This article reiterates many of the points I have been arguing for years. I found it searching for published evidence that spinal and nerve compression causing LBP “is a real thing.”
Again, my arguments against the assertion that ‘disc herniation’ causes low back pain is supported by a lack of evidence; (1) neither disc herniation nor spinal ‘compression’ contribute to non-traumatic LBP (90%), (2) advanced imaging is not necessary in order to provide excellent LBP care, (3) neither surgery nor steroids are a suitable course of care for non-specific nor radicular LBP, (4) patient education with an activities-based course of care is the gold-standard model of LBP care.
Lumbar Degenerative Disk Disease
Donnally III CJ, Hanna A, Varacallo M.
“Slightly more than 90% of herniated discs occur at the L4-L5 or the L5-S1 disc space, which will impinge on the L4, L5, or S1 nerve root. This compression produces radiculopathy into the posterior leg and dorsal foot. In the absence of motor deficits, a nonoperative course of analgesia, activity modification, and injections should be tried for several months.
“Most intervertebral disc degenerations are asymptomatic, making a true understanding of the prevalence difficult. Additionally, due to the lack of uniformity in the definitions of disc degenerations and disc herniations, the actual prevalence of the disease is difficult to review across multiple studies. This study supports that the mere incidental finding of disc disease is common and should not necessitate specialist evaluation in the absence of pain or limitations.
“The radiation of back pain associated with disc disease is thought to be due to the compression of the nerve roots in the spinal canal from either one or a combination of the following elements, [however] HNP material predictably is resorbed over time, with the sequestered fragment demonstrating the highest degree of resorption potential. In general, 90% of patients will have a symptomatic improvement in radicular symptoms within 3 months following nonoperative protocols alone.
“Evaluation of patients with low back pain typically includes anterior-posterior (AP) and lateral radiographs of the impacted area. Some physicians will obtain radiographs of the entire spine. An MRI should not be ordered at the initial presentation of suspected acute disc herniations in patients lacking “red flags,” because these patients will initially trial a 6-week course of physical therapy and frequently improve. An MRI likely is an unnecessary financial and utilization burden in the initial presentation. Over time, both symptomatic and asymptomatic disc herniations will decrease in size on MRI. The finding of disc disease (degeneration or herniation) on MRI does not correlate with the likelihood of chronic pain or the future need for surgery. Many patients are mistakenly led to the belief that the disorder can be cured by surgery, sadly failed surgeries and residual neurological deficits are common. For those who undergo surgery, the outcomes do vary from poor to fair. In fact, poor results are universal.
“Fortunately, the majority of patients will improve without surgical treatment. A course of at least 6 weeks of physical therapy with an emphasis on core strengthening and stretching should be attempted. The patient needs to understand that while surgical intervention has favorable outcomes for relieving radicular pains, the results are less predictable for non-radiating lower back pain.
“In regards to microdiscectomy postoperative rehabilitation, one study showed superior results when neuromuscular exercise programs were started 2 weeks post-surgery (compared to those starting at the traditional 6-week mark). Furthermore, at 4 to 6 weeks postoperatively, evidence shows that intensive exercise programs result in the more rapid short-term improvement of function as well as a return to work when compared to mild intensity programs.
“The key is patient education. The nurse and the physical therapist are in a prime position to educate the patient about changes in lifestyle that can lead to significant improvement and a better quality of life. Weight loss must be encouraged; the patient must enter an exercise program and eat a healthy diet. In the majority of patients with lumbar disc disease, a positive change in lifestyle leads to a marked improvement in symptoms.”
1. Bozzio AE, Johnson CR, Fattor JA, Kleck CJ, Patel VV, Burger EL, Noshchenko A, Cain CMJ. Stand-alone Anterior Lumbar Interbody, Transforaminal Lumbar Interbody, and Anterior/Posterior Fusion: Analysis of Fusion Outcomes and Costs. Orthopedics. 2018 Sep 01;41(5):e655-e662. [PubMed]
2. Mostofi K, Gharaie Moghaddam B, Karimi Khouzan R, Daryabin M. The reliability of LERI’s sign in L4 and L3 radiculalgia. J Clin Neurosci. 2018 Apr;50:102-104. [PubMed]
3. Paul CPL, Emanuel KS, Kingma I, van der Veen AJ, Holewijn RM, Vergroesen PA, van de Ven PM, Mullender MG, Helder MN, Smit TH. Changes in Intervertebral Disk Mechanical Behavior During Early Degeneration. J Biomech Eng. 2018 Sep 01;140(9) [PubMed]
4. Solomou A, Kraniotis P, Rigopoulou A, Petsas T. Frequent Benign, Nontraumatic, Noninflammatory Causes of Low Back Pain in Adolescents: MRI Findings. Radiol Res Pract. 2018;2018:7638505. [PMC free article] [PubMed]
5. Abi-Hanna D, Kerferd J, Phan K, Rao P, Mobbs R. Lumbar Disk Arthroplasty for Degenerative Disk Disease: Literature Review. World Neurosurg. 2018 Jan;109:188-196. [PubMed]
6. Martínez-Quiñones JV, Aso-Escario J, González-García L, Consolini F, Arregui-Calvo R. Are Modic Changes Able to Help Us in Our Clinical Practice? A Study of the Modic Changes in Young Adults During Working Age. Clin Spine Surg. 2017 Jul;30(6):259-264. [PubMed]
LBP Blog General information
These articles intend to (1) re-evaluate the prevailing clinical practices thought to manage low back ‘pain’, (2) submit and debate novel low back ‘pain’ contributors and mechanisms, (3) meet patient expectations & satisfaction and clinically meaningful results, (4) recommend a conservative non-surgical course of care to over-ride ‘pain’ instantly, and (5) restore ADLs and patient confidence on the first visit at low cost. This article has a companion podcast.
Dr. Dean Bio
Forester Dean is a chiropractic and physiotherapy sports medicine doctor practicing in Los Angeles, California. Dr. Dean is a lifetime athlete, and currently teaches tennis, track, boxing, yoga. The Core X System™ Campus flagship location was opened by Dr. Dean in 2020. www.preformancecxs.org
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