Study: Surgery Just One Option for Herniated Disk

A new study looking at treatments for herniated disks found that nonoperative remedies, such as physical therapy and painkillers, are almost as effective as surgery in alleviating pain.

"In back surgery for this particular condition, there's actually a choice," said lead author Dr. James Weinstein of Dartmouth Medical School. "If you don't want the risk of surgery, you can do watchful waiting" and still get well.

Patients were followed for two years after being randomly assigned to surgery or noninvasive treatment, which included education, physical therapy or painkillers. Surgery involved removing part of the bulging disk in a standard operation often done on an outpatient basis.

Patients in both groups had much improved scores on measures of pain, physical function and disability during periodic evaluations; differences between the groups weren't statistically significant.

The study appears in the upcoming issue of the Journal of the American Medical Association.

Q & A: Surgery and Back Pain

Dr. James Weinstein, chair of orthopedics at the Dartmouth-Hitchcock Medical Center, tackles your questions, from back pain in children to whether it's safe to jog with a "bad back:"

Experts Answer Your Questions

Q: What did you do about your back problem? I had a similar situation where I just bent over and had that terrible pain where you can't get upright. — Mike Stanton, Rochester, N.Y.

I followed my own advice and research. I had recently published with a colleague, Richard Deyo, an article in the New England Journal of Medicine.We suggested the best thing to do for lower-back pain is to get back to your normal activities as soon as possible. You should not spend more than three to five days resting.

Study: Deyo RA, Weinstein JN. Low Back Pain. NEJM, 344(5):363-370, 2001

Q: At my son's school, there are no lockers, so the students have to carry everything that they will need for the day in their backpacks. Sometimes his backpack is at least 35 to 40 pounds. Does carrying this amount of weight on a daily basis affect his spine as he grows? — Kimberly Rose, Mesa, Ariz.

Research suggests there is a relationship between backpacks and back pain. One study looked at backpack use in different types of schools and at different ages. Some of these backpacks weighed quite a bit — up to 46 pounds for an 8-year-old. That's half his weight! And the researchers found that students with back pain carried significantly heavier backpacks, and that students who used backpacks reported back pain more often.

An acceptable load is about 10 to 15 pounds, if that's possible. Don't carry a big bottle of fluids —they're very heavy — and the school should have a locker to store what a child's not using. I think the backpack is a nice tool, but investigate which type of pack seems to be most comfortable for your child. And don't put everything, including the kitchen sink, in it. It can't be their home away from home.

Study: Sheir-Ness GI, Kruse RW, Rahman T, et al. The association of backpack use and back pain in adolescents. Spine Journal. Spring, May 1, 2003:28(9), pp922-30.

Q: I am a 75-year-old woman and I have had an almost constant backache (which is bearable) for many years. About 15 years ago while working in a school, the school nurse said I have slight scoliosis. Will this condition worsen as I age? Or should I just forget about it? I do exercises every morning, walk two miles every day and take a tai chi class once a week. — Anne Santino, Merrick, N.Y.

Your back pain could be from a curvature of the spine — or from tired muscles. For adults, curvature of the spine is often due to arthritis and other changes in the spine associated with aging. When the curvature puts pressure on a specific nerve root or a specific nerve and leads to leg pain, you might want to consider a surgical procedure.

Depending on how progressive the curvature is — beyond the usual one degree per year — these operations can be significant and often require two procedures or more to straighten the spine and free up the nerves. Your general health status is incredibly important here. If you feel that your general health is good, i.e., you have no major health problems, then you may be a candidate for surgery.

If your pain is coming from muscle fatigue, however, the exercises you do every morning are excellent and help maintain good muscle tone and spinal health.

Q: Many people wrote to NPR detailing numerous surgeries and rounds of physical therapy, painkillers, steroid injections and nerve blocks. The common thread was that after years of this, they're still in pain, despondent and feel abandoned by their doctors, who say there's nothing left to be done. What advice do you have for people in this situation?

Chronic pain is an incredibly difficult problem for many patients with back problems. I often use the analogy of the amputee and phantom-limb pain. If you talk to amputees who have lost a leg or an arm, some will tell you their missing leg or arm still hurts. This example demonstrates how your brain still can interpret something as painful even when you don't have a limb.

With chronic back pain, a patient can experience the same type of response. Painful information can be encoded in your brain and a memory pattern of the pain can be difficult to get rid of.

Multidisciplinary functional restoration programs, like we have here at Dartmouth, have been one of the better success stories for chronic back pain. These are programs that take a team approach; a pain doctor, social worker, nurse, physical therapist and a surgeon may all work on your case.

One of the main goals is to get patients off chronic pain medication. This can be a very frustrating experience and that's why the support that comes with these multidisciplinary programs helps.

Q: How do we prevent back pain? How do we strengthen our backs? — Karen Barnard, Lexington, Ky.

The best thing is to keep your back healthy. Staying in good aerobic condition with good cardiovascular function is really one of the best things you can do for your back. A variety of activities can help with this, from a brisk walk to jogging. Yoga and stretching also can help. Remember, hurt does not mean harm; just because your back hurts doesn't mean you are going to harm yourself when you stay active.

This doesn't mean that you won't have back pain if you exercise. But it does mean your muscles will be in better shape and you will get better faster.

Q: When I stand in one place for any length of time, as when you're ironing or washing dishes, I get severe back pain, to the point where I have to step away and bend over to relieve the pain. This can't be normal, but is it serious enough to see an orthopedist? — Shelly Stalnaker, Aloha, Ore.

This is often more about your muscles getting tired than a structural problem. Pain might increase depending on the type of floor you're standing on, or whether you're standing for a long period of time after a long day of sitting or driving.

If you're inactive for much of the day, your muscles might not have the ability to sustain standing or sitting positions that might be considered normal for most people. This goes back to our preventive strategies and trying to maintain good physical condition. Changing positions frequently is always recommended.

Q: Is there a way to regenerate a degenerated disc, such as by a dietary supplement or by direct injection of gelatinous material? — Nathaniel Sterling, Palo Alto, Calif.

There's not much research on the spine and dietary supplements, such as glucosamine-chondroitin, that I can point to. People looking to regenerate the aging disc have been experimenting with several options, such as gene therapies and other chemicals that cause the disc cells to make new proteoglycans. Those are the basic substances that make the disc gelatinous and soft. To date, there is no effective treatment that provides sustained change in these proteoglycans.

Q: My back is fine EXCEPT when I sleep! For the past three years I have to sleep in the fetal position, never on my back or stomach as the pain wakes me. That's it. No pain any other time. Should I see someone? — Steve Berry, Washington, D.C.

Sleeping in whatever position is comfortable for you is best. People lying in the fetal position on their sides with their knees bent up are usually very comfortable. For most people, it relaxes the spine, opens up the spinal canal and allows people to feel comfortable while they sleep.

If your problem wakes you at night, and this has been going on for a period of time (several weeks), it would be worth discussing it with your doctor. Having night pain in your back that wakens you from a sleeping position is not normal.

Q: What are three things I should ask a surgeon before I agree to back surgery? — Barbara Waring, Sandwich, Mass.

I'm afraid I can't limit it to just three! You first need to be clear about what your diagnosis is, which is the basis for any surgery you might be considering. A doctor bases your treatment plan on your diagnosis, so it's important to be thorough when explaining your pain to your doctor. If your doctor suggests surgery, ask these questions:

1. What will I likely experience if I don't have surgery?

2. If I do have surgery, what will I likely experience a) immediately afterwards; b) over the next few months; c) over the next couple of years?

3. Might I be likely to need further surgery in the future?

4. How many of these surgeries have you performed? (Don't be shy about this one, it's very important. How frequently your doctor has done a procedure is important to know.)

5. Do you have any statistics about outcomes, i.e. how have your patients done with my diagnosis and the treatment you are recommending?

6. Can I talk to one of your patients who had this procedure?

Q: I am a 44-year-old male diagnosed with degenerative disc disease. I have always been very active. Thus far, I have been treated only with physical therapy and anti-inflammatories. The condition has worsened to the point where I can't run, and dance (jazz, ballet) is increasingly difficult. I am desperate to find a way to heal my back so I can resume my favorite activities at a high level. What do you recommend? — John Alan, Burbank, Calif.

Being active may actually be the best treatment for you at this time. Remember, hurt does not always mean harm. I would like to encourage you not to give up your physical activity; giving up running and dancing may not make you better.

As for the label "degenerative disc disease" — nobody's degenerating here. I don't like the word "degenerative." Most of these processes are natural aging, whether it's arthritis in your knees or in your spine, and aging cannot be undone.

Q: What would you suggest to a person who had spinal fusion 10 years ago and still has moderate-to-severe back pain constantly? — Joseph Gaworecki, Lakewood, N.Y.

With spinal fusion, two or more bones in your back are joined together to create less motion. It's thought this will help one's pain. Unfortunately, it doesn't always provide the relief that patients would like. There are a fair number of people who continue to have pain and/or go on to another operation. The multidisciplinary programs we've already discussed are probably the best places to get a full evaluation at this time. Spine problems are multidimensional and often times they need a multidimensional approach.

Q: Has there been any medical research done on hanging upside down for a period of time, to relieve back pain? — Michael Naimo, Janesville, Calif.

This was a fad, I think dating from the early '80s. It's often called inversion therapy, and the idea is to change the forces on the disc. Some patients have found this helpful, but the research on this is limited.

You have to be careful: Hanging upside down could be dangerous depending on your blood pressure, heart condition, age and the condition of your joints. It's not such a simple thing. Obviously you would want to have appropriate guidance and assistance if you're considering this.

Q: I had been a runner/jogger most of my life until a year and half ago when I experienced a herniated disc. I received eight weeks of physical therapy and a cortisone shot and now do most everything I did before except jog. I wonder if jogging really is all that bad for your back? I really would like to jog again. — Nicollete Nicar, Normal, Okla.

As a runner myself, I strongly encourage you to begin jogging. One my patients, who was interviewed last week on NPR, is a triathlete who had a herniated disc. He actually got better faster when he went back to his usual activities, which included jogging, biking and swimming. Of course this is not true in every case, but I would encourage you to try it as long as you don't feel you're making yourself worse, and in consultation with your doctor.

It's commonly the case that people are told not to do things, like jogging, but I think you need to go back to your normal activities as soon as possible.

Q: After a hard day at work, I like coming home and stretching my back in various positions. Many of the stretches will cause a crack or a pop in parts of the spine, which also feels good. Are there any long-term effects on doing these techniques a few times a week? I don't have specific ongoing pain. — Marcel Luc Sell, Minneapolis, Minn.

It's a common habit to crack your back, like cracking your knuckles. I don't know of any down side to this or any positives either. If it makes you feel better and you are not having any discomfort, I would not discourage you. Most people eventually stop doing it as they grow older; you don't see that many adults sitting around the table cracking their knuckles. They realize at some point it's not helping them, or that it hurts more than it helps.

Q: Is arthroscopic surgery more successful than open procedures? — Eric Grosch, Fort Myers, Fla.

There is no evidence that arthroscopic surgery is more successful. There is very limited literature on this for the spine and it is mixed. Some people say you can get home quicker and it is a smaller incision. The overall results of the treatment aren't any better. Of course, there is the risk of working through a small space near the spinal nerves and the spinal cord, but your doctor's experience and his/her results should be discussed at length before making this kind of decision. A second opinion is always good.

Q: With the imaging capabilities and diagnostic testing now available, why can surgeons only guess the source of debilitating pain? And who is better able to deal with back pain, neurologists, neurosurgeons or orthopedic surgeons? — Susan Tessem, Chestertown, Md.

Back pain is often difficult to diagnose specifically. I think sometimes it's like a hidden disability. An amputation of a hand or arm is easy to see, but you can't see the back. It's not something the doctor can put in his hands and see, examine, touch and put through its normal range of motion. MRIs now allow us to see inside, but we still can't feel it or touch it.

As for what kind of doctor, I'm not sure their title is the issue as much as their abilities and their results. See somebody in your neighborhood who has a reputation for caring for spinal problems. Find out numbers of patients treated, what their results are, and talk to other patients in that facility. Inform yourself about whom you are seeing.

Q: Why is it that there are so few studies on the long-term efficacy of surgery? It seems that this would be a rather obvious and critical question for anyone considering surgery. — Richard Lindquist, Fort Pierce, Fla.

This is obviously a critical question. It is hard to do clinical trials, especially surgical trials, and the reasons are many. It is hard to do them with independent funding, with patients willing to participate, and with surgeons willing to participate. It's important to enroll two groups of patients who are similar to each other, one in the procedure group and one in a group that doesn't get a procedure, so that we can compare the two groups to see how well the surgery works compared to an alternative.

A trial demands that patients come back for multiple visits over time so that we can follow them and see the results of the treatment. These studies are clearly possible, but they are very expensive and require a great deal of dedication by the patient and the surgeon to do them. They are sorely needed and we need to encourage our government and industry, working together, to support them.

Q: I was wondering if you had any recommendations for a specialist here in the Los Angeles area, possibly at UCLA or Cedars. I'm a 50-year-old father of a 2-year-old daughter that really keeps me on my toes. But I've been struggling with nearly constant pain from a herniated disc diagnosed nearly two years ago. — Gary Kibler, Marina Del Rey, Calif.

If it's a surgical problem, I suggest looking for recommendations on the Web sites of the American Academy of Orthopaedic Surgeons and the American Association of Neurosurgeons.

Q: Many people with back pain turn to chiropractic care. What's your opinion? — Amy Lujan, Nome, Alaska

Many patients use nontraditional medicine for the care of their spine, whether it's chiropractic, different herbal therapies or acupuncture. Most of these treatments have not been proven or been studied in a way that proves they work. But chiropractic for back pain has been studied pretty well. According to a 2003 meta-analysis of the literature cited by NIH's National Center on Complementary and Alternative Medicine, chiropractic is "at best, no worse than traditional treatment."

Dr. Weinstein is chair of orthopedics at the Dartmouth-Hitchcock Medical Center and professor of orthopedic surgery and community and family medicine at Dartmouth Medical School.

Dr. William Abdu, medical director of the Spine Center at Dartmouth-Hitchcock Medical Center, consulted with Dr. Weinstein on these answers.

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