Herniated Lumbar Disc Treatment
There are many treatments for a herniated disk. We will discuss a few in this section however this is not intended to be a complete list of treatment options available. The severity of the disc herniation and symptoms is usually what determines the best options. It is important to remember that symptoms of a herniated disc are caused by both the mechanical narrowing of the canal and the inflammation caused by disc.
- Anti -inflammatory Medications: These medications are often very effective in treating the symptoms of acute back strain. The most common group of these medications is known as non-steroidal anti-inflammatory medications (NSAIDs). There are many of these medications available both over the counter as well as by prescription. Common examples are ibuprofen (Motrin, Advil), aspirin, and naproxen (Aleve, Naprosyn). These medications work by reducing the formation of inflammatory chemicals in our bodies called prostaglandins. In 2005, the Food and Drug Administration placed a “black box warning” on all NSAIDS. The purpose was to alert patients and doctors about the association between NSAIDS and an increased risk of heart attack, stroke, gastrointestinal bleeding, and a serious skin reaction. It is very important to first check with your doctor prior to starting an NSAID to be sure it is safe for you.
- Steroid Anti-Inflammatory Medications: At times, with severe flare ups of pain, your doctor may consider giving you a steroid type anti-inflammatory medicine. Prednisone and methyprednisolone (Medrol) are commonly used. These medications are strong anti-inflammatory drugs and are usually used over a short period of time such as 7-10 days in a decreasing dose (steroid taper). In some types of arthritis long term use of these medicines are necessary. As these medicines have significant side effects when taken for longer periods of time, these are not used as a constant medicine in most people with disc herniations. As with all medications it is important to check with your doctor before starting any medication to be sure this is safe for you.
- Acetaminophen (Tylenol): Acetaminophen is a medication that reduces pain in a different manner than the NSAID or steroids. It has minimal anti-inflammatory effects. Acetaminophen can be effective in controlling the pain. As many over the counter medications such as for headache, allergy, sinus and colds contain acetaminophen it is very important to read the labels of the medicines you are taking and know what you are taking. Acetaminophen overdose has occurred in people taking several different over the counter medications that contain this medicine. Also, some of the common prescribed narcotic type pain medications such as Vicodin, Lortab, Percocet and Endocet contain acetaminophen. As acetaminophen can affect the liver, it is important to check with your doctor particularly if you have any conditions affecting the liver, to see if it is safe for you to take this medication.
- Anti-Epileptic Drugs (AEDs): Several medications in this group have been used for years to treat pain caused by irritated nerves. A herniated disc can result in pinching of the spinal nerves; hence, several of these medications can be helpful in reducing the symptoms of a herniated disc. Two of the more common of these medications are gabapentin (Neurontin) and pregabalin (Lyrica). There are several reasons these medications reduce the pain of a herniated disc; however, the underlying effect is to reduce the firing of irritated nerves. These medications are generally quite safe although the frequently cause sedation which can increase the risk of falling. Other common side effects include nausea and swelling. These medicines are only available with a prescription from your doctor.
- Opioid (Narcotic) Pain Relievers: At times the symptoms of a herniated disc can prove difficult to treat with simpler means. In some people the careful use of a limited dose of opioid pain medications can be effective in controlling their pain. Consideration of these medications is only after other treatments have been tried. Frequently these are used if the only other option is surgery. While there are many of these medications, two of the more common medicines used in this case are hydrocodone/APAP (Vicodin, Lortab) and oxycodone/APAP (Percocet, Endocet). Both of these medicines contain a narcotic medication and acetaminophen (APAP). It is important to realize this as many over the counter medicines also contain acetaminophen. These medicines are relatively short acting 3-4 hours but can be helpful in spinal stenosis where the symptoms often only occur with certain activities. Tramadol (Ultram) is mild narcotic type medication. Although it is not a legally controlled medication, it does have some effects of the opioid type medicines. These medicines can be habit forming, and can cause dependency and tolerance. They do cause sedation, slowing of reflexes and must be used with great caution when considering driving or using potentially dangerous equipment. They also can increase the risk of falling. Other common side effects including nausea and constipation. Tramadol should be used with caution if you are taking an antidepressant medicine as the combination of tramadol with some of these medications can result in seizures. As many of these types of medications have been misused, many physicians are reluctant to prescribe them. If you and your doctor decide to start one of these medicines, the doctor may ask you to sign an opioid contract stating the risks of the medications and that only your doctor will prescribe these medicines. You may also be asked to submit urine screen from time to time.
- Other Medications: The medicines listed above are only a small sample of some of the medicines that can be useful to treat a herniated disc. Medicines such as muscle relaxants, some of the anti-depressant medicines, medicines to treat osteoporosis among others are also common used for the treatment of this and other conditions.
- Physical Therapy: Physical therapy can be a very useful technique both in the treatment and also in the prevention of pain and symptoms from a herniated disc. Strengthening the “core” muscles including abdominal, pelvic back and hip muscles can help to reduce stress and forces on the spine. Improved posture and mechanics of daily activities such as walking, standing, lifting and others also can be helpful in reducing pain. Abnormalities of gait and balance are also a concern in some people with herniated discs. This can lead to increased risk of falling and injury. Therefore working on gait training and balance techniques is also a very important goal for physical therapy. Working on home exercise programs and general conditioning including weight reduction are an important component of any physical therapy program for more chronic medical conditions. Often, the results of physical therapy are very dependent upon the person’s motivation to “keep with the program”. At CPMC we are strong advocates of biomechanical therapies such as physical therapy. We very frequently will include physical therapy as part of your program for improvement. We work closely with several physical therapists in the Charlottesville and outlying areas. A great advantage that your physical therapist has is that they are with you for extended periods of times. We keep in contact with the physical therapists as they can inform us of your condition and findings with their treatments. This close relationship helps us better understand your condition as there are many components to back pain that can contribute to your pain. Our philosophy is the better we understand the underlying causes of your pain the better we will be able to come up with effective solutions.
- Chiropractic care: Chiropractic care also works to achieve many of the benefits of physical therapy. Chiropractic care also adds manual therapies to help with postural effects of herniated discs. Many of the home exercise programs and modalities such as TENS (discussed below) are also used by chiropractors. Patients sometimes feel that their medical doctors may have concerns about this option of care. There is no doubt that there are real benefits of chiropractic care. Just as with any other medical treatment there are indications for chiropractic care. Some people benefit from the treatments and some people do not. This is no different than any treatment for back pain. Unfortunately, nobody has “the answer” for all back pain. We have worked with specific chiropractic doctors in the area for years and work in concert with them to afford you the best chances of an optimal outcome.
- TENS: TENS is a common treatment used for many different pain problems. With TENS a small electrical current is used to help reduce muscle spasm and theoretically help to block some of the painful messages sent to the brain by peripheral nerves. The device is simple. It consists of the TENS unit which is a small plastic box that generates the electrical stimulus with batteries. The TENS unit is generally slightly larger than most cell phones. This is attached to wires that carry the electrical signal to surface electrodes that you attach to your skin like band aids. Many theories exist to explain the effects of TENS units from blocking the electrical impulse of nerves to the release of endorphins which are the body’s own pain reducing chemicals. TENS can be effective for short term use however many people find that with time they become tolerant to the electrical stimulation. However in some people the TENS unit can help to relieve pain for long periods of time. There are several advantages of using the TENS unit including: patient controlled (use it when you want to use it), noninvasive (not a pill or an injection), and almost no side effects. Frequently people are referred to a physical therapist who demonstrates the proper use of the TENS unit. They can also arrange for rental or purchase of these units.
- Epidural steroid injections are cortisone injections used to treat pain in the low back and legs from a herniated disc. The term epidural is frequently associated with labor epidurals and epidural anesthesia. Although epidural steroid injections involve the injection of steroids in the epidural space, the purpose is not to numb the nerves but to reduce swelling of the degenerative disc and the nerve. Epidural steroid injections have been done for many years. In fact, the first documented epidural steroid injection was in 1952. The technique has been perfected over the years and we now use live x ray (fluoroscopy) to guide the injection. The x ray allows for accuracy and precision in needle placement. The two basic techniques are the interlaminar and transforaminal epidural steroid injection. The interlaminar epidural steroid injection is performed in the midline and is intended to spread cortisone over a wider area and is frequently used when there is pain on both sides. The transforaminal epidural steroid injection is performed on the side of the spine and the cortisone is injected into the small canal where the nerve actually exits the spine. These injections are often repeated up to three times over a period of several weeks or months. The concept is that with each injection there is further reduction in swelling and pressure on the nerve. Clinically this is seen as a progressive or booster response. These injections can also be used to help in more clearly diagnosing the cause of the pain when there are several levels of degenerative disc disease.
Surgery: Many different types of surgical procedures are offered for the treatment of a herniated disc. In general these procedures involve removing disc material to increase the size of the narrowed spinal canal.