role in treatment, and is certainly an
important part of therapy, even in patients who have undergone surgery
for degenerative disc disease.  Spine-Health.com has a good summary of
exercises that are recommended for patients with sciatica, complete
with diagrams.  I highly recommend formal evaluation by a professional
Physical Therapist, however, before undertaking any of these
exercises.  From going through PT for my own back problems, I know
that there are other exercises that may be recommended that are not
discussed on this page - the treatment regimen should be tailored to
the individual patient.

http://www.spine-health.com/topics/conserv/sciaex/sciaex04.html


One study from Norway looked at surgery vs. cognitive intervention
plus exercise, finding that they were equivalent.  Here is the
Abstract of their work:

"Study Design. Single blind randomized study.

Objectives. To compare the effectiveness of lumbar instrumented fusion
with cognitive intervention and exercises in patients with chronic low
back pain and disc degeneration.

Summary of Background Data. To the authors? best knowledge, only one
randomized study has evaluated the effectiveness of lumbar fusion. The
Swedish Lumbar Spine Study reported that lumbar fusion was better than
continuing physiotherapy and care by the family physician.

Patients and Methods. Sixty-four patients aged 25?60 years with low
back pain lasting longer than 1 year and evidence of disc degeneration
at L4?L5 and/or L5?S1 at radiographic examination were randomized to
either lumbar fusion with posterior transpedicular screws and
postoperative physiotherapy, or cognitive intervention and exercises.
The cognitive intervention consisted of a lecture to give the patient
an understanding that ordinary physical activity would not harm the
disc and a recommendation to use the back and bend it. This was
reinforced by three daily physical exercise sessions for 3 weeks. The
main outcome measure was the Oswestry Disability Index.

Results. At the 1-year follow-up visit, 97% of the patients, including
6 patients who had either not attended treatment or changed groups,
were examined. The Oswestry Disability Index was significantly reduced
from 41 to 26 after surgery, compared with 42 to 30 after cognitive
intervention and exercises. The mean difference between groups was 2.3
(-6.7 to 11.4) (P = 0.33). Improvements inback pain, use of
analgesics, emotional distress, life satisfaction, and return to work
were not different. Fear-avoidance beliefs and fingertip-floor
distance were reduced more after nonoperative treatment, and lower
limb pain was reduced more after surgery. The success rateaccording to
an independent observer was 70% after surgery and 76% after cognitive
intervention and exercises. The early complication rate in the
surgical group was 18%.

Conclusion. The main outcome measure showed equal improvement in
patients with chronic low back pain and disc degeneration randomized
to cognitive intervention and exercises, or lumbar fusion."


The specifics of the cognitive interventions, exercises, and surgeries
are described in the body of the paper.

 Ivar Brox J, Sorensen R, Friis A, Nygaard O, Indahl A, Keller A,
Ingebrigtsen T, Eriksen HR, Holm I, Koller AK, Riise R, Reikeras O
Randomized clinical trial of lumbar instrumented fusion and cognitive
intervention and exercises in patients with chronic low back pain and
disc degeneration. [Clinical Trial. Journal Article. Randomized
Controlled Trial] Spine. 28(17):1913-21, 2003 Sep.



The Cochrane Database of Systematic Reviews looked at the literature
behind exercise and lower back pain.  They concluded that the
literature is not of the best quality, but were able to conclude the
following:

"Evidence from randomized controlled trials demonstrates that exercise
therapy is effective at reducing pain and functional limitations in
the treatment of chronic low-back pain, though cautious interpretation
is required due to limitations in this literature. Overall, mean
improvements in outcomes across all research settings are small,
though significant, over other conservative treatment options.
Clinically important improvements are more likely in healthcare
settings. There is some evidence of effectiveness of a graded-activity
exercise program in subacute low-back pain in occupational settings,
though the evidence for other types of exercise therapy in other
populations is unclear and further research is required. This
literature suggests exercise therapy is as effective as either no
treatment or other conservative treatments for acute low-back pain."

Hayden, JA; Tulder van, MW; Malmivaara, A; Koes, BW.  Exercise therapy
for treatment of non-specific low back pain.  The Cochrane Database of
Systematic Reviews.  Date of Most Recent Update: 25-May-2005 Updated. 
Date of Most Recent Substantive Update: 28-February-2005.  Volume (3),
2005.

==============================

The following are some alternative (aka complimentary) therapy options:

____________________________


Acupuncture:

One randomized study performed by Drs. Wang and Tronnier at the
University of Heidelberg Department of Neurosurgery found that
acupuncture was effective in relieving patients' symptoms.  Here is
the abstract of their study, which summarizes their results:

"Management of acute and chronic low back and leg pain often includes
the use of acupuncture. The effectiveness of this form of therapy is
dependent upon compliance, which in turn is dependent on availability,
response, treatment of proper acupoints, and the placebo effect. We
hypothesized that classical acupuncture would be more effective than
placebo acupuncture. One hundred and thirty-two patients with acute
and chronic low back and leg pain were examined before and after
surgery for lumbar disc protrusion. Diagnosis was based on CT and MRT
findings. Patients received acupuncture drug-free throughout the study
period. The visual analogue scale was used to assess pain intensity
before and after (i.e. 30 min. 60 min. 2 h and 6 h) acupuncture.
Classical acupuncture resulted in a significant reduction in pain that
become increasingly stronger during the 6h study period. Placebo
acupuncture lead to same early pain relief that did not reach
statistic significant and then declined thereafter."

Wang RR, Tronnier V.  Effect of acupuncture on pain management in
patients before and after lumbar disc protrusion surgery--a randomized
control study.  The American journal of Chinese medicine. 28(1):25-33,
2000.

Acupuncture is still being studied for the treatment of many disorders
and the above study, based on 132 patients, does not constitute the
last word on the subject by any means.

In terms of neurological outcome, the results portion of the paper
describes how well patients in the discectomy and steroid injection
groups did:

"The discectomy group had earlier motor recovery than did the group
treated with the epidural steroid injection-i.e., significantly fewer
patients in the discectomy group still had a motor deficit at one to
three months following treatment (p = 0.001; Fig. 1). However, at the
two to three-year follow-up point, there was no significant difference
between the two groups with regard to the percentage of patients who
still had weakness (p = 0.201). At the time of presentation, six
patients-three in the discectomy group and three in the injection
group-exhibited a profound motor weakness (less than grade 3, with 5
being the highest grade possible). Two of the three patients in the
discectomy group had full recovery of motor strength and the other
patient had mild weakness (grade-4 strength) at the time of final
follow-up. In the injection group, two of the three patients with
profound weakness subsequently underwent discectomy (became part of
the crossover group); one had the discectomy at two months and the
other, at nine months. One of those two patients had full recovery of
grade-5 strength, and the other had improvement to grade-4 strength.
The third patient in the injection group who had profound weakness did
not undergo discectomy; that patient also demonstrated a peroneal
nerve deficit on electromyography in addition to an L5 radiculopathy
and had only minimal recovery at the time of final follow-up."

Buttermann GR.  Treatment of lumbar disc herniation: epidural steroid
injection compared with discectomy. A prospective, randomized study. 
The Journal of bone and joint surgery American volume. 86-A(4):670-9,
2004 Apr.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15069129&query_hl=1

You can request a full text reprint of the above article from Dr.
Buttermann at this address:
butte011@umn.edu

____________________________

A single case report from a group in the Netherlands suggests that
long term use of chondroitin sulfate and glucosamine may aid in disc
recovery.  These so-called nutriceuticals have been primary studied in
osteoarthritis of the knees, for which there is little convincing
evidence of their efficacy.  Little literature exists on their
potential use in patients with degenerative disc disease.  This single
case report is far from the last word on the subject.  Although the
one patient studied had some evidence of improvement of disc
degeneration on MRI, a well conducted clinical trial is required to
better evaluate this potential treatment.

Here are the Background, Case Presentation, and Conclusions portions
of their article, for convenience:

"Background
Glucosamine and chondroitin sulfate preparations are widely used as
food supplements against osteoarthritis, but critics are skeptical
about their efficacy, because of the lack of convincing clinical
trials and a reasonable scientific rationale for the use of these
nutraceuticals. Most trials were on osteoarthritis of the knee, while
virtually no documentation exists on spinal disc degeneration. The
purpose of this article is to highlight the potential of these food
additives against cartilage degeneration in general, and against
symptomatic spinal disc degeneration in particular, as is illustrated
by a case report. The water content of the intervertebral disc is a
reliable measure of its degeneration/ regeneration status, and can be
objectively determined by Magnetic Resonance Imaging (MRI) signals.

Case presentation
Oral intake of glucosamine and chondroitin sulfate for two years
associated with disk recovery (brightening of MRI signal) in a case of
symptomatic spinal disc degeneration. We provide a biochemical
explanation for the possible efficacy of these nutraceuticals. They
are bioavailable to cartilage chondrocytes, may stimulate the
biosynthesis and inhibit the breakdown of their extracellular matrix
proteoglycans.

Conclusion
The case suggests that long-term glucosamine and chondroitin sulfate
intake may counteract symptomatic spinal disc degeneration,
particularly at an early stage. However, definite proof requires
well-conducted clinical trials with these food supplements, in which
disc de-/regeneration can be objectively determined by MRI. A number
of biochemical reasons (that mechanistically need to be further
resolved) explain why these agents may have cartilage structure- and
symptom-modifying effects, suggesting their therapeutic efficacy
against osteoarthritis in general."



Glucosamine and chondroitin sulfate supplementation to treat
symptomatic disc degeneration: Biochemical rationale and case report. 
van Blitterswijk WJ, van de Nes JC, Wuisman PI.
BMC Complement Altern Med. 2003; 3: 2. published online before print June 10, 2003

http://www.ncbi.nlm.nih.gov.ezproxy.umassmed.edu/entrez/query.fcgi?db=PMC&cmd=Search&term=1472-6882[jour]+AND+3[volume]+AND+2[page]

You can find the free full text here:
http://www.pubmedcentral.gov/articlerender.fcgi?tool=pmcentrez&artid=165439

____________________________

An Italian group published a paper describing combined minimally
invasive therapy with oxygen/ozone along with steroid injections for
the treatment of lumbar disc herniations.  Here is the abstract and
results of their study:

"BACKGROUND AND PURPOSE: Oxygen-ozone therapy is a minimally invasive
treatment for lumbar disk herniation that exploits the biochemical
properties of a gas mixture of oxygen and ozone. We assessed the
therapeutic outcome of oxygen-ozone therapy and compared the outcome
of administering medical ozone alone with the outcome of medical ozone
followed by injection of a corticosteroid and an anesthetic at the
same session.

METHODS: Six hundred patients were treated with a single session of
oxygen-ozone therapy. All presented with clinical signs of lumbar disk
nerve root compression, with CT and/or MR evidence of contained disk
herniation. Three hundred patients (group A) received an intradiscal
(4 mL) and periganglionic (8 mL) injection of an oxygen-ozone mixture
at an ozone concentration of 27 g/mL. The other 300 patients (group
B) received, in addition, a periganglionic injection of corticosteroid
and anesthetic. Therapeutic outcome was assessed 6 months after
treatment by using a modified MacNab method. Results were evaluated by
two observers blinded to patient distribution within the two groups.

RESULTS: A satisfactory therapeutic outcome was obtained in both
groups. In group A, treatment was a success (excellent or good
outcome) in 70.3% and deemed a failure (poor outcome or recourse to
surgery) in the remaining 29.7%. In group B, treatment was a success
in 78.3% and deemed a failure in the remaining 21.7%. The difference
in outcome between the two groups was statistically significant (P <
.05).

CONCLUSION: Combined intradiscal and periganglionic injection of
medical ozone and periganglionic injection of steroids has a
cumulative effect that enhances the overall outcome of treatment for
pain caused by disk herniation. Oxygen-ozone therapy is a useful
treatment for lumbar disk herniation that has failed to respond to
conservative management."


Andreula CF, Simonetti L, De Santis F, Agati R, Ricci R, Leonardi M. 
Minimally invasive oxygen-ozone therapy for lumbar disk herniation.
AJNR Am J Neuroradiol. 2003 May;24(5):996-1000.

You can find the free full text of this article here:
http://www.ncbi.nlm.nih.gov.ezproxy.umassmed.edu/entrez/utils/lofref.fcgi?PrId=3051&uid=12748111&db=pubmed&url=http://www.ajnr.org.ezproxy.umassmed.edu/cgi/pmidlookup?view=long&pmid=12748111

____________________________

As one commenter stated, chiropractors often treat low back pain, with
or without the types of focal neurological findings you describe.  The
UCLA Low Back Pain Study compared multiple treatment modalities,
including physical therapy, medical, and chiropractic treatments. 
Here are their conclusions:

"Medical and chiropractic care without physical therapy or physical
modalities yielded similar improvements in pain severity and
disability after 6 months of follow-up. The findings suggest that
physical therapy patients may have greater reductions in disability,
on average, than do patients in the medical care-only group from 6
weeks to 6 months, resulting in relatively better 6-month disability
outcomes; however, these small differences may be chance findings and
may not persist with continued follow-up. Assessment of the costs and
potential risks associated with each treatment strategy would be
helpful in more fully understanding the roles of medical providers,
chiropractors, and physical therapists in the treatment of low back
pain."

Essentially, chiropractic care was similar to medical treatment. 
Physical therapy was somewhat superior to both.

Here are the interventions used for medical, chiropractice, and
physical therapy treatments:

Medical:
"Patients assigned to this group received one or more of the following
at the discretion of the medical provider: instruction in proper back
care and strengthening and flexibility exercises; prescriptions for
pain killers, muscle relaxants, anti-inflammatory agents, and other
medications used to reduce or eliminate pain or discomfort; and
recommendations regarding bedrest, weight loss, and physical
activities."

Chiropractic:
"Patients assigned to this group received spinal manipulation or
another spinal-adjusting technique (e.g., mobilization), instruction
in strengthening and flexibility exercises, and instruction in proper
back care. Chiropractic practice at the study site is consistent with
chiropractic philosophy and training throughout the United States. The
chiropractors routinely use the diversified technique, which is the
general type of spinal manipulation taught in most chiropractic
schools and is the most frequently used form of manipulation. [10]"

Medical care plus physical therapy:
"Patients assigned to this group received medical care as described
above, instruction in proper back care from the physical therapist,
plus one or more of the following at the discretion of the physical
therapist: heat therapy, cold therapy, ultrasound, electrical muscle
stimulation (EMS), soft-tissue and joint mobilization, traction,
supervised therapeutic exercise, and strengthening and flexibility
exercises. All physical therapy was administered in the medical
group?s physical therapy department and supervised by a licensed
physical therapist"

Chiropractic care plus physical modalities:
"Patients assigned to this group received chiropractic care as
described above plus one or more of the following at the discretion of
the chiropractor: heat or cold therapy, ultrasound, and EMS."


Reference:
A randomized trial of medical care with and without physical therapy
and chiropractic care with and without physical modalities for
patients with low back pain: 6-month follow-up outcomes from the UCLA
low back pain study.  Hurwitz EL, Morgenstern H, Harber P, Kominski
GF, Belin TR, Yu F, Adams AH.  Cochrane Central Register of Controlled
Trials.  Spine. 27(20):2193-204, 2002 Oct.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?CMD=search&DB=pubmed

The full text is not available for free, but you may request a reprint
from Dr. Hurwitz at this address:
ehurwitz@ucla.edu


____________________________

In a similar vein, osteopathic manipulation has been investigated as a
potential treatment for lower back pain.  Many studies have been done
to look into this therapy's efficacy.  A particularly useful review of
this subject can be found in the Cochrane Database of  Systematic
Reviews.  Below is the relevant excerpt from this topic review, which
summarizes their analysis of thousands of papers on the subject:

"Spinal manipulative therapy had clinically and statistically
significant benefits only when it was compared with either sham
manipulation or the group of therapies judged to be ineffective or
even harmful. Compared with other advocated therapies for low-back
pain, including analgesics, physical therapy, exercises, or back
school, therapy that included spinal manipulative therapy had neither
statistically nor clinically significant benefits. Our comparison of
spinal manipulative therapy with a sham therapy suggests that spinal
manipulative therapy is probably more effective than a placebo, but
its effectiveness compared with other advocated therapies is
substantially less than previous reviews and meta-analyses have
suggested. Our sensitivity analyses supported the robustness of our
results with respect to the type of manipulative therapy, profession
of manipulator, and the quality of the studies included."


Spinal manipulative therapy for low-back pain.  Assendelft, WJJ;
Morton, SC; Yu Emily, I; Suttorp, MJ; Shekelle, PG.  Cochrane Back
Group.  Cochrane Database of Systematic Reviews. 3, 2005. Date of Most
Recent Update: 23-February-2005.  Date of Most Recent Substantive
Update: 17-September-2003.

____________________________

More on the cutting edge of back care, various methods of gene therapy
have been proposed for treatment of disc degeneration, but none of
them are near non-experimental clinical use.

You can read more about these applications in, for example, this article:

Wallach CJ. Gilbertson LG. Kang JD. Gene therapy applications for
intervertebral disc degeneration.  Spine. 28(15 Suppl):S93-8, 2003 Aug
1.

Here is their Conclusion, which nicely summarizes the current state of the art:

"The potential of gene therapy to alter the biologic processes
occurring in the degenerated intervertebral disc has been clearly
established, yet significant work remains before clinical application
can be considered. The most promising growth factor(s) or combination
of factors must be identified, and the specific dose(s) to allow the
optimal autocrine and paracrine effect, while minimizing potential
rejection and toxicity, needs to be established. Further biochemical
studies are warranted to clarify the relationships among viral
concentration, transgene synthesis, and protein expression. Equally
important will be the development of strategies that enable the strict
regulation of vector expression in order to control both the presence
and quantity of endogenously produced transgene. Improved in vitro
models that closely simulate the in vivo environment [37] will assist
this process, but in vivo studies of gene therapy in clinically
recognizable degenerated intervertebral disc must be undertaken to
clarify the potential benefit, as well as further investigate its
potential toxicity. Despite the hurdles that remain, the potential of
gene therapy to alter the course of intervertebral disc degeneration
holds much clinical promise and will continue to stimulate future
investigation"


==================


I hope this information was useful.  Please feel free to request any clarification.

        -welte-ga
sheilakm-ga rated this answer:5 out of 5 stars and gave an additional tip of: $10.00
Thanks for a very precise and detailed answer, presented in a clear
and accessible form.

Comments  
Subject: Re: Spinal cord compression from degeneration
From: angy-ga on 30 Jul 2005 01:47 PDT
 
Has he tried a good chiropractor or osteopath ?

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