Saturday, November 25, 2017

“Eight out of 10 people will experience low back pain (LBP) at some point in their lives” is the introductory line of so many articles about back pain. From my experience, that number is low! A very large percent of individuals with low back pain have a problem with their lumbar discs (the shock-absorbing jelly doughnuts) between the vertebrae. Treatment options are many and diverse but, unfortunately, too often not based on scientific fact but rather on tradition or misconceptions.

The following paragraphs address whether there is evidence supporting various treatments for lumbar disc disease, which is the most common source of LBP. These comments do not apply to all sources of LBP.

Weight loss is often recommended as a treatment or prevention of LBP, but there is no evidence of a correlation between weight and LBP. However, tallness is likely a risk for severe back pain and the need for back surgery. Young and middle-aged patients often express concern about how disabling their back pain will become as they age. Fortunately, pain from lumbar disc disease becomes progressively less-prevalent as we age past 55.

There is no scientific evidence that bedrest contributes to a faster resolution of acute discogenic LBP. In fact, given all of the medical and psychological negatives of bedrest, it is ill-advised as a treatment of LBP unless absolutely necessary. It is best to keep moving when possible.

The application of heat or cold can afford temporary relief of any pain but does not alter the course of the condition. In answer to the patient’s question as to whether to use one or the other for LBP, it is generally whichever feels better.

“Muscle relaxants” (Flexeril, Robaxin, Soma, Skelaxin, etc.) as a drug class have a very appealing name but have not been proven to shorten the course of a back-pain episode. They probably “relax” brains more so than muscles which, at times, is therapeutic, particularly at bedtime.

Anti-inflammatory medications (ibuprofen, naproxen, Mobic, Celebrex, etc.) are taken by a large percentage of patients. Although they may afford short-term relief, they have not been shown to contribute to a faster resolution of discogenic LBP. In addition, one must be concerned about the risks of this class of drugs, which includes GI inflammation or bleeding, elevation of blood pressure, kidney toxicity and vascular disease.

Many highly reputable back specialists prescribe a short course of oral steroids for acute sciatica, often in the form of a Medrol Dosepak. There may be short-term benefit to this medication, particularly if the disc has compressed a nerve causing sciatica; however, by two weeks after beginning treatment, patients are no different whether or not they took steroids. Once again, there are potential side effects, including rare, serious side effects.

Patients frequently ask whether an MRI will offer guidance in their care. In fact, obtaining an MRI usually will not alter care of acute back pain. The reason to get an MRI is if there is a concern about a serious diagnosis such as an infection, fracture or tumor or if surgery or spinal injections are being seriously considered. For most patients, their history and examination guide care. In addition, it is important to realize that MRIs are very sensitive and frequently reveal abnormalities that are not clinically relevant.

OK. Enough negativity! What can we do to help patients who have pain from lumbar disc disease?

Activity modification is of great importance. There is a large mechanical component to disc problems, with clear evidence that pain and neurological symptoms are worse with elevated pressure within the disc. Patients are advised to minimize sitting, bending, lifting and twisting. They are educated as to how to perform these activities with the least amount of disc pressure. Standing desks, lumbar rolls and supports, and at times corsets contribute to resolving disc episodes and preventing future ones.

There is strong scientific evidence that physical therapy plays a large role in recovery from a disc attack even in the very acutely painful patient. “McKenzie certified or trained” therapists utilize positioning techniques called centralization to influence the position of the gel within the disc. Many individuals respond well to this approach and are also educated in self-care strategies. Pelvic traction helps a number of patients with radicular pain. Core strengthening may have a role in the non-acute patient if done properly and carefully. If done improperly, I am convinced that core strengthening can do more harm than good.

Epidural injections can accelerate recovery, at times dramatically, when properly placed for patients with nerve root compression and lower extremity pain.

Surgery has a definite role for patients with disc herniations that prove difficult to manage non-operatively. Surgery is elective except in the rare instances of progressive neurological deficits or when there is compression of the “cauda equina,” which is the group of nerves supplying the bowel and bladder. The goal of surgery should always be to decompress the involved nerve root(s) while performing as little intervention as possible. There must be a very clear reason for a fusion before one is done.

In summary, a great deal can be done to help the patient with disc disease. However, one must realize that many established treatments are not scientifically supported. A careful evaluation can lead to a very specific diagnosis and individually tailored treatment.

 

 Dr. Howard Liss

 Howard Liss, of the Howard Liss, M.D. Rehabilitation Institute, is an assistant clinical professor of Rehabilitation Medicine at Columbia University. He has offices at the following locations: 177 North Dean, Suite 203, Englewood, NJ 07631, 201 390 9200; 2150 Center Avenue, Suite 1B, Ft. Lee, NJ 07024, 201 820 7610; 3333 Henry Hudson Pkwy, Suite 1L, Riverdale, NY 10463, 718 873 6362.  He can be reached at www.lissrehab.com. Call today to schedule an appointment with Dr. Liss.

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