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Re: treatment of acute lumbar disc herniations
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Re: treatment of acute lumbar disc herniations - February 20, 2003 1:40:00 PM
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mcap56
Posts: 619
Joined: October 26, 2002
From: New York, NY
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JSSH:
I completely disagree with your CI. It doesn't sound like he/she reading the literature.
1. Some people can have extrusions and be asymptomatic. Do they need surgery?
2. The size of the lesion does not correlate to the clinical picture. AS previously stated, sometimes the larger herniations do better.
3. Surgery is indicated in cases of progressive neurological deficit or significant neurological deficit that doesn't improve within the first 2-3 months or red flags or severe functional limitation.
4. Even if a patient has surgery for a neurological deficit, the ten year outcomes after surgery show no signficcant difference with those who did not have surgery. So.....in my opinion, a significant neurological deficit with significant pain and functional limitations together are a better indicator for surgery. One or the other can be handled with other measures.
5. Nuclear fragments and materials do get absorbed over time.
A good article is by Saul. Natural History of Lumbar Disc Herniation. I am not sure of the exact title but the article is a great summary. If my medline wasn't acting up, I'd get it for you.
P.S. No matter what we might say about your CI, you should be diplomatic in your relationship with him or her.
Best,
mcap56
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Re: treatment of acute lumbar disc herniations - February 24, 2003 3:20:00 PM
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JSSSH
Posts: 45
Joined: September 10, 2000
From: Kingston, Ontario, Canada
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Thanks for all your advice! I think I am finally clear on this topic. I will dig up those references. = ) I was confused by my new CI when he told me there is no resorption of nucleus.
PTupdate: what is your program you mentioned in the post? Do you find core stabilization exercise helpful when you had the disc herination?
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Re: treatment of acute lumbar disc herniations - February 25, 2003 5:27:00 AM
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PTupdate.com
Posts: 1477
Joined: October 8, 2001
From: Pittsburgh, PA USA
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I used the same basic protocol I use on most patients, but performed things daily and threw in everything except the kitchen sink!
Basically this:
Aggressive ES to reduce piriformis/sciatic pain, steroids and then Indomethacin, flexion rotation mobilization, gentle and then more aggressive dural stretching/flossing, elastic back support with orthoplast molded stabilizer, lumbar support, NMES to anterior tib/peroneals, strengthening, extension with hips shifted, mechanical traction, mobilization of hypomobile segments, and eventually some back strengthening. I did not want surgery, nor was I able to have it at that time, so pulled out all the stops, evidence be ****ed!
John Duffy, PT OCS [URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
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Re: treatment of acute lumbar disc herniations - March 3, 2003 12:24:00 PM
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Shill
Posts: 1096
Joined: February 13, 2003
From: Madison WI USA
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To those out there who think we cant effectively treat HNP's with conservative care, you are doing yourself, your patients, and your field a great disservice.
Before you go any further or reply to this, read every research paper or article you can find about centralization, include lit reviews of RCTs. Then, attend a course by a man named Angelo Dimaggio PT, MDT. "Strategic Orthopedics" -How to Out think and out Maneuver LBP. He has found the answer(s). The approach he has developed will blow your mind (in a therapeutic way) with the attention to detail, focus, and will point out to you where you have gone wrong in the past. The research backs it up, this is not anecdotal information. We have gone too far in the wrong direction, mistreating LBP, which is evident by the 60-85% recurrence rate. This is the only approach that correctly recommends appropriate methods for tissue protection, placing the patient responsible for success or failure (provided the clinician is properly trained). It expands upon the shortcomings of the McKenzie approach, while capitalizing on its strengths.
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Re: treatment of acute lumbar disc herniations - March 3, 2003 2:27:00 PM
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arufa
Posts: 26
Joined: February 23, 2003
From: Syracuse, NY
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I just had a pt today who's MRI showed a large L5/S1 extrusion. She was in a lot of pain, which is now masked by meds. It took some time but she finally told me she has been having urinary leakage, saddle N/T, constipation and little to no sensation with sexual intercourse. This as all occurred since the back and LE's sx began(2 months). I tried to call her MD but could not reach him. Should I definitely not treat this patient even if the MD wants me to?
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Re: treatment of acute lumbar disc herniations - March 3, 2003 4:04:00 PM
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jma
Posts: 2414
Joined: August 24, 2000
From: NY
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Hello,
You should make every effort to have that patient contact/visit the doctor as soon as possible. There may be something serious going on and it needs to be addressed promptly. Any further PT may complicate things and may need to be stopped to prevent further complications. Better to play it safe.
JMA
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Re: treatment of acute lumbar disc herniations - March 3, 2003 4:26:00 PM
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flexion
Posts: 151
Joined: August 7, 2002
Status: offline
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Arufa:
I hope the term "cauda equina" was at some point mentioned by your referring physician.
Red flags all over the place here for a neurosurgeon visit immediately.
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Re: treatment of acute lumbar disc herniations - March 3, 2003 4:54:00 PM
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Sam Betts
Posts: 37
Joined: January 30, 2003
From: Peoria, IL, USA
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Shill, you said:
"Before you go any further or reply to this, read every research paper or article you can find about centralization, include lit reviews of RCTs. Then, attend a course by a man named Angelo Dimaggio PT, MDT. "Strategic Orthopedics" -How to Out think and out Maneuver LBP. He has found the answer(s)"
This statement does not make sense to me, despite reading it several times.
If I read all the research that is out there on the histology and natural history of disc herniations ( in this discussion, we redefined it as a prolapse for discussion sake) are you saying that this research will confirm/complement Mr DiMaggio's approach, or his approach will prove the research wrong?
Explain why we are doing our profession and our patients a disservice by not treating an acute disk prolapse. When I say "treat" I am assuming you mean actually movement and some form of actual specific intervention?
Thanks,
Sam
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Re: treatment of acute lumbar disc herniations - March 4, 2003 1:24:00 PM
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Bournephysio
Posts: 585
Joined: April 25, 2002
From: Calgary
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About four or five years ago I had a patient with similar symptoms. She had been on holidays and was having back problems so she saw a chiropractor. She started getting the cauda equina signs/symptoms after the chiro. The chiro wanted to continue to manip her so she went to a physio. The physio somehow thought that ultrasound to the piriformis would help her. When she got back from vacation she saw me. Because it had been two weeks since she had seen the chiropractor I didn't think that half a day more would make a difference so I wrote a note and sent her to see her doctor immediately. To my suprise she comes back after a couple of days to see another therapist in the clinic. She had a referal from her doctor for traction. We ended up sending her to emergency. I'm not sure what happened to her after that. I don't think that I would ever again send someone with these signs/symptoms back to their doctor. I'd send them straight to emerg with a note.
Doug
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Re: treatment of acute lumbar disc herniations - March 4, 2003 2:14:00 PM
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arufa
Posts: 26
Joined: February 23, 2003
From: Syracuse, NY
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Thanks for all the responses. I had the same concerns as all of you. . I was very worried and thought about sending her to the er however, it had been occurring for several months so I figured what’s another day. Also the referring MD is a close friend of my boss and it would not look good for the MD. I did talk with the MD today and his response was, the MRI showed a left lateral (L5/S1) disk bulge and that it could not cause these sx. He wants me to treat this patient!! I am not worried about increasing her sx because I am going to do little to nothing with her, however I am worried about increased damage as more time goes on!!! Any advice
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Re: treatment of acute lumbar disc herniations - March 4, 2003 3:45:00 PM
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flexion
Posts: 151
Joined: August 7, 2002
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There are so many negatives to treating a patient like this that its worth pissing off the MD. There is no physical Tx that works.
All kinds of DiffDx: Conus medullarus syndrome, MS, CA, cord problems. If you are lucky its the idiopathic variety.
If they get better it won't be because of your Tx and if they delay seeing a neurosurgeon or get worse who do you think will get the blame? Its a no win situation on your part if you continue to Tx them IMO.
If you can't help them and you have some major liability with it why do it?
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Re: treatment of acute lumbar disc herniations - March 4, 2003 3:51:00 PM
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jma
Posts: 2414
Joined: August 24, 2000
From: NY
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Hello
Although you have managed to talk with the MD and was told to continue with tx, I would document this conversation and what was exactly said.
If the symptoms are still there and not being causing by the bulging disk, something else may be going on and needs to be investigated regardless. If the MD is a neurologist, then the pt should ask for a investigation of the problem and maybe pay a visit anyway. As long as you told the pt to do this and the pt understood your concerns, you should document this conversation as well. At least then, you have covered yourself should something happen in the future, regardless of how little you give tx to this pt.
JMA
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Re: treatment of acute lumbar disc herniations - March 13, 2003 10:45:00 AM
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Shill
Posts: 1096
Joined: February 13, 2003
From: Madison WI USA
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Sam Betts.
I believe we have a misunderstanding here. What I wrote, and you quoted, was to read all you can find on the centralization phenomenon, NOT the research that is out there on the histology and natural history of disc herniations. To clarify, Mr Dimaggio's approach helps to confirm and complement the research that supports that we can in fact treat acute, sub acute, and chronic LBP effectively. Now you may note that I didnt say "disc" in this clarification. We can argue all day long as to whether the disc is the source of the pain, but until we find out for sure, its not worth the argument.
Now, I have read this statement many times, and found it to be difficult to understand as well..."When I say "treat" I am assuming you mean actually movement and some form of actual specific intervention?" Did you wonder if I meant actual movement?" I'll have to get back to you on the specifics for the disservice portion.
SHILL
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Re: treatment of acute lumbar disc herniations - March 13, 2003 3:04:00 PM
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Sam Betts
Posts: 37
Joined: January 30, 2003
From: Peoria, IL, USA
Status: offline
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[QUOTE]Originally posted by Shill:
[B]To those out there who think we cant effectively treat HNP's with conservative care, you are doing yourself, your patients, and your field a great disservice.
Before you go any further or reply to this, read every research paper or article you can find about centralization, include lit reviews of RCTs. Then, attend a course by a man named Angelo Dimaggio PT, MDT. "Strategic Orthopedics" -How to Out think and out Maneuver LBP. He has found the answer(s).
Shill.
Hi. You have said above that if we think that we cannot treat HNP's with conservative care, we are doing the public a great disservice. I suspect this is where I am misunderstanding you, because there is no explaination accompanying this statement as to why you think this is so. I do not know Mr DiMaggio, but I am assuming he is a master clinician from your descriptions. Is the approach you are describing related to HNP's, or to an overall approach to the LBP population, in which case, we are discussing two separate things here?
Respectfully,
Sam
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Re: treatment of acute lumbar disc herniations - December 5, 2003 7:16:00 AM
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Tim Olson
Posts: 1
Joined: December 3, 2003
From: royal oak mi
Status: offline
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Is your Medline up yet??? Very interested in non-surgical rehab of lateral hernitation of L5. I'm an RN who herniated 3 months ago, and had 2 relapses since!!!! Worst pain ever! this form has had more information on the subject then "MD Consult" and the medical books at the library. I've been fishing for months for info, got scared after a surgeon took 3 minutes to decided that he wanted to do surgery; didn't even take the time to answer questions. THEN searching on the WEB, "Have surgery now and get a free pen, while supplies last." whoooo....scary. Marketing surgery like used cars. He cancelled surgery after a few questions.
Hey, any advise about Back Supports? I've heard they help support the spine, but the support can also make the Abd muscles weaker due to less demand on them.
Diet? Does increasing protein help?
I tried swimming, but I think the twisting of the thorax set me up for the last relapse of pain- It hurt's, screamed into a pillow for 6 hours last time-never, never, had pain like that.
Someone recommended Yoga??? (A OB/GYN that had a herniated disc in the past).
Thanks
Timkelli.mi@netzero.com
[QUOTE]Originally posted by JSSSH:
Thanks for all your advice! I think I am finally clear on this topic. I will dig up those references. = ) I was confused by my new CI when he told me there is no resorption of nucleus.
PTupdate: what is your program you mentioned in the post? Do you find core stabilization exercise helpful when you had the disc herination? [/QUOTE]
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Re: treatment of acute lumbar disc herniations - December 5, 2003 7:38:00 AM
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Sam B
Posts: 73
Joined: August 6, 2003
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Hi Tim,
I am sorry to hear of your problem. try reading this article for some ideas, and then weigh your options. This article discusses a decision making algorithm for surgeons regarding surgery, as well as prognosis for those who do and don't.
Saal, J Natural history and non-operative tretment of lumbar Disc herniation. Spine Vol 21; 21 pp 25-95
You can buy the article online through PUBMED, or take it to your hospital library, and they should retreive it for you. I think you can even get them through your local library.
There is certainly controversy surrounding when to operate and when not to, and a lot depends on the type of surgeon you have seen. Hopefully decisions are made based on a carefully hought out examination, and understanding of the literature. Waiting too long can be harmful, if surgery is in fact indicated. You can always get another opinion from another spine surgeon re epidurals, physical therapy post epidurals, or just physical therapy.
Good luck,
Sam B
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Re: treatment of acute lumbar disc herniations - December 7, 2003 3:51:00 PM
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DocZon
Posts: 70
Joined: April 19, 2003
From: Winchester, MA
Status: offline
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Kopp found that 97% of patients who were treated non-operatively for an acute herniated lumbar disc were able to achieve extension within three days. Of the patients who required surgery, 85% had either a free fragment or evidence of a bulging annulus with nerve root deformity. On long-term follow-up, the extension sign effectively predicted a favorable response to non-operative therapy for HNP in 91% of the cases.
I think provactive discograms are under-utilized in management of HNP's and back pain. As many have said, the presence back or leg pain accompanied with a positive MR scan does identify the source of the pain. The prov. discogram is and should be the gold standard for determining pain of discogenic origin.
An interesting technique/study using a Braun electric toothbrush with a fabricated blunt end to deliver vibratory stimulation at the spinous process (in lat. recumbent patient, symptomatic side down) may elicit the pain associated with internal disc disruption. Such vibration pain provacation agrees with discographic provaction in 70.9% of the cases. In contrast, the spec. of MRI compared with discographic findings was only 55.7%. (Clin J. Pain 1998; 14(3) 239-247).
Sounds like we could just get some electric toothbrushes and skip the MRI's.
Centralizers with positive discograms have an intact nucleus in about 91% of the cases. Peripheralizers with a positive discogram have a higher tendency toward outer annulus disruption. those who neither centralize or peripheralize usually have a small positive rate on discogram and a high percentage of outer annulus disruption.
Epidurals, which I now see being given in the doctor's offices without the use of fluroscopic guidance are a sham. One study showed that 35% of the time, the injection is given at the wrong location (when not using guidance). hence the patient does not get better and they go to surgery. A properly delivered epidural could have possibly saved the patient the hassle of surgery. At 3 months, 48-50% of patients report good to excellent satisfaction after an epidural injection. 17 percent are not satisfied.
Better go get that electric toothbrush, the one in the study was a Braun, not sure if that matters.
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Re: treatment of acute lumbar disc herniations - December 7, 2003 3:53:00 PM
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DocZon
Posts: 70
Joined: April 19, 2003
From: Winchester, MA
Status: offline
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Made a mistake in my post, line 6 should read "does not identify the source of the pain." Sorry.
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