Published in UAB Insight, Spring 2008
ABSTRACT: A herniated lumbar disc does not demand immediate surgery unless a patient has cauda equina syndrome. Careful evaluation and a 4- to 6-week course of medical therapy is recommended before considering disc surgery.
CME OBJECTIVE: The reader will be aware of the current recommendations for evaluation and treatment of patients with suspected herniated lumbar discs.
Mark N. Hadley, MD, no conflicts of interest
General practitioners frequently encounter patients presenting with complaints of neck or low back pain. In a 3-month period in the United States, 26% of adults reported experiencing low back pain and 14% reported neck pain (JAMA. 2008;299[6]:656-664).
Although acute disc herniation accounts for only 2% of patients with low back pain, lumbar discectomy is the most commonly performed neurosurgical procedure. In the United States low back pain results in 15 million clinician visits and approximately 300,000 lumbar discectomies a year (Neurosurg Focus. 2002;13[2]:1-6).
A continuing controversy in this arena has been the efficacy of surgical versus nonoperative interventions. A recent randomized trial of treatment of intervertebral lumbar disc herniation (LDH) compared efficacy of lumbar discectomy with nonoperative medical therapy. The Spine Patient Outcomes Research Trial (SPORT), designed by an orthopaedist, sought to assess the efficacy of the two modalities for LDH, spinal stenosis, and degenerative spondylolisthesis.
UAB spinal neurosurgeon and Charles A. and Patsy W. Collat Professor of Neurological Surgery Mark N. Hadley, MD, recent past president of the Congress of Neurological Surgeons, says, “Early concerns about the SPORT study design, which did not include input from neurosurgeons, centered on how potentially inaccurate study findings could affect patient care.” SPORT did not address the more relevant issue of which patients would benefit from each type of treatment, he says.
“Providing optimal patient care, with optimal patient outcomes in mind, should be uppermost in any treatment decision-making process,” Hadley says. SPORT neglected to account for multiple variables that could affect study results, effectively assuming a homogeneous study population.
The study had two groups. The first randomized patients to surgical intervention or standard nonoperative treatments. A second observational group had the opportunity to choose either treatment. Requirements for enrollment included signs and symptoms of lumbar radiculopathy for a minimum of 6 weeks and a previously unsuccessful course of medical management for LDH.
The highly anticipated results showed that patients who received surgical intervention had significantly better self-reported outcomes than their nonsurgical counterparts (JAMA. 2007;296[20]:2451-2459). Hadley was not surprised, noting, “Carefully selected patients with LDH who present with the appropriate clinical symptoms and concordant imaging studies who have failed to respond to medical therapy respond better to surgery than they do to additional medical treatment. Unfortunately, in the interest of time surgeons today may make the decision to intervene before an adequate trial of medical treatment. Medical management of LDH requires repeated, extensive patient interaction, but it is often effective.”
Surgery vs Medical Management
Evaluation of Low Back Pain
- Obtain thorough patient history
- Evaluate patient narrative for nerve function-related complaints
- Clinical examination: Evaluate for evidence of nerve pathology
- Initial course of treatment
- NSAIDS
- Analgesics
- Steroid dose pack
- Narcotics — acute pain
- Lifestyle changes
- Weight loss
- Standing vs sitting
- Limited bed rest
- Order and evaluate MRI studies
- Physical therapy
- Chiropractic
- Anesthesia pain specialist
- No improvement after 4 to 6 weeks: surgical referral Improvement after 4 to 6 weeks: continue medical management
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LDH does not usually require immediate surgery. The exception is cauda equina syndrome, a compression, entrapment, or injury to terminal nerve roots of the lumbar spine, typically at the L5-S1 level. Without immediate treatment patients with cauda equina syndrome may experience permanent loss of bladder, bowel, and sexual function, although these complications are rare.
“No patient or family member of mine would undergo elective spinal surgery without an initial trial of extensive medical management,” Hadley says. “No surgical procedure is associated with 100% success and all have an element of risk. With spinal surgery, complications are uncommon but can be devastating and permanent. Unless there is a medical emergency, medical treatment should be tried first.”
Carefully selecting LDH patients who do not achieve a satisfactory response with an adequate course of medical management is key to providing the best medical care and achieving optimal results, he says.
Up to 80% of LDH patients undergoing medical management spontaneously recover in 8 to 12 weeks without surgery. Determining when and if to offer surgery for LDH should occur after several weeks of evaluation and after medical management has failed. Primary care physicians have a number of therapeutic options to offer patients with lumbar radiculopathy from a disc herniation before referring them to a neurosurgeon, Hadley says.
“Surgical evaluations for back and neck pain can be like putting together pieces of an intricate puzzle,” Hadley says. “The key during the initial exam is evaluating patients’ complaints by listening to them describe their symptoms and their experiences with their pain and their body — not focusing on what previous medical providers have said about their condition or X-ray findings,” he says.
Following a thorough clinical history to rule out any potential comorbid conditions, a clinical examination to evaluate nerve function is paramount. Numbness, tingling, and muscle weakness are characteristic of radiculopathy and indicate nerve root involvement. Coexisting radiculopathy and low back pain suggest lumbar disc pathology. Evaluating the sensory, motor, and reflex functions of lumbar nerves allows physicians to assess the three crucial areas of nerve function prior to imaging studies.
Physical maneuvers such as a straight leg test evaluate the presence of a disc herniation compressing a nerve in the low back. Performed with the patient seated or supine, the legs are raised one at a time to a 90° angle. In a nondiseased patient, this position might create tightness in the hamstring muscles. Severe pain deep into the affected leg, however, indicates a compressed nerve root being stretched over a herniated disc.
Subsequent evaluation of the spine may reveal impending mechanical problems not related to a potential herniated disc. Bony changes in the spine, a tumor pressing on a nerve, a disc infection, diabetes, or even viral infections can cause symptoms resembling early signs of lumbar radiculopathy.
“A thorough exam can reveal a great deal about a patient’s condition and any existing nerve injury or compression. It is not always necessary to obtain an MRI at a patient’s first visit,” Hadley says. “A comprehensive history and meticulous exam provide the first pieces necessary to evaluate a patient’s suitability for surgery or for continued medical management.”
Conservative Management
Medical management for low back pain involves numerous pharmaceutical, educational, and subspecialty treatment options. Nonsteroidal anti-inflammatory drugs, analgesics, narcotics, muscle relaxers, steroid dose-packs, and some antidepressants provide relief for nerve pain symptoms and muscle spasms associated with a suspected LDH.
Lifestyle changes can be an important part of a conservative treatment plan. For example, increased abdominal girth places strain and load on the back and its muscles. Prescribing a weight loss program and exercise plan for obese patients may optimize symptom relief. Standing for short periods to avoid prolonged sitting may provide temporary pain relief and relieve pressure on the affected disc and nerve.
After an initial course of treatment, diagnostic magnetic resonance imaging studies can reveal damage, injury, or herniation of intervertebral discs and direct future management decisions. In addition to prescribing pharmacotherapy and lifestyle changes, physicians may refer patients to a physical therapist, chiropractor, or anesthesiologist. The use of epidural and nerve root steroid injections in LDH patients with radiculopathy also are options.
Patients experience varied results and symptom resolution following epidural steroid use, which can provide short term relief. If patients respond to therapy and medication within 4 to 6 weeks, it is likely that continued conservative intervention and medical management will relieve LDH. Surgery should be considered when, during the same period, there is symptom progression or no improvement in motility, neurological symptoms, or pain.
Surgical intervention for herniated lumbar discs is preferred when medical management fails and when the appropriate signs and symptoms are present alongside corroborating imaging studies. “Although some patients may respond after a prolonged period of medical management, I would not ask them to endure that type pain and dysfunction for more than 4 to 6 weeks,” Hadley says.
For more information:
Dr. Mark Hadley
1.800.UAB.MIST
mist@uabmc.edu