Nonsurgical Treatments for a herniated disc
Q: WHEN IS NONSURGICAL TREATMENT INDICATED?
As long as your doctor does not note the need for emergency surgery, within the first six weeks it is reasonable to try different medications, modalities and therapies to try to alleviate the pain from the herniated disc and to give the disc herniation time to heal. With time the body can reabsorb the disc herniation, and if the symptoms start to abate within the six-week period, continued nonsurgical treatment is warranted.
Conservative treatment — mainly avoiding painful positions and following a planned exercise and pain-medication regimen — relieves symptoms in nine out of 10 people with a herniated disk. Many people get better in a month or two with conservative treatment. Imaging studies show that the protruding or displaced portion of the disk shrinks over time, corresponding to the improvement in symptoms.
Q: WHAT TYPES OF NONSURGICAL TREATMENT ARE THERE?
1. Medications for a Herniated Disc
- Acetaminophen: Acetaminophen, such as Tylenol, is a great first-line of defense. However, it’s not for everyone. While acetaminophen is a good painkiller, it won’t reduce your inflammation.
-non-steroidal anti-inflammatory drugs (NSAIDs) can reduce the inflammation caused by the disc herniation.
-Oral steroid medication may achieve a stronger anti-inflammatory effect, although their use is a little riskier. Many of these drugs carry a risk of gastrointestinal bleeding.
-Narcotics. If your pain doesn’t improve with over-the-counter medications, your doctor may prescribe narcotics, such as codeine or a hydrocodone-acetaminophen combination (Vicodin, Lortab, others), for a short time. Sedation, nausea, confusion and constipation are possible side effects from these drugs. Decrease or eliminate your Tylenol use if these combination medications are prescribed.
-Nerve pain medications. Drugs such as gabapentin (Neurontin), pregabalin (Lyrica), duloxetine (Cymbalta), tramadol (Ultram, Ryzolt) and amitriptyline often help relieve nerve-damage pain. Because these drugs have a milder set of side effects than do narcotic medications, they’re increasingly being used as first-line prescription medications for people who have herniated disks.
- Muscle relaxers. Muscle relaxants such as diazepam (Valium) or cyclobenzaprine (Flexeril, Amrix) also may be prescribed if you have back or limb spasms. Sedation and dizziness are common side effects of these medications.
- Anti-depressants: Anti-depressants block pain messages from getting to your brain and increase the effects of endorphins, which are essentially your body’s natural painkillers. Another added benefit—anti-depressants help you sleep better.
Physical therapists can show you positions and exercises designed to minimize the pain of a herniated disk. As the pain improves, physical therapy can advance you to a rehabilitation program of core strength and stability to maximize your back health and help protect against future injury.
Deep Tissue Massage: There are more than 100 types of massage, but deep tissue massage is an ideal option if you have a herniated disc because it uses a great deal of pressure to relieve deep muscle tension and spasms, which develop to prevent muscle motion at the affected area.
Hot and Cold Therapy: Both hot and cold therapies offer their own set of benefits, and your physical therapist may alternate between them to get the best results.
Your physical therapist may use heat to increase blood flow to the target area. Blood helps heal the area by delivering extra oxygen and nutrients. Blood also removes waste byproducts from muscle spasms.
Conversely, cold therapy (also called cryotherapy) slows circulation. This reduces inflammation, muscle spasms and pain. Your physical therapist may place an ice pack on the target area, give you an ice massage, or even use a spray known as fluoromethane to cool inflamed tissues.
Hydrotherapy: As the name suggests, hydrotherapy involves water. As a passive treatment, hydrotherapy may involve simply sitting in a whirlpool bath or warm shower. Hydrotherapy gently relieves pain and relaxes muscles.
Transcutaneous electrical nerve stimulation (TENS): A TENS machine uses an electrical current to stimulate your muscles. It sounds intense, but it really isn’t painful. Electrodes taped to your skin send a tiny electrical current to key points on the nerve pathway. TENS reduces muscle spasms and is generally believed to trigger the release of endorphins, which are your body’s natural pain killers.
Traction: The goal of traction is to reduce the effects of gravity on the spine. By gently pulling apart the bones, the intent is to reduce the disc herniation. The analogy is much like a flat tire “disappearing” when you put a jack under the car and take pressure off the tire. It can be performed in the cervical or lumbar spine.
Other modalities that may be used include ultrasound and short-term bracing for the neck or lower back
The exercises prescribed by your physical therapist can also help relieve pressure on your nerves, reducing the symptoms of pain and weakness. The exercise program often includes stretching exercises to improve flexibility of tight muscles and aerobic exercise such as walking or using a stationary bike to build endurance and improve circulation.
Other exercises might help to strengthen the muscles of your back, abdomen, and legs.
The benefit of aerobic exercise for relieving radicular pain is controversial. Advocates believe that strengthening of the abdominal and back muscles can relieve symptoms, reduce weight and alleviate depression and anxiety. Exercise and massage techniques are easily taught to the patient and family members. Extension and isometric exercises are performed first and, after sufficient strength and pain relief are achieved, flexion exercises are allowed. Flexion exercises are delayed because flexion motions apply the greatest load to the intervertebral disc.
The McKenzie exercise program is believed to be one of the most beneficial. This program is individualized to the patient’s symptoms and emphasizes exercises that minimize or centralize radiating pain.
3. Chiropractic Care and Herniated Discs
A common chiropractic technique is the flexion-distraction technique, which can be used to help address herniated disc symptoms.
Flexion-distraction involves the use of a specialized table that gently “distracts” or stretches the spine. This allows the chiropractor to isolate the affected area while slightly “flexing” the spine using a pumping rhythm.
There is usually no pain associated with this treatment. Instead, the flexion-distraction technique’s gentle pumping to the painful area allows the center of the intervertebral disc (called the nucleus pulposus) to assume its central position in the disc. Flexion-distraction may also improve disc height.
This technique can help move the disc away from the nerve, reducing inflammation of the nerve root, and eventually any associated pain and inflammation into the leg (if there is any related to your herniated disc).
With flexion-distraction, you generally need a series of treatments combined with adjunctive physiotherapy, supplementation, and at-home treatments (your chiropractor will let you know what those are). Gradually, specific exercises to treat your herniated disc will be incorporated into your treatment plan.
Pelvic blocking treatments include using cushioned wedges, which are placed under each side of the pelvis. Gentle exercises may also be used. These will allow changes in mechanics to draw your disc away from the nerve it may be pressing on.
A herniated disc may require 1 or 2 days rest to alleviate pain. However, you should resist the temptation to lie in bed for days at a time because your muscles need conditioning to aid the recovery process. If you forgo exercise and physical activity, your body may not respond to treatment as well as it could.
Even if you have strong muscles to support your back, you must lose weight to truly support your spine. Carrying around extra weight constantly strains your back— you’re practically doing heavy lifting all the time! Losing weight will reduce your pain and promote the health of your back. If you need to lose weight, talk to you doctor about options.
6. Alternative medicine-
If you’re considering these treatments, you should consult a complementary and alternative medicine (CAM) practitioner. This title can be confusing—even though alternative medicine and complementary medicine follow the same methods, they are different in that alternative forms are used in place of conventional medicine, whereas complementary treatments are used with conventional medicine.
Acupuncture: This ancient Chinese practice is rooted in the belief that everyone has an energy force called the Chi (sometimes spelled Qi, but both are pronounced “chee”). When the Chi is blocked or unbalanced, your body may respond with pain and illness. Traditional acupuncturists aim to free up Chi channels, known as meridians, by inserting extremely thin needles into specific points in your body’s meridians.
Based on your specific diagnosis, the practitioner will likely insert multiple needles that are left in for about 20-40 minutes.
It has also been suggested that acupuncture triggers the release of endorphins into the blood stream. Simply put, endorphins are your body’s natural pain relievers. As such, their release decreases your perception of pain.
Similarly, the Gate Control Theory may play a role in acupuncture’s effectiveness at reducing pain. This theory asserts that pain signals travel slowly from the area of injury to the spinal cord into the brain because the nerves can only handle a limited number of signals at once. Acupuncture is thought to generate faster signals to crowd out the slow-moving pain signals, thus blocking out the pain.
Acupressure: Not surprisingly, acupressure is very similar to acupuncture. Both are ancient techniques that restore a healthy flow of energy through the body by stimulating specific meridian points. But acupressure simply relies on fingers, hands, and elbows—not needles—to administer pressure. Acupressure is for people of all ages but not for pregnant women (some acupressure points may cause miscarriage) and those with high blood pressure.
Massage: When received regularly, massage may offer chronic low back pain relief. A massage involves the stroking, kneading, and manipulation of your back tissues. These movements increase blood flow, which delivers more oxygen and nutrients to the muscles. Extra blood also carries away waste byproducts that may accumulate over time.
While massage is not a proven treatment for herniated discs, it’s generally safe and free of side effects. However, massage may not be right for you if you suffer from osteoporosis, deep vein thrombosis, skin infections, open wounds, or arthritis in or near the area to be massaged.
There are more than 100 types of massage techniques. A Swedish massage, for instance, uses long strokes to impact the superficial layers of your muscles. In contrast, a deep tissue massage uses direct pressure and slow strokes to soothe your deep layers of muscle and relieve chronic muscular tension. Your massage therapist will work with you to determine what specific massage will best reduce your pain.
7. Spinal injections —
An injection of a cortisone-like medicine into the lower back might help reduce swelling and inflammation of the nerve roots, allowing for increased mobility. These injections are referred to as epidurals or nerve blocks.
Approximately 50% of the time, an epidural steroid injection will provide pain relief that may last from one week up to one year. Up to three epidural injections may be done in a one-year time frame (at least two weeks apart).
Some physicians believe trigger point injections can provide extended relief for localized pain sources. An injection of 1 to 2 mL of 1 percent lidocaine (Xylocaine) without epinephrine is usually administered. The use of either ultrasound (phonophoresis) or electricity (iontophoresis) over the injected area may provide additional relief, although the benefits of these methods have not been proved. Epidural steroid injection therapy has been reported to be effective in patients with lumbar disc herniation with radiculopathy.