|Clincal Review of Lumbar Disc Herniation/ Sciatica|
|By Dr. Sireen Gopal - Medical Literature review|
Medical Spine Update and Literature Review of the Management of Lumbar Disc Herniation/ Clinical Sciatica!!
The minority of patients with back or neck pain, who do not recover by
3 months account for up to 90% of total expenses related to this health
problem,1-7 which exceed $60 billion per year in the United States
Multiple studies have demonstrated little correlation to exist between
strict radiographic signs of disc degeneration, disc herniation and
** Advances in diagnostic imaging has lead
to Over-estimation of disease prevalence; Over-treatment of the disease
with passive care (passive physical therapy, chiropractic etc);
Validation of pain behavior and disability
** Prolonged bed rest
has been shown to be one of the most costly errors in musculoskeletal
care15. 2 days of bed rest has shown to be as effective as 2 wks 16
Spontaneous disc resorption has been reported after disc
herniations17-22, especially with large disc herniations19. The notion
that surgery is necessary in a patient with a large disc extrusion is
not supported in the literature, except in the one with serious
neurological insult. Failure of passive non-operative treatment is not
sufficient for the decision to operate 18
** Multiple studies
have shown success rate up to 80-90% in treating lumbar herniated
nucleus pulposus/clinical sciatica with radiological evidence of nerve
root entrapment by aggressive conservative management 17-23
Recent studies 24-26 have indicated that pain factors such as substance
P, calcitonin gene-related peptide and inflammatory factors such as
phospholipase A2 26 are present in significant abnormal amounts after
disc herniation, causing a chemical radiculitis 27- clinically
manifested as radiating limb pain
guided transforaminal epidural steroid injections (ESI) 28-41 allow for
precise, safe and effective delivery of high concentrations of
injectate directly at the ventral aspect of the nerve root sleeve and
posterior annulus. This allows effective pain control, facilitates
active physical rehabilitation and time for spontaneous disc resorption
Acute and subacute back and radiating limb pain should be controlled
aggressively in the first three months to help retard chronic pain
syndromes and prevent the 4D Syndrome of - Drug dependence, Disuse,
Depression & Disability
** If pain is not controlled with
specific source of pain treatments, surgery should be offered. This is
often the case in spine conditions with coexisting spinal stenosis,
spondylolisthesis etc. These patients with clear structural
abnormalities should be discouraged from allowing chronic persistent
symptoms to linger.
1. Webster BS, Snook SH: The cost of 1989 worker, compensation low back pain claims. Spine 19: 1111, 1994.
Snook SH: Low back pain in industry. In White AA, Gordon SL (eds):
Symposium on Idiopathic Low Back Pain. St Louis, CV Mosby, 1982.
Spengler DM, Bigos SJ, Martin NA, it al: Back injuries in industry: A
retrospective study. I. Overview and cost analysis. Spine 11: 241, 1986.
Frymoyer JW, Pope MH, Clements JH, it al: Risk factors in low-back
pain: An epidemiological study. J Bone Joint Surg (Am) 65: 213, 1983.
Andersson GBJ, Pope MH, Frymoyer JW: Epidemiology. In Pope MH, Frymoyer
JW, Andersson G (eds); Occupational Low Back Pain. New York, Praeger,
1984, pp 101-114
6. Morris A: Identifying workers at risk to back injury is not guesswork. Occup Health Saf 55:16, 1985
Frymoyer W: Epidemilogy. In Frymoyer JW, Gordon SL (eds): Symposium on
New Perspertives in Low Back Pain. Park Ridge, American Academy of
Orthopaedic Surgeons, 1989, pp 19-33.
8. Frymoyer JW, Newberg A,
Pope MH, et al: Spine radiographs in patients with low-back pain: An
epidemiological study in men. J Bone Joint Surg (AM) 66: 1048, 1984
9. Fullenlove TM, Williams AJ; Comparative roentgen findings in symptomatic and asymptomatic backs. JAMA 168: 572, 1957
10. LaRocca H, Macnab IA: Value of pre-employment radiographic assessment of the lumbar spine. Can Med Assoc J 101: 383, 1969
11. Magora A, Schwartz A: Relation between the low back pain syndrome and x-ray findings. Scand J Rehabil Med 8: 115, 1976
12. Splithoff CA: Lumbosacral junction: Roentographic comparison of patients with and without back ache. JAMA 152: 1610, 1953
Torgeson WR, Dotler WE: Comaprative roetgenographic study of the
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14. Dabbs VM, Dabbs LG: Correlation between disk height narrowing and low-back pain. Spine 15: 1366, 1990
Spitzer WO Le Blanc FE, Dupuis M, it at: Scientific approach to the
assessment and management of activity-related spinal disorders: A
monograph for clinicians. Report of the Quebec Task Force on Spinal
Disorders. Spine 12(Suppl 7): S1, 1987.
16. Deyo RA, Diehl AK, Rosenthal M: How many days of bed rest for acute low back pain?. N Engl J Med 315: 1064, 1986
Bush K, Cowan N, Katz DE, et al: The natural history of sciatica
associated with disc pathology: A prospective study with clinical and
independent radiologic follow-up, Spine 17: 1205, 1992.
18. Teplick JG, Haskin ME. Spontaneus regression of hernated nucleus pulposus. AJR Am J Roentgenol 1985; 145: 371-5.
Saal JA, Saal JS, Herzog RJ. The natural history of lumbar
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20. Delauch-Cavallier MC, Budget C, Laredo JD, et al. Disc
herniation: Computed tomography scan changes after conservative
treatment of nerve root compression. Spine 1992: 17; 927-33
Maigne JY, Rime B, Deligne B. Computed tomographic follow-up study of
forty-eight cases of nonoperatively treated lumbar intervetebral disc
herniation. Spine 1992, 17: 1071-4
22. Kimori H, Shinomiva K, Nakar
O, et al. The natural history of herniated nucleus pulposus with
radiculopathy. Spine 1996; 21(2); 225-9
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24. Weinstein J, Claverie W, Gibson. The pain of discography. Spine 1988; 13: 1344-8
Chatani K, Kawakami M, Weinstein JN, Meller ST, Gebhart GF.
Characterization of thermal hyperalgesia, c-fos expression, and
alterations in neuropeptides after mechanical irritation of the dorsal
root ganglion. Spine 1995; 20: 277-89.
26. Saal JS, Franson RC,
Dobrow R, Saal JA et al: High levels of inflammatory phospholipase A2
activity in lumbar spinal disc herniations. Spine 1990; 15:674-8
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