CHAPTER 5:PROFESSIONAL TREATMENT

Before discussing professional treatments, there is one important point I’d like to address.  Many patients turn to professional health care providers looking for a permanent solution to their disc problems. 

The nature of disc problems is such that a truly permanent solution simply doesn’t exist in most cases. 

Although surgical removal of an offending disc will permanently prevent that disc from causing symptoms again, surgical excision of one disc creates scar tissue and shifts mechanical stress onto other discs, making them susceptible to injury.  In fact, one of the leading statistical predictors that someone will need spinal surgery in the future is having had spinal surgery already. 

Rather than thinking of treatment for disc problems in terms of “cure”, it is usually more realistic to think in terms of “management”.  Once maximum improvement has been achieved from whatever treatment is being used, it is very important to continue to manage disc problems by means of the self-treatment and prevention measures discussed earlier, as well as by means of any recommended preventive treatment administered by your health care provider(s).
 
Most of you reading this book have probably been through one or more professional treatment programs for your disc problems.  As many people have found out, the most commonly used approaches may not provide adequate results, even in the short-term.  Let's look at the options available.

Medication: 
Whether we are talking about over the counter or prescription medication, there are a number of products available that may provide short-term symptom relief for disc-related problems.  Unfortunately, medication is rarely an acceptable long-term solution because of side-effects (ranging from annoying to life-threatening) and diminishing effectiveness as the body becomes accustomed to the medication.  In fact, research indicates that the daily long-term use of pain relievers actually may make pain worse over time because the medications can cause hyper-sensitivity of the nervous system. 

NSAIDS (Non-Steroidal Anti-Inflammatory Drugs) like aspirin, ibuprofen, and even the new NSAIDS like Celebrex and Vioxx  have the additional problem that they inhibit the body’s ability to produce cartilage, and may actually speed up degeneration when used continuously over time.  In addition, some drugs, such as narcotic pain relievers and muscle relaxants, may not be suitable for some patients who must be mentally alert to safely perform their daily activities.  Although medication can be very helpful for a few days at a time during periods of severe symptoms, they fall far short of being an effective means of managing disc problems long-term.

Epidural Steroid Injections (ESIs): 
Also called "cortisone shots" because cortisone is the most common steroid used, ESIs can be quite effective at temporarily reducing inflammation and thereby reducing symptoms related to disc bulges and degeneration.  Steroid injections are primarily effective in milder disc bulges because in these situations, inflammation is one of the primary sources of nerve compression. 

In more severe bulges, there is more direct nerve compression by the disc itself, so reducing inflammation may not have much of an effect on symptoms, and may actually increase symptoms temporarily because the fluid of the shot itself will increase pressure around the nerve until the body absorbs it. 

In any case, ESIs do not heal anything, they simply reduce pressure on nerves due to inflammation, and sometimes bring temporary symptom relief. 

The symptom relief from ESIs may last anywhere from a few days to several months, depending on the case.  Unfortunately, because the injections do nothing to heal the disc (and in fact actually weaken the discs further - more on that in a moment), the symptom relief they bring can give people a false sense of security.  The lack of pain leads some people to be less careful with their neck or back, and this can set them up for further injury and damage down the road. 

As just mentioned, cortisone and other steroids have the side effect that they significantly interfere with the body's normal healing mechanisms and may actually weaken the bones and soft tissues in the area around the injection site.  This is why doctors typically limit a patient to a maximum of three rounds of steroid injections per year.  In addition to the tissue-weakening effect, steroids also weaken the body's immune system, making the body more susceptible to infections. 

Finally, although often promoted as a means of avoiding surgery, a recent study of over 200 patients published in the September-October, 2004 edition of Spine Journal reported that more than 2 out of 3 people initially treated with steroid injections wound up having additional invasive procedures, i.e. surgery, within two years.  As you can see, although they are sometimes helpful in alleviating symptoms temporarily, steroid injections are not an ideal, or even a very effective means of treating disc problems in the long-run for the majority of people. 

Trigger Point Injections:
This is covered in the full version of this book.

Nerve Blocks: 
Covered in the full version of this book.  To order, Click Here.

Radiofrequency Ablation:
Covered in the full version of this book.

IDET (Intra Discal Electrothermal Therapy):
Covered in the full version of this book.

Physical Therapy:
Physical therapy encompasses a wide range of treatments and may include everything from massage, to electrical muscle stimulation, to ultrasound, to traction, to exercises.  Physical therapy can be divided into two main types of treatment:  passive therapies and active therapies.

Passive therapies would include any treatment done TO the patient.  Electrical muscle stimulation, massage, ultrasound, ice, and heat are among the most commonly used passive therapies for disc herniations and degeneration. 

Some therapies like ice and some kinds of electrical stimulation are intended primarily to reduce inflammation, and these are typically used when there is acute severe pain.  Massage, ultrasound, and heat are used with the intention of improving circulation and reducing muscle spasm and constriction, and these are used more in cases where there is stiffness, soreness, and reduced range of motion.  Massage in particular can be quite helpful in alleviating muscles that have become tight and sore from disc-related nerve irritation.  If you have sciatica and you do see a massage therapist, be sure to tell the therapist about the sciatica so he or she will know to use caution in the buttock area.  Passive therapies can be quite helpful in reducing symptoms, but are rarely a long-term solution to disc problems.

Additional information covering physical therapy treatments such as TENS units, microcurrent, and light therapy with lasers and LED devices is presented in the full version of this book.
 
Now, let’s switch gears and talk about active therapies.  Active therapies are things done BY the patient, namely various types of exercises.  Most exercises for disc related problems should only be done once major symptoms are gone and there is no active inflammation.  Unfortunately, for a variety or reasons (often related to insurance company demands) some healthcare practitioners may institute active therapy too soon, and this can result in a patient getting worse because of being forced to exercise before the body was sufficiently healed. 

When incorporated into treatment at the appropriate time, exercise can be a very valuable means of helping a patient recover.  Different types of exercise may be used.  Some therapists have patients exercise on special machines, many of which have computerized monitoring and feedback systems to customize the workout to each patient.  While these machines can be excellent and have many advantages in the clinical setting, they do have at least one big disadvantage.  Because any exercise program must be maintained essentially for life in order to maintain the benefits, therapy programs with these expensive machines leave patients in an awkward situation when they are released from treatment.  If a patient has learned how to exercise only on the special machines, they have little opportunity to maintain the benefits of the therapy program once they no longer have access to the machines.

Because of this, many therapists have recognized the importance of teaching patients exercises they can do at home with simple or even no equipment.  In my opinion, this "low-tech" form of exercise is the most likely to provide the patient with long-term benefit.  Some basic exercises were covered in the chapter on self-treatment.  For more advanced exercise programs it is highly recommended to work with a health care professional who can customize the program for an individual's needs and who can provide basic equipment to facilitate home exercises when the patient is ready to implement the exercises on their own.  

Acupuncture / Acupressure:
This information is included in the full version of this book.

Cranio-Sacral Therapy (CST):
Covered in the full version of this book.

Chiropractic: 
Chiropractic treatment is often helpful in alleviating the symptoms of disc herniations and degeneration, and in some cases may actually assist in disc healing.  Chiropractic has two main beneficial effects in disc problems.  First, by improving spinal joint function, it can reduce abnormal mechanical stress on the discs.  In some cases, this reduces pressure on the damaged part of the disc and thereby reduces the sources of irritation and inflammation and improves the chances of healing. The second beneficial effect of chiropractic is that it produces stimulation of special nerve endings in the spine and surrounding tissues called mechanoreceptors. When stimulated, these nerve endings send signals to the brain that block the perception of pain to varying degrees. 

In addition, some chiropractors utilize additional types of treatment, including the passive and active therapies just discussed under “Physical Therapy”, as well as may provide nutritional supplementation to reduce inflammation and muscle tension.  Certain chiropractic techniques have been developed specifically for the treatment of disc-related problems.  These include Flexion-Distraction (also called Cox or Leander technique), Sacro-Occipital Technique (SOT), and a relatively new technique called Advanced Biostructural Correction (Advanced Biostructural Correction is not a “disc treatment technique” per se, but the lumbar adjustment is one of the most effective methods I’ve found for quickly alleviating acute disc-related back pain).  One other very new method of chiropractic treatment utilizes a computer-controlled adjusting device (the "Pro-Adjuster") to analyze and correct spinal joint function with minimal force and discomfort to the patient.  It is a great technique for those patients who are too fragile or fearful for more traditional types of chiropractic treatment.

Figure 32. The Pro-Adjuster computerized spinal analysis and treatment system.

Although doctors of chiropractic in general have a good track record in treating disc problems in both the neck and back, in my opinion, the doctors who use techniques that are specifically-designed for disc problems have a definite advantage in getting results in such cases.   

Orthotics (Shoe Inserts):
Covered in the full version of this book.  For ordering information, Click Here. 

Non-Surgical Spinal Decompression: 
This relatively new FDA-approved treatment for disc herniations and degeneration in the low back and neck is fast becoming very popular.  Used by doctors of chiropractic, osteopathic doctors, and medical doctors, spinal decompression has the advantages of being safe, comfortable for the patient, non-invasive, and extremely effective (over 80% effective in the lumbar spine and 70% effective in the cervical spine).  Furthermore, unlike most disc treatments, spinal decompression not only reduces symptoms but in many cases actually reduces the size of disc herniations and improves disc hydration and nutrition and thereby slows and often partially reverses disc degeneration.  It has even shown to be effective in many cases where surgery was performed and failed to provide results. 

There are a few disadvantages and limitations associated with spinal decompression.  First, because it is so new, there is limited availability of the treatment and not all insurance companies cover the treatment.  Second, it generally cannot be used in cases where metal is implanted in the spine (in the area needing treatment) or in cases where there is severe osteoporosis or spinal instability.  Finally, there is some controversy as to what constitutes spinal decompression. 

When the clinical studies started to come out that showed the success of spinal decompression treatment for treating disc problems, a lot of companies started marketing ordinary traction machines as "spinal decompression" machines.  You see, spinal decompression machines are themselves traction machines, but they are very special traction machines that used sophisticated computer-controlled motors that allow the muscles around the spine to stay relaxed during the treatment.  This is critical to getting good results with decompression.  Regular traction machines often provoke muscle contraction around the spine, and this severely limits the effects of the traction pull at the discs. 

Research has shown that regular traction will lower disc pressure somewhat - from a starting pressure of 90 mmHg down to about 30 mmHg (mmHg is what barometric pressure is measured in when you see it on the weather forecast).  This is somewhat helpful and it stretches the muscles, but it doesn't do very much to help the discs. 

On the other hand, because spinal decompression machines “trick” the muscles into staying relaxed (and therefore do not have to fight muscle resistance), there is a much greater effect on the discs - dropping the pressure to -150 mmHG (that's negative 150 mmHG - which is actually a suction).  This drastic change in disc pressure literally sucks disc herniations back in, as well as pulls fluid and nutrients into the disc to help it heal.  In addition, because the muscles stay relaxed during treatment, spinal decompression is very comfortable for most patients, whereas traction can sometimes be quite uncomfortable, or even painful. 

As of this writing, there are arguably only a few true spinal decompression machines on the market today - the    VAX-D (the first spinal decompression machine developed),  the DRX9000, and the SpineMed Table.  Most, other "spinal decompression" machines are regular traction machines.  Although regular traction machines do help in some cases, they do not have the documented results of true spinal decompression units.  Be aware of this if you are shopping around for spinal decompression treatment.  Traction machines are much cheaper than true spinal decompression machines and consequently the treatments on traction systems typically cost less than true decompression treatments.  Unfortunately, traction (even when it is called "spinal decompression") often does not get the same results as true spinal decompression.  My advice is if you want to try spinal decompression, stick with a provider who uses either the VAX-D, the DRX9000, or the SpineMed machines. 

Figure 33.  The DRX-9000 spinal decompression system.

Incidentally, as of this writing, the only published research on the effectiveness of spinal decompression was done using the VAX-D and the DRX9000 machines.  Based on what I have seen of the technology incorporated into the Spine-Med, I am speculating that it would get equivalent results.  Other machines on the market now or in the future may also get equivalent (or possibly superior) results, but at this time I have not seen any other machines I feel confident in recommending.

Surgery: 
I've saved surgery for last because, in my opinion, surgery should always be a last resort for disc problems.  Make no mistake, there are definitely times when surgery is the best option, and sometimes the only option, but in many cases there are treatment options that are considerably safer and have a much greater long-term success rate than surgery. 

In some cases, I think people rush into surgery thinking  that it will solve their disc problems once and for all, so they can get on with their lives and not have to worry about the disc problem anymore.  This is simply not a realistic view of surgery.  Although surgery can bring about dramatic reductions in pain and other symptoms, these results do not always last.  It needs to be recognized that a disc surgery does not restore things to normal, but in fact creates alterations in spinal biomechanics and/or disc stability that leave you susceptible to new disc injuries if you don’t take very good care of your spine for the rest of your life. 

There are a variety of surgical techniques that are used for disc problems, but they all have inherent risks that are much higher than any non-surgical form of treatment.  Reactions to anaesthesia, potential infection, and "slips of the knife" make spine surgery a risky proposition. 

Surgical techniques can range from “minimally invasive” procedures that are done through small incisions using a surgical viewscope to full fusion procedures with or without metal hardware implanted in the spine.  If you really need surgery, the recommended procedure depends on the specific nature of your problem, as well as the preferences of the surgeon(s) you happen to consult with. 

Typically, the risks of the procedure increase with the complexity, and with the use of general anaesthesia (in which case you are unconscious) versus local anaesthesia (in which case you are awake).  Local anaesthesia is primarily used in the minimally invasive type of surgery.  Regardless of the procedure though, any disc surgery potentially exposes the spine to infection, and other than the risks of anaesthesia, infection is the biggest risk of spinal surgery.  A spinal infection is extremely serious and difficult to treat.

For all the risk, there is no guarantee that surgery will help long-term, and it is not unusual for things to get worse after surgery.  Even in cases where surgery helps in the short-term, there are often problems that occur from scar tissue development in the months and years that follow the surgery.  Over time, scar tissue can create as much or more compression on the nerves as the original disc problem did.  Most surgeons are very up front about the risks and the uncertainties of getting the desired results, but you need to be aware that a few surgeons will give their patients unrealistic expectations that can result in major disappointments. 

Different surgical procedures have different strengths and weaknesses.  Minimally invasive techniques have the advantages of lower risks from anaesthesia and infection, and the fact that recovery is relatively easy.  In a minimally invasive surgery, the surgeon makes small incisions and the area is viewed through a scope, while small surgical tools are inserted.  This allows for trimming of bulging disc material and/or excess bone from around nerves, and this method can yield good results almost immediately, with very little down time on the part of the patient.  One potential disadvantage of this procedure is that if part of the disc is trimmed away, the trimmed area is left, at least temporarily, in a weakened state.  Because many patients feel better, they may resume activities that place a lot of stress on the now-weakened disc, and this can set the stage for a re-injury. 

The more invasive types of surgery usually require general anaesthesia, and also have a higher risk of infection due to larger incisions.  Depending on the nature of the problem and the preferences of the surgeon, the damaged disc might be partially or completely removed, and the spine may be left to fuse naturally (the bones that were separated by the disc grow together over time), or may be fused by the surgeon using bone grafts and/or some type of metal hardware. 

While there are definitely situations where this type of surgery is necessary, once the spine is fused, there are few other treatment options available if the surgery doesn’t work.  For this reason, it is strongly recommended that all other treatment options be exhausted before resorting to an invasive type of surgery, except in emergency cases in which permanent neurological damage is imminent. 

The warning signs indicating an emergency situation in which surgery must be done quickly to prevent permanent nerve damage include when there is sudden onset of paralysis, there is a sudden loss of bowel and/or bladder control, and/or the onset of “saddle anaesthesia” (loss of sensation in the inner thighs, groin, and lower buttocks). 

Except in the emergency situations just mentioned, I strongly recommend getting at least two doctors' opinions, and probably three or four, before deciding on getting surgery. 

Disc Replacement: 
I want to briefly cover this subject as a separate issue from surgery because it is one of the latest treatments for disc problems, and is still considered experimental by most insurance companies.  Disc replacement surgery involves removing the damaged disc and replacing it with a man-made disc.  Early results for this procedure have been favorable as compared to other surgical methods; however, disc replacement still has the same risks as other spine surgery, and the long-term results are still largely unknown. 

One of the common problems with other types of spine surgery would presumably still be a problem with disc replacement: the development of scar tissue.  Because scar tissue creates quite a few problems in other types of spine surgery, there is a good chance that disc replacement surgery, although probably an advancement over other surgical techniques, may not provide the long-term results most patients are hoping for.

Treatments For When All Else Fails: 
Unfortunately, there are a few cases where not much can be done to correct the causes of disc-related pain.  In these situations, there are some options for pain control that offer better and longer-lasting effects than standard treatments. 

One option is what’s called a dorsal column stimulator.  In concept, this is somewhat like a TENS unit (described earlier), but TENS units use external electrodes.  The dorsal column stimulator uses electrodes that are surgically implanted in the spine and controlled by an external control box.  The device administers electrical stimulation directly to the spinal cord to block the perception of pain.  Because of the implantation in the spine, there are significant risks with these devices, and so they are not a first-line of treatment, but they can usually offer at least partial relief to some people with severe chronic pain. 

Another implanted device is a morphine pump, which automatically releases the narcotic pain reliever drug morphine in controlled doses to suppress the function of pain receptors.  Again, because the device is implanted near the spine, there are risks involved, and morphine may not fully alleviate all pain, but these devices can be helpful for some people. 

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