Herniated Disc and Sciatica: What is Appropriate Management

by Craig Liebenson

What is a Herniated Disc?
Herniated discs are probably the most common diagnosis for severe back pain and sciatica (leg pain). Discs are large cushions that lie between the individual vertebrae of our spinal columns.
 The disc is composed of layers of ligaments (annulus fibrosis) arranged in a criss-crossing matrix that hold in a gel-like substance (nucleus pulposus), giving the disc its “shock-absorbing” ability.  
   Sometimes the gel swells (which is called a disc protrusion or bulge).
A more problematic situation occurs if the gel pushes through its ligamentous wall (which is a disc prolapse or extrusion). Both situations can led to pressure or irritation of the vulnerable spinal nerve roots. This can lead to sciatica – an abnormal sensation felt anywhere from the buttocks to the feet.  

Are Bed Rest and Surgery Necessary?

For more that 50 years, orthopedists have believed that most lower back pain and sciatica were caused by herniated discs. The “dynasty of the disc” led to the typical medical advice of bed rest and medication. Gordon Waddell, a renowned British orthopedic surgeon, wrote in the journal Spine, “There is remarkably little scientific or clinical evidence to support the value of bed rest for low back pain or even sciatica.” Bed rest is now known to cause prolonged pain, muscle weakness, joint stiffness, and depression.

If bed rest failed, surgery was the usual next step. Unfortunately, due to poor patient selection, many unnecessary surgeries were performed. Waddell said, “surgical successes unfortunately only apply to approximately one percent of patients with low back pain.” According to Alf Nachemson, M.D., editor of the journal Spine, bulging discs are found and taken as an excuse to do a lot of surgery and percutaneous discectomy. Discs are made to bulge; that is a normal finding.”

Back and even leg pain can arise from the muscles, joints, or ligamentous structures of the spine. Whatever the cause, evidence is growing showing that rehabilitation not surgery is the treatment of choice for most lower back disorders.

What Treatments Have Been Proven to Work?

A recent study from a leading orthopedic center in San Francisco demonstrated that more than 90 percent of patients with disc herniations responded to non-surgical treatment. Most of these patients had already been referred by neurologists for immediate surgery. Their treatment included simple pain control methods in combination with rehabilitation. According to Nachemson, “All the structures in the back fare better with early, controlled motion….if something is injured and you start to slowly move it under controlled conditions, then the structure heals quicker and better.”

Modern Management of Back Pain and Sciatica

Pain Control/First-Aid

Goal: reduce pain, swelling and inflammation

  • physical therapy
  • chiropractic adjustments
  • anti-inflammatory/pain medication if necessary

 

Rehabilitation

Goal: stabilize back through better flexibility, strength, and endurance

  • education about lifting, sitting, etc.
  • exercises to increase back and cardiovascular fitness
  • encouragement to achieve and maintain a healthy back