1. Does degeneration and disc herniation automatically warrant a surgery?

The short answer is NO. Although degeneration, bone spurs and disc herniations can look alarming on x-ray and MRI, they are not always relevant to one’s pain and dysfunction. In fact, a 2015 review ⁽³⁾ says what you see on your films most likely has nothing to do with your pain. In other words, pain, along with degenerative changes, are not good enough reasons for back surgery. Read more about this topic here.

2. When to consider surgery for back and leg pain?

Although there are spinal emergencies that need immediate surgical evaluations, sciatica caused by herniated disk or spinal stenosis ALMOST NEVER requires back surgery. ⁽⁴⁾ It is known that even patients with a massive disc herniation can do very well under conservative treatment. ⁽⁵⁾

If you have leg pain without neurological symptoms, then you should be treated conservatively. ⁽⁶⁾ Having a negative straight leg raise test means surgery most likely won’t work for you. ⁽⁷⁾ If you have sciatica, you are over 40, and you have severe leg pain, surgery probably won’t work for you. ⁽⁸⁾ When your MRI only shows a little compression on the nerve, you likely will do worse after surgery. ⁽⁹⁾ Most patients with chronic low back pain will NOT benefit from surgery. ⁽¹⁰⁾

Surgery may be appropriate when you have

1. severe or worsening neurological deficits ⁽⁴⁾ OR
2. leg pain that is worse than back pain AND positive straight leg raise test AND none-responsive to conservative therapy in 4-12 weeks AND imaging correlates with the symptoms. ⁽⁴⁾

3. Does back surgery have superior results compared to conservative care?

So far, most of the studies available to answer this question are low quality studies. The consensus is that long-term results of back surgery are NOT superior to conservative treatment. ^(8,11,12) As of 2016, back surgery cannot be confidently recommended for lumbar spinal stenosis, because it doesn’t provide better outcomes, and the side effects are much higher than conservative treatment (24% vs. 0%). ⁽¹³⁾

On average, one year after having a low back discectomy for disc herniation, a quarter of the patients have another herniation at the same level that received the surgery. ⁽¹⁴⁾ 22% patients have worsening low back pain in a year, and recurrent low back pain is as high as 36% among these people. ⁽¹⁵⁾

Fusion surgery is in your favor if you have a large compression onto the space surrounding the spinal cord, specifically greater than 1/3 thecal sac compression. ⁽⁹⁾ However, 1 out 10 patients will be operated on again in a couple years, and 1 out of 5 will be operated on again in 10 years. ⁽¹⁶⁾ Basically, the studies are saying patients do pretty well after the fusion surgery…the outcomes are good…except that a good portion of them will have to come back and get the surgery again in the future. ⁽¹⁷⁾ So therefore, make sure it’s risk you are willing to take if surgery is what you opt for.

The Bottom Line

If you have back pain and you visit a surgeon, there is a good chance you will end up having back surgery, as demonstrated by a 2013 study. ⁽¹⁸⁾ (see graphic below). If you see a chiropractor first, there is a good chance you will avoid the back surgery that may not be necessary in the first place.

The bottom line is if you are experiencing back pain, find a good chiropractor who is familiar with the research, who knows what to look for, who knows how to check for the different indicators and neurological signs, and recommend care (surgical or not) based on existing evidence.

References:

1. Rajaee SS, Bae HW, Kanim LE, Delamarter RB. Spinal fusion in the United States: analysis of trends from 1998 to 2008. Spine. 2012 Jan 1;37(1):67-76. [PubMed]
2. Cowan JA Jr, Dimick JB, Wainess R, Upchurch GR Jr, Chandler WF, La Marca F. Changes in the utilization of spinal fusion in the United States. Neurosurgery. 2006 Jul;59(1):15-20. [PubMed]
3. Brinjikji W, Luetmer PH, Comstock B et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015 Apr;36(4):811-6. [PubMed]
4. Atlas SJ, Deyo RA. Evaluating and managing acute low back pain in the primary care setting. J Gen Intern Med. 2001 Feb; 16(2):120-31. [PubMed]
5. Benson RT, Tavares SP, Robertson SC, Sharp R, Marshall RW. Conservatively treated massive prolapsed discs: a 7-year follow-up. Ann R Coll Surg Engl. 2010 Mar;92(2):147-153. [PubMed]
6. Atlas SJ, Nardin RA. Evaluation and treatment of low back pain: an evidence-based approach to clinical care. Muscle Nerve. 2003 Mar;27(3):265-84. [PubMed]
7. Sedighi M, Haghnegahdar A. Lumbar disk herniation surgery: outsome and predictors. Global Spine J. 2014 Dec;4(4):233-244. [PubMed]
8. Lequin MB et al. Surgery versus prolonged conservative treatment for sciatica: 5-year results of a randomized controlled trial. BMJ Open 2013;3:e002534. [BMJOpen]
9. Lurie JD et al. Magnatcie resonance imaging predictors of surgical outcome in patients with lumbar intervertebral disc herniation. Spine. 2013 Jun 15;38(14):1216-25. [PubMed]
10. Last AR, Hulbert K. Chronic low back pain: evaluation and management. Am Fam Physician. 2009 Jun 15;79(12):1067-74. [PubMed]
11. Schoenfeld AJ, Weiner BK. Treatment of lumbar disc herniation: evidence-based practice. Int J Gen Med. 2010;3:209-214. [PubMed]
12. Jacobs WCH et al. Surgery versus conservative management of sciatica due to a lumbar herniated disc: a systemic review. Eur Spine J. 2011 Apr;20(4):513-522. [PubMed]
13. Zainea F et al. Surgical versus non-surgical treatment for lumbar spinal stenosis. Cochrane Database Syst Rev. 2016 Jan 29;1:CD010264. [PubMed]
14. Lebow RL et al. Asymptomatic same-site recurrent disc herniation after lumbar discectomy: results of a prospective longitudinal study with 2-year serial imaging. Spine. 2011 Dec 1;36(25):2147-51. [PubMed]
15. Parker SL et al. Incidence of low back pain after lumbar discectomy for herniated disc and its effect on patient-reported outcomes. Clin Ortho Relat Res. 2015 Jun;473(6):1988-99. [PubMed]
16. Kim CH et al. Reoperation rate after surgery for lumbar spinal stenosis without spondylolisthesis: a nationwide cohort study. Spine J. 2013 Oct;13(10):1230-7. [PubMed]
17. Liang L, Jiang WM, Li XF, Wang H. Effect of fusion following decompression for lumbar spinal stenosis: a meta-analysis and systematic review. Int J Clin Exp Med. 2015;8(9):14615-14624. [PubMed]
18. Keeney BJ, Fulton-Kehoe D, Turner JA, Wickizer TM, Chan KC, Franklin GM. Early predictors of lumbar spine surgery after occupational back injury: results from a prospective study of workers in Washington State. Spine. 2013 May 15;38(11):953-64. [PubMed]

About the Author

Dr. Lily Semrow is a Board Certified Chiropractic Neurologist who focuses on Neuro-Structural Correction. She has a B.S. in Nutrition and a doctorate in Chiropractic. She has a passion for serving families, and helping people who could not get better through traditional and alternative means.

Want to keep up with future posts?

The post 3 Questions You Must Ask Before Back Surgery – Chiropractor in Holland appeared first on Holland, MI Chiropractors | Brain and Body Chiropractic.

Heroin addiction came up in the Democratic debate before the holidays. All three candidates acknowledged that prescription opioid pain medications, such as Vicodin and Oxycontin, often open the door to heroin abuse, and we need to tighten up regulations on opioid prescriptions.

Tighter regulation is a great start, but that only solves half of the problem. The thing is, people are in pain. They choose pain medications with serious side effects, because they are not aware of or are apprehensive about alternative methods for pain relief, including chiropractic adjustments.

Chiropractic Myth

Traditional chiropractors tell their patients that chiropractic works by realigning the spinal bones and removing pressure on the nerves. This statement is, at its best, an outdated and oversimplified view of human body.

Current research suggests that a mechanistic model does not adequately explain Chiropractic, and we ought to take neurophysiology into consideration.

The Force

Chiropractic adjustments introduce a mechanical force to a joint that, in turn, kick starts a chain of neurological reactions. (1) Think about a chiropractic adjustment as the force needed to activate certain sensors of the nervous system, rather than the force to move a bone. I know the mechanical, bone-aligning concept is much easier to grasp, but reality is more complicated.

3 Mechanisms Of How A Chiropractic Adjustment Relieves Pain

Our nervous system has a peripheral (yellow) and a central (purple) component. The long, skinny purple portion represents the spinal cord, and the rest of the purple part is the brain. Evidence has suggested that chiropractic adjustments affect ALL three parts of our nervous system.

1. Peripheral mechanism:

An animal study (2) had found that one single adjustment was able to significantly reduce inflammatory proteins (cytokines) in the blood. These cytokines stimulate sensors on nerve fibers that cause one to have pain and increase sensitivity to pain. (3)

2. Spinal mechanism:

Chiropractic adjustments activate sensors in the muscles (Golgi organs and muscle spindles) (1) that send signals through large sensory fibers. These large sensory fibers are thought to inhibit pain fiber signaling at the spinal cord level. (4)

3. Brain-based mechanism:

Advancing technology has allowed us to directly observe brain activity by measuring blood flow. This gives us direct evidence of how a specific therapy affects the brain. A recent study (5) using functional magnetic resonance imaging (fMRI) had observed that chiropractic adjustment changed the connectivity between brain regions that process pain.

Why Do We Care

1. Manual therapists often depend upon an alleged biomechanical mechanism in evaluation and treatment. (1) Unnecessary effort may be spent to correct the biomechanical fault (e.g. a disc bulge), while it has little to do with what the patient is experiencing. More on this topic in my previous blog post on spinal degeneration.
2. The neurophysiological model allows the clinicians to consider other potential mechanisms in the treatment of pain.
3. Understanding the mechanisms behind the treatment help build patient confidence and trust in their chiropractors.

References:

1. Bialosky JE, Bishop MD, Price DD, Robinson ME, George SZ. The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model. Man Ther. 2009 Oct;14(5):5310538. [PubMed]
2. Teodorczyk-Injeyan JA, Injeyan HS, RueggR. Spinal manipulative therapy therapy reduces inflammatory cytokines but not substance P production in normal subjects. J Manipulative Physiol Ther. 2006;29:14-21. [PubMed]
3. Sommer C, Kress M. Recent findings on how proinflammatory cytokines cause pain: peripheral mechanisms in inflammatory and neuropathic hyperalgesia. Neurosci Lett. 2004 May 6;361(1-3):184-7. [PubMed]
4. Moayedi M, Davis KD. Theories of pain: from specificity to gate control. J Neurophysiol. 2013 Jan;109(1):5-12. [PubMed]
5. Gay CW, Robinson ME, George SZ, Perlstein WM, Bishop MD. Immediate changes following manual therapy in resting state functional connectivity as measured by magnetic resonance imaging (fMRI) in subjects with induced low back pain. J Manipulative Physiol Ther. 2014 Nov-Dec;37(9):614-627. [PubMed]

About the Author

Dr. Lily Semrow is a Board Certified Chiropractic Neurologist who focuses on Neuro-Structural Correction. She has a B.S. in Nutrition and a doctorate in Chiropractic. She has a passion for serving families, and helping people who could not get better through traditional and alternative means.

Want to keep up with future posts?

The post How Do Chiropractic Adjustments Relieve Pain? – Chiropractor in Holland appeared first on Holland, MI Chiropractors | Brain and Body Chiropractic.