As medical science continues to evolve it's always good to reflect on what was done in days gone past and consider whether sometimes our predecessors got it right. A recent article in the journal of Bone and Joint Surgery (http://www.bjj.boneandjoint.org.uk/content/89-B/6/782), a prestigious international journal, provides an interesting consideration of the surgical versus conservative treatment debate. Admittedly a small sample size limits the power of this investigation but it does provide an interesting discussion.
The reference article delineates the various stages and sizes of differing disc disruptions. Early in an episode of disc rupture, inflammation around the disc remnants and the released internal disc material itself causes local centralised low back pain and potentially nerve root irritation that refers pain down the leg. This “peripheralised” pain, often referred to as sciatica, is something that the health professional considers in light of the overall presentation of the patient and mostly signifies a larger disc disruption.
Nothing new, it all seems to make sense. But here is the interesting bit, once the internal disc material is liberated from the inside of the disc, macrophages (the bodies clean up cells) can start to “clean them up” and therefore remove part of the pain provocation mechanism. Once the rest of the inflammatory build up is also dealt with, this pain referral into the leg can disappear and normal pain levels and function can return. This study outlined large bulges which invaded the spinal cord space by more than 50% of the available area, were found to shrink 70-80% on long term follow up scans.
So bigger can be better, but not always. Cauda Equina syndrome ( which can permanently affect the bowel and bladder nerves) must always be considered in large disc disruptions and surgery often also helps in the short term to relieve severe pain. It does however appear that in time significant healing can occur and an equivalent long term result found from “the wait and see” approach.
One disclaimer though – progression of signs and symptoms needs to be closely monitored and any progression must be considered by a health professional as although “wait and see” seems great in theory, the consequences of non-surgery are severe and limiting. Loss of bowel and bladder function or muscle activation is not to be trivialised. Other studies (http://jbjs.org/content/93/20/1906) have also suggested that if symptoms are of longer duration then a poorer prognosis will likely result. So the issue is not simple and must be weighed with many considerations of the presenting problem, person and situation. Always when experiencing significant or prolonged back pain, contact a medical professional.
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Jason is the Leichhardt Physiotherapy's practice principal and has been practicing as a physiotherapist for over 16 years