Slip Disc with Sciatica – Newer Non-Surgical Treatment
Neeraj Jain
Senior Consultant Spine & Pain Specialist, Spine & Pain Clinics & Sri Balaji Action Medical Institute,
Max Hospital, Pitampura, New Delhi, India
Abstract: Patients who are not helped by weeks of conservative therapy are often referred for surgery on the premise that further non-operative care
is unlikely to help. Ideally, a patient with low back pain that has persisted beyond a four-week period should be referred to a multidisciplinary pain
centre. With interventional pain management patients are getting back to life. It has both diagnostic and treatment values, as sometimes all
investigations put together do not give the exact diagnosis. Early aggressive treatment plan of pain has to be implemented to prevent peripherally
induced CNS changes that may intensify or prolong pain making it a complex pain syndrome. Only 5% of total LBP patients would need surgery &
20% of discal rupture or herniation would need surgery. Nonoperative treatment is sufficient in most of the patients, although patient selection is
important even then. Depending upon the diagnosis one can perform & combine properly selected percutaneous fluoroscopic guided procedures
with time spacing depending upon patient‘s pathology & response to treatment.
INTRODUCTION
The inter-vertebral discs are made-up of two concentric layers, the inner
gel like Nucleus Pulposus and the outer Annulus fibrosus. As a result of
advancing age, the nucleus looses fluid, volume and resiliency and the
entire disc structure becomes more susceptible to trauma and compression.
This condition is called as degeneration of the disc. The disc then is highly
vulnerable to tears and as these occur, the inner nucleus pulposus protrudes
through the fibrous layer, producing a bulge in the inter-vertebral disc.
This condition is named as herniated disc. This can then cause compression
to the spinal cord or the emerging nerve roots and lead to associated
problems of Sciatica radiating pain from back to legs in the distribution
of the nerve. Other symptoms could be weakness, tingling or numbness
on the areas corresponding to the affected nerve. Sometimes bowel or
bladder sphincter compromise is also present, which is made evident for
urine retention and this need to be taken care as an emergency.
“Do not take your back for guaranteed” says Dr. Jain who is heading
Spine & Pain Clinic, New Delhi. One can prevent back pain with spine
care and avoiding risk factors like bad postures like slouch & couch,
osteoporosis, obesity, smoking, prolonged driving, sedentary lifestyle, too
heavy or too little exercise, bad spine postures and wrong way of pushing
or lifting heavy objects.
While spinal arthritis is the common reason of young age back pain at
prime of their carriers including some sports & film celebrities, disc
diseases including slip disc is prevalent in all age groups, in young age
due to trauma & in old age due to degeneration. Also, it has to be known
that those who had a herniated disc have 10 times more chances of having
another herniation than the rest of the population.
The first steps to deal with a herniated or prolapsed lumbar disc are
conservative. These include rest, analgesic and anti-inflammatory
medication and in some cases physical therapy. At this point it is convenient
to have some plain X-rays done, in search of some indirect evidence of
the disc problem, as well as of degenerative changes on the spine.
If in a few days these measures have failed, the diagnosis has to be
confirmed by means of examinations that give better detail over the troubled
area, as the MRI, CT which will show the disc, the space behind it and in
the first case, the nerves. In some instances the EMG (electromyography)
is also of great value, as this will show the functionality of the nerves and
muscles.
Provocative Discography: coupled with CT: A diagnostic procedure
& prognostic indicator for surgical outcome is necessary in the evaluation
of patients with suspected discogenic pain, its ability to reproduce
pain(even with normal radiological finding), to determine type of disc
herniation /tear, finding surgical options & in assessing previously
operated spines.
NEED FOR NON-SURGICAL OPTIONS
Outcome studies of lumber disc surgeries documents, a success rate
between 49% to 95% and re-operation after lumber disc surgeries ranging
from 4% to 15%, have been noted. “In case of surgery, the chance of
recurrence of pain is nearly 15%. In FBSS or failed back surgery the
subsequent open surgeries are unlikely to succeed.
Reasons for the failures of conventional surgeries are:
1. Dural fibrosis
2. Arachnoidal adhesions
3. Muscels and fascial fibrosis
4. Mechanical instability resulting from the partial removal of boney &
ligamentous structures required for surgical exposure &
decompression
5. Presence of Neuropathy.
6. Multifactorial etiologies of back & leg pain , some left unaddressed
surgically.
NON-SURGICAL TREATMENTS
Patients who are not helped by weeks of conservative therapy are often
referred for surgery on the premise that further non-operative care is
unlikely to help. Ideally, a patient with low back pain that has persisted
beyond a four-week period should be referred to a multidisciplinary pain
centre. Early aggressive treatment plan of pain has to be implemented to
prevent peripherally induced CNS changes that may intensify or prolong
pain making it a complex pain syndrome.
Depending upon the diagnosis one can perform & combine properly
selected percutaneous fluoroscopic guided procedures with time spacing
depending upon pt‘s pathology & response to treatment. Different non
surgical interventions can be employed successfully:
• Epidural Steroid Inj. Via interlamminar/ transforaminal or caudal
route.
• BALLOON NEUROPLASTY & Nerve root sleeve block.
• Epidurogram & Epidurolysis.
• Nucleoplasty- Laser, Coblation, Drill, RF Biacuplasty
decompressions.
• Ozone Discolysis
• Facet Joint Block & RF Denervation
• SI Joint Block
Once the diagnosis has been confirmed, one of the best alternatives existing
today is the Ozone Discolysis as the results obtained are excellent and
practically has no complications. In most patients left with pain killers as
the only treatment, the symptoms eventually disappear, only that this could
take weeks to months. Ozone speeds up these developments, seen the
same result in a few weeks. The problem has to be seen and approached
integrally and frequently the combination of therapies has to be used,
most frequently physiotherapy.
OZONE DISC TREATMENT
Ozone Disc Treatment a revolutionary newer technology cures many of
the patients of slip disc & sciatica, as ozone’s nascent oxygen atom shrinks
the disc, taking away pressure from pain sensitive nerves. It is non surgical,
safe & effective alternative to open spine surgery, now the treatment of
choice for prolapsed disc (PIVD) done under local anaesthesia in a day
care setting with success rate of 80% in early degenerative disc disease.
This procedure is ideally suited for cervical & lumbar disc herniation
with nerve compression. Total cost of the needle procedure is much less
than that of surgical discectomy. Patient does not require bed rest for
more than a day or two & prolonged absence from work realizing the
importance of time, at much lower cost with almost no complications.
This procedure is done under radiological guidance for precise needle
placement and best results. Then patient is given advice for spine care &
healthy habits. This technology is latest & many people including medical
caregivers don’t know about it. It has benefited millions in developed
world and is now available in India also.
Only 5% of total low back pain patients would need surgery & 20% of
Various Stages of Disc Disease
Sciatica- Back pain radiating to Leg
Cervical Disc Ozone Injection Disc Cervical Ozone Injection
Cervical Disc Pressing Nerve Disc – IDET
Postero-lateral Approach for Lumbar Disc AP & Lat. Views of Intradiscal needle
Needle Discectomy for Slip Disc Ozone Chemonucleolysis
discs rupture or hernia patient would need surgery. Non-operative treatment
is sufficient in most of the patients, although patient selection is important
even then. If despite the ozone therapy the symptoms persist, Percutaneous
intradiscal decompression can be done with Drill Discectomy/ Laser or
Coblation Nucleoplasty/ Biacuplasty are good alternatives before open
surgerical Discectomy which has to be contemplated in those true
emergencies, as mentioned above as the first choice.
DEKOMPRESSOR DRILL DISCECTOMY
A mechanical device cuts & drills out the disc material debulking the
disc reducing nerve compression curing Sciatica & Brachialgia. It comes
in needle size of 17G for lumbar discs & 19 G for cervical discs. In
lumbar region postero-lateral approach is used & in cervical discs anterolateral
approach is used. In Biacuplasty radiofrequency energy is used in
bipolar manner heating & shrinking the disc & making it harder as well
for weight bearing. In Laser or Coblation Nucleoplasty energy is used
to evaporate the disc thereby debulking to create space for disc to remodel
itself.
Dr. Neeraj Jain‘s massage is “pain is real and treatable- there is no merit
in suffering” “No one needs to suffer as so many good and effective
treatments are now available at specialty pain clinics”. You must see a
pain specialist if you still suffer from pain after a month of conservative
treatment. Sooner your pain is managed better are the overall results.
With interventional pain management patients are getting back to normal
life.
BIBLIOGRAPHY
1. Olmarker K, Rydevik B. Pathophysiology of sciatica. Orthop Clin North Am 1991; 22:223-234.
2. McCarron RF, Wimpee MW, Hudkins PG, Laros GS. The inflammatory effect of nucleus pulposus:
a possible element in the pathogenesis of low-back pain. Spine 1987; 12:760-764
3. Bogduk N, Aprill C, Derby R. Epidural steroid injections. In: White AH, eds. Spine care. Vol 1. St
Louis, Mo: Mosby, 1995; 322-343.
4. Dussault RG, Kaplan PA, Anderson MW. Fluoroscopy-guided sacroiliac joint injections. Radiology
2000; 214:273-277.
5. Kinard RE. Diagnostic spinal injection procedures. Neurosurg Clin N Am 1996; 7:151-165
6. Deer T, et al.. Initial experience with a new rechargeable generator: A report of twenty systems at
3 months status postimplant in patients with lumbar postlaminectomy syndrome. Abstracts of the
9th Annual Meeting of the North American Neuromodulation Society, Nov 10-12, 2005, Washington,
D.C.
7. Dr. Neeraj Jain. Balloon neuroplasty: expanding the scope and effectiveness of interventional
techniques for management of pivd with disco-radicular conflict in new and previously failed
interventions or surgeries. 1st WIPF 2013, 911939 _ WIPF_DEF.indd 67, 8/11/13 17:27
Correspondence: Dr Neeraj Jain, Senior Consultant Spine & Pain
Specialist, Spine & Pain Clinics & Sri Balaji Action Medical Institute,
Max Hospital, Pitampura, New Delhi & Sant Parmanand Hospital, New
Delhi. e-mail: managepain@yahoo.com www.spinenpain.com