Herniated disc alternative treatment
Exercises In some patients, the pain response may limit their flexibility. Prescribed stretching exercises can improve flexibility of the trunk muscles. Flexion exercises may help to widen the intervertebral foramen. The intervertebral (between the vertebrae) foramen are small canals through which the nerve roots exit the spinal cord. The intervertebral foramen are located on the left and right sides of the spinal column. Extension exercises, such as the McKenzie method, focuses on the muscles and ligaments. These exercises help maintain the spine’s natural lordotic curve, important to good. Aerobics (no/low impact) offers many benefits including improved muscular endurance, coordination, strength, strong abdominal muscles, and weight loss. Strong abdominal muscles work like a brace (or corset) to reduce the loads to the lumbar spine. It is also known that aerobics help to combat anxiety and depression. The loads on the discs during walking are only slightly greater than when lying down. Walking, bicycling, and swimming are forms of aerobic exercise a physician may suggest. Acupuncture Acupuncture, a type of alternative medicine, has been shown to control pain. It has been suggested that acupuncture stimulates the production of endorphins, acetylcholine, and serotonin. However, acupuncture should be combined with an exercise program for many of the reasons outlined in prior paragraphs. Acupuncture involves the use of fine needles inserted along the pathway of the pain to move energy locally and relieve the pain. An acupuncturist determines the location of the nerves affected by the herniated disk and positions the needles appropriately.
During the acute phase of low back pain, drugs may be prescribed. Some of these may include narcotics, acetaminophen, anti-inflammatory agents, muscle relaxants, and anti-depressants. Narcotics are used on a short-term basis partially due to their addiction potential. When low back pain is caused by muscle spasm, a muscle relaxant may be prescribed. These drugs have sedative effects. Depression can be a factor in chronic low back pain. Anti-depressant drugs have analgesic properties and may improve sleep. Massage therapists may also provide short-term relief from a herniated disk.Today manipulation is performed by Chiropractors and Physical Therapists. For patients without radiculopathy (pain stemming from a spinal nerve root), manipulation may be effective during the first month. Thereafter, benefits are unproven. Manipulation Manipulation is believed to be effective because of its effect on spinal mobility. Acute low back pain, chronic low back pain, and DDD without nerve compression may respond to manipulation. A new method of manipulation is Intervertebral Disc Decompression or IDD. The device is known as the Accuspina made by North American Medical Corporation. This is a method where a patient lies on a special table with a special custom harness attached. The segment of interest (disc space involved) is localized and a gentle traction and relaxation is administered. The exact angle of distraction is done according to the disc space involved. Simultaneous heat and massage is administered. The duration and amount of distraction is delivered according to body weight. Clinical studies have demonstrated up to an 86% response. Because it is non-invasive and non-surgical it is worth a try for many patients with disc herniation. In our clinic we are seeing response rates of about 71%. Prolotherapy A ligament is a band of fibrous tissue that holds bone together and can become "over-stretched." The resulting laxity can cause severe pain as bones rub together, or muscles are over-worked as they tighten in an attempt to stabilize the bones. Prolotherapy is a treatment where a proliferant solution of natural substances is injected directly into the site where the weakened ligament attaches to the bone. These injections trigger the body's immune system to grow the new, healthy tissue that properly stabilizes the bones and joints, relieving musculoskeletal pain and stiffness. Prolotherapy (sometimes called ligament reconstructive therapy) is known to have been in existence for more than 2500 years when Hippocrates used a somewhat crude but successful technique to treat the injured shoulder of a javelin thrower. The more modern techniques were developed by Osteopaths (DO) and Allopaths (MD) beginning in the 1930's. The collagen fibers of ligaments and tendons are flexible, but they do not stretch very far. In certain instances, they are frayed or even torn by injuries. Pain is perceived when otherwise normal tensions on these collagenous structures stretches them beyond their normal limits of motion. This in turn results in abnormal tension and stimulation of pain transmitting sensory nerves, because these nerve fibers are not meant to stretch. Therefore, the chief symptom of ligament and tendon relaxation is pain. The pain is aggravated by activity, when tension is placed upon the injured ligament and tendon, and usually subsides when they are not under tension. This painful stimulation can result in muscle spasm, loss of range of motion or joint movement, and a myriad of sensations and feelings that radiate from the injury site into the arms and legs. Many times, the symptoms can lead to erroneous diagnosis of a "nerve injury." When the ligament or tendon does not heal by itself, prolotherapy is used to assist the healing process. The treatment consists of the injection of a proliferant solution within the relaxed ligament or tendon near the attachments to the bone. The solutions cause a controlled inflammation at the site of injury to stimulate cells called fibroblasts to make more collagen fibers. This in turn "strengthens" the "weld" of the ligament or tendon to the bone, and stabilizes the formerly loose and painful connection. As with many treatments, prolotherapy is not without risks or side effects. Since intent of the technique is to create a specifically localized inflammation, pain, swelling, redness, soreness, temporary stiffness, and bruising at the injection site are normal. Often there is temporary numbness, tingling, or itching over the injection site. Piercing the skin with a needle always allows for the possibility of infection, although very few have ever been reported. For this reason, needle placement technique is important. Four times the prolotherapy solution had been intentionally placed by practitioners into the spinal canal of cancer patients to relieve pain, without dangerous effects. In trained hands, prolotherapy is a safe, effective, and highly successful technique when utilized appropriately, to give long sought relief from pain arising from over-stretched ligaments and tendons. Invasive techniques include: Radiowave New Radio Wave Treatment to Correct Back Disorders Offers Alternative to Drugs, Open-Spine Surgery Boston--May 2002, Harvard Medical School affiliate Beth Israel Deaconess Medical Center--If you are one of the estimated 1.5 million Americans who will be diagnosed this year with a contained herniated disc--also known as a 'thrown-out back' or 'pinched nerve' of the upper leg--the answer may be as familiar as your radio. Doctors at Beth Israel Deaconess Medical Center are using radio waves the same energy that sends signals to your car radio--to gently dissolve small amounts of unwanted disc tissue and relieve the pressure often associated with lower back and upper leg pain. For patients whose body motion is restricted by a spine disc attack and who can't stand the prospect of a sometimes lengthy and painful convalescence, radio wave injection may be just the answer, says Joshua A. Hirsch, M.D., an interventional neuroradiologist and associate professor of radiology at Harvard Medical School. Virtually bloodless and exceptionally precise, Nucleoplasty radio wave injection is more like getting a vaccination or epidural steroid injection than traditional open-spine surgery. "Nucleoplasty fills a serious technology gap that has existed for millions of spine disc sufferers," says Hirsch. "Since approximately 80 percent of back and leg pain sufferers are not appropriate candidates for disc surgery, the focus until now has been on trying to manage the problem with drugs, epidural injections and physical therapy. Nucleoplasty radio waves provide patients with the possibility of a permanent solution that drugs and therapy can't provide, but without the stress of traditional open-spine techniques." Nucleoplasty radio wave injection is an offshoot of a technology used to treat over one million patients since 1995 for a variety of common medical problems, ranging from knee injuries to sleep apnea. A version of the technology for decompressing spine discs was approved for physicians' use by the FDA last summer. Hirsch is the first doctor in New England to offer radio wave injection for treating disc problems associated with lower back and upper leg pain. He says his success rate so far is comparable to that of major surgeries but without the trauma, recovery time and cost. Nucleoplasty (literally, removing part of the disc's nucleus) usually takes about 30 minutes and is typically performed while the patient is awake and under a local anesthetic and light sedation. Most patients walk out of the clinic in about an hour and are back at work in two to three days, Hirsch says. The only cutting required is for a one-millimeter opening (about the diameter of a lead of pencil) in the lower back where the injection device is inserted. In the past, most spine disc attacks were treated with weeks and possibly up to two months of bed rest, plus narcotics for pain, anti-inflammatory drugs and physical therapy for body motion, and a variety of alternative techniques ranging from acupuncture to massage. In extreme cases, open-spine procedures may be required to remove some (microdiscectomy surgery) or most (fusion surgery) of the nucleus in problem discs. Nucleoplasty radio wave injection is intended for the vast middle of the market--people with mild-to-moderate cases who want quicker and potentially more permanent relief than drugs and bed rest can offer, but who are not severe enough for open-spine procedures. Contained herniated disc begins when the soft, gel-like substance in the center, or nucleus of the disc comes into contact with a weakened area in the disc shell. If the shell is weak enough, the nucleus material can create an unnatural bulge in the shell. In other cases, the material seeps out of the shell. In both cases, the soft nucleus material that is supposed to function as a shock absorber for the spine actually becomes an irritant, creating pressure on the spine's sensitive nerve endings and bringing pain to the lower back and-or upper leg. Radio wave injection is designed to gently dissolve the excess nucleus material that creates bulges in the disc and irritates nearby nerve endings in the spine. Although radio waves have been used on a limited basis in medicine for years, recent technological advances have enabled radio wave devices to replace more conventional devices. Radio waves are considered a potentially optimal energy source for certain surgeries because these signals can be exceptionally precise and controllable in a doctor's hands, uniform in the way they heat and dissolve unwanted tissue, and, because they are cooler than some other energy sources, more gentle on the patient since damage to surrounding tissue is minimized. "With Nucleoplasty radio wave technology, I believe we are on the threshold of a new generation of medical devices that will treat ordinary diseases with greater precision for the surgeon and greater gentleness for the patient," Hirsch says.
A medical treatment first developed in a laboratory some 30 years ago is gaining new recognition as a safe alternative to back surgery in many cases. In the early 1960s, Dr. Lyman Smith, an orthopaedic surgeon from Illinois, began investigating the ability of chymopapain, a natural enzyme derived from the papaya plant, to relieve the back and leg pain (sciatica) caused by slipped or herniated disc. When the enzyme was injected into the nucleus of the disc, Smith found, it broke down and partially liquefied the jelly-like material that was exerting painful pressure on the nerve root. Dr. Smith injected the first human patients in 1963. Clinical trials lasted 12 years and involved 75 investigators, predominantly orthopaedic surgeons. Of the 16,985 patients injected during this period, about 80 percent found relief from sciatic pain. Today, chemonucleolysis -- the name given to the process of injecting chymopapain into a herniated disc -- has been demonstrated to be about 80 percent effective for the over 400,000 patients worldwide who have received it since 1963. By comparison, laminectomy, or surgical removal of the lumbar disc, has been shown to result in three times as many deaths, 10 times as many neurologic complications and 16 times as many post-operative infections as chemonucleolysis. Surgery in many cases results in the failed back surgery syndrome (FBSS), creating long-term disability at tremendous cost for the patient and society. According to the experts at Knoll Pharmaceutical Company, who market chymopapain under the brand name CHYMODIACTIN®, chemonucleolysis is safe and effective when performed by skilled surgeons on carefully screened patients. In some cases, the response is immediate, though many patients may experience back pain, stiffness and soreness for a short time. Special exercise performed at home can help. If the treatment is not successful, it would not jeopardize the success of later surgery.
The type of surgical procedure(s) is dependent on the patient, the diagnosis, and the goals of surgery. Surgical removal of an inferior disc may involve a limited laminotomy and partial disc excision. The disc fragments are removed and the nerve is decompressed. Micro-discectomy is often a preferred procedure requiring smaller incisions resulting in reduced scarring and a more rapid recovery. If the entire disc is removed, spinal column instability may warrant fusion. Patients who are obese, smoke, or who have psychological problems exhibit lower rates of success. Smoking in particular negatively impacts the process of fusion and healing in general. Spinal fusion may be combined with spinal instrumentation, the use of medically designed hardware (e.g. screws, cages). Artificial disc The Food and Drug Administration has approved an artificial spinal disc for use in treating pain associated with degenerative disc disease (DDD). The device is intended to replace a diseased or damaged intervertebral disc. The first of its kind, the device is called the Charité artificial disc and is manufactured by DePuy Spine, Inc. It has been approved for use in patients who have DDD at one level in the lumbar spine (from L4-S1) and who have had no relief from low back pain after at least six months of non-surgical treatment. Read more from the FDA about this new treatment option. Laser is used in different fields of medicine with unique advantages. In treatment of lumbar disc disease, it is useful and advantageous. Laser discectomy is an outpatient procedure with one-step insertion of a needle into the disc space. Disc material is not removed; instead, nucleus pulposus is burned by the laser. In comparison to other discectomy procedures, laser discectomy is free of postoperative pain syndromes. It is, however, underused.
The aim of percutaneous laser disc decompression (PLDD) is to vaporize a small portion of the nucleus pulposus of an intervertebral disc, thereby reducing the volume of a diseased disc and the pressure within it. A small amount of tissue is excised from the center or nuclear part of the disc, which is believed to exert an effect on a noncontiguous portion of nucleus that is protruding through the annulus fibrosus and abutting an exiting nerve root. First described by Hijikata in relation to the percutaneous discectomy method, the central cavity created by laser is believed to allow the nuclear protrusion to move back within the disc. A small change in disc nucleus volume can exert disproportionately large changes on the disc. Yunezawa and coworkers first demonstrated significant alterations in intradiscal pressure in response to vertical load after Nd:YAG laser treatment. Their study also reported the equivalency of laser to aggressive manual curettage. Choy and Altman (1995) reported greater than 50% reduction of intradiscal pressure in response to load following treatment with 1000 J of Nd:YAG laser energy. Prodoehi and associates reported similar results using 1200 J from the holmium (Ho):YAG laser. No specimen is available to weigh after laser discectomy; therefore the amount of disc removed can only be approximated. By calculating the geometry of the laser tract, Choy and Altman (1995) estimated that 1000 J of Nd:YAG laser energy vaporized 98.52 mg of disc. Lane and coworkers, who compared effectiveness of 1200 J each of carbon dioxide, argon, and Ho:YAG laser energy, reported that Ho:YAG was superior, ablating 2.4 g of disc tissue. By comparison, a clinical trial of automated percutaneous discectomy reported removal of 2-7 g of disc tissue with a suction cutting device. Quigley's group compared an automated device, Nd:YAG laser, and Ho:YAG laser and clearly demonstrated the superiority of the automated device in removing the greatest mass of tissue.
Ascher and Choy and colleagues performed the first Nd:YAG laser discectomy in the mid-1980s. Their procedure consisted of fluoroscopically guided insertion of a needle into the disc space to be treated and threading of a thin laser fiber through the needle into the disc space. Activation of laser with delivery of approximately 1200 J of energy (in short bursts to avoid heating the adjacent tissues) into the disc cavitated the nucleus and ablated a small amount of tissue. The products of vaporization (steam and carbon particles) were allowed to escape through the spinal needle surrounding the laser fiber. At the end of the procedure, the needle site was covered with an adhesive bandage, and the patient was discharged. These investigators postulated that removal of even a small volume of tissue from the disc resulted in a large drop in intradiscal pressure. They believed this may be the mechanism responsible for prompt and marked pain relief in patients who were treated for sciatica secondary to degenerative disc protrusion and contained herniations. They suggested that the procedure would not be useful for patients with uncontained herniations or sequestered disc fragments outside the disc space loose in the spinal canal. Ascher, Choy, and others have performed this procedure in more than 1000 patients. Long-term pain relief has been reported in 70-80% of patients. The procedure is appealing in that it is performed on an outpatient basis with conscious sedation. PLDD with a 1.06 Nd:YAG laser has been approved by the US Food and Drug Administration (FDA). Generally, laser discectomy is believed to be equivalent to other percutaneous discectomy procedures, such as chemonucleolysis and automated percutaneous lumbar discectomy (APLD) using a reciprocating suction cutter.
This minimally invasive technique can be performed in patients who need surgical intervention for disc herniation with leg pain. Exclusion criteria include stenosis or facet hypertrophy and disc fragment. Relative contraindications are progressive neurological deficit, involvement in workers' compensation cases, and previous surgery at the same disc level. In general, the herniation must have continuity with the parent disc; rupture of the annulus is not a contraindication. All patients must be considered on an individual basis. Criteria for inclusion are undergoing continuing change. What is unacceptable now may, with modifications, become acceptable in the future. During this early stage of PLDD, not adopting a fixed position is important.
The most extensive experience in the literature was published by Choy and Ascher, who used an Nd:YAG laser. They observed 333 patients for a mean duration of 26 months. The success rate was 78.4% (as measured by a good or fair response) according to MacNab. Siebert (1995) reported on his first 100 patients treated with Nd:YAG. The success rate was 78% at mean follow-up point of 17 months. Davis reported an 85% success rate with the KTP laser, with success rate defined as minimal discomfort and the ability to return to gainful employment (follow-up duration was not specified). Yeung (2000) reported preliminary assessment of more than 1000 patients whose herniated lumbar discs were treated with KTP laser. The reported success rate (good or excellent results) was 84%. No specifics were supplied. Sherk and colleagues used Ho:YAG laser in a comparison of laser discectomy and conservative treatment. No differences were noted between treated and control groups. They concluded that laser discectomy is a safe procedure that appears to be effective in relieving symptoms in some patients. The author uses Ho:YAG laser, and successful results are approximately 80% (comparable to those of other investigators). According to Kramer, the best clinical results were found in discographic stages 7 and 8. In cases of epidural leak of contrast medium and in cases of total degeneration, the clinical results were significantly poor (stages 6 and 9). The literature now includes 23 well-documented cases of erectile dysfunction caused by spinal cord disc herniation. PLDD is a minimally invasive procedure that that can be used to treat such herniation. From 1991-1993, 31 patients with herniated cervical discs were treated with PLDD. In 1990, a few of these patients were treated with the Nd:YAG laser with no complications. Since 1991, the authors have used the Ho:YAG laser; 28 of 31 patients experienced pain relief in a 6-week follow-up period. PLDD is a viable therapy for cervical discs.
Discitis is the only documented complication of laser discectomy. In 1993, Choy's group tabulated the world experience with laser discectomy. Choy reported 2 cases of discitis. Subchondral marrow abnormalities may occur in the vertebral endplates after Ho:YAG laser discectomy. Possible causative mechanisms include thermal injury and photoacoustic shock. However, these changes probably do not affect surgical outcomes and appear to resolve over time.
The rapid acceptance of minimally invasive surgery in the United States has occurred largely without statistical proof of its superiority over traditional methods. All members of the healthcare field now see the need for valid outcome studies supporting the efficacy of new treatment techniques. PLDD will gain wide acceptance only if it is demonstrated statistically to be a safe and effective alternative treatment to lumbar disc herniation. Various laser wavelengths have been used, but no consensus exists regarding which is most efficacious. Good candidates for this procedure have a classic clinical syndrome and neuroimaging evidence. In cases of ruptured posterior longitudinal ligament (ie, epidural leak of contrast medium in discography), PLDD is not indicated. Indications for the operation first of all depend on the clinical symptoms, but the success of the operation depends on the discographic findings. Percutaneous microdecompressive endoscopic cervical discectomy with laser thermodiscoplasty has proven to be a safe and efficacious minimally invasive procedure in one case series of patients with herniated cervical discs with unilateral radicular pain. PLDD performed with CT scan and fluoroscopic guidance appears to be a safe and effective treatment for herniated intervertebral discs. It is minimally invasive, is performed in an outpatient setting, requires no general anesthesia, results in no scarring or spinal instability, reduces rehabilitation time, is repeatable, and does not preclude open surgery should that become necessary. Lumbar herniation causing loss of bowel or bladder control, or major lower extremity deficit, requires immediate surgery. These symptoms are caused by nerve root compression. Cauda Equina Syndrome is a serious disorder that may be caused by a large central herniation. The cauda equina begins at the end of the spinal cord. The cauda sac is filled with nerves resembling the tail of a horse. When this sac is compressed the patient may present with the following symptoms: low back pain, bilateral lower extremity weakness, radiculopathy (pain from a nerve root), and incontinence. When these symptoms present, surgery is required immediately. Most herniated discs often do not require surgical intervention and respond quite nicely to non-surgical treatments (within 6 weeks). Although degenerative disc disease is relatively common in aging adults, it seldom means a surgical sentence. When medical attention is warranted, the majority of patients respond well to non-operative forms of treatment. By eliminating tobacco and maintaining a fitness regiment along with a good diet, most people can enjoy the benefits of a healthy spine.
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