The best conventional medicine has to offer for lumbar disc herniation and associated lumbar radiculopathy are surgeries that do not work that well
Let’s look at research from August 2017 appearing in the British journal of neurosurgery:
“Though different techniques have been successfully employed in the treatment of recurrent lumbar disc herniation, the one which should be considered most ideal has remained a controversy, (minimally invasive surgical techniques).”
“In view of the currently available data and evidence, minimally invasive techniques for revision of recurrent disc herniation do not really appear to be superior to the conventional open surgical approaches and vice-versa. Spinal fusion should not be undertaken in all recurrences but should only be considered as an option for revision when spinal instability, spinal deformity or associated radiculopathy is present.”1
In other words, the best conventional medicine has to offer for lumbar disc herniation and associated lumbar radiculopathy are surgeries that do not work that well. Please see the article: Non-surgical treatment of a herniated disc.
Unfortunately, treatments with less than great results in the medical literature are given until “all has failed,” and the patient is sent to surgery.
Lumbar Radiculopathy can be confusing. In recent research doctors call some cases “so-called Lumbar Radiculopathy” because it is not radiculopathy
Many individuals who are diagnosed with lumbar radiculopathy are more likely to have a “pseudo” radiculopathy. This is a condition where radicular pain comes and goes with changes in activity or changes in position, pinching the nerve intermittently.
If this is the case, then we can look for an underlying ligament injury to the lumbar spine which is often overlooked in pre-surgical consults. If ligament injury is there, we can offer the patient Prolotherapy as a non-surgical means to repair the damage, strengthen the spine, alleviate the pain and symptoms of lumbar radiculopathy.
Doctors writing in the Swiss Medical Review (Revue médicale suisse) highlight:
A lumbar disc herniation is a condition frequently encountered in primary care medicine. It may lead to a “compressed nerve,” leading to a nerve root irritation,“a so-called radiculopathy”, with or without a sensorimotor deficit (varying levels of loss of sensory or motor skills).
The majority of lumbar disc herniations can be conservatively treated with physical therapy, analgesics (pain killers), anti-inflammatory therapy or corticosteroids, which may be eventually administered by infiltrations (various injection or infusion techniques).
If a clinico-radiological (MRI and other scans) correlation is present and moderate neurological deficit appears suddenly, if it is progressive under conservative treatment or if pain is poorly controlled by well-conducted conservative treatment performed during four to six months, surgery is then recommended.2
What is described above is the typical road to surgery.
Pseudo-Radiculopathy or confirmed-radiculopathy The longer you wait, the worse your situation becomes
This was a warning issued by doctors writing in the medical journal Clinical spine surgery. Here the doctors noted that the success rates of surgical interventions for lumbar disorders vary significantly depending on multiple factors and, among them, the duration of symptoms.
What these doctors from Boulder Neurosurgical Associates were looking for was to see if there was a “cutoff” time when lumbar decompression and fusion surgery becomes less effective in the conditions with chronic nerve root compression symptomatology. Thus they analyze whether duration of symptoms has any effect on clinical outcomes and primarily resolution of radicular pain symptoms due to degenerative disk disease and stenosis with spondylolisthesis in patients undergoing transforaminal lumbar interbody fusion (TLIF).
The results they achieved showed that the duration of symptoms was a significant predictor of better leg pain resolution, but not back pain resolution, or improvement in disability.
The patients with shorter duration of symptoms had significantly better radicular symptom resolution compared with patients who waited at least 24 months or longer to undergo fusion.3
Researchers at Penn State University writing in the medical journal Clinical spine surgery found:
- The duration of the patient’s symptoms was found to be negatively significantly related to lesser pain improvement.
- For each week of the duration of symptoms, the percentage of improvement decreased.
- The longer the patient waited for treatment, the less likely the caudal epidural steroid injections would work.4
Doctors writing in the Journal of back and musculoskeletal rehabilitation, note that even one epidural steroid injection can be effective in the short term, suggesting radiculopathy can be a transient condition that can be treated without surgery.5
Back to the Penn State research, the doctors also found that patients with pain with lumbar extension (most commonly a popular exercise where patients “stretch” their spine by bending backwards) was negatively and significantly related to length of relief duration from the caudal epidural steroid injections.
- The average length of relief duration is 38.37 weeks for individuals without painful lumbar extension and 14.68 weeks for individuals with painful lumbar extension. The mean length of relief following a caudal injection is reduced by 62% in patients who exhibit pain with lumbar extension.4
Epidural steroid injection
It is interesting that patients who failed to have their symptoms managed with epidural injections are treated with epidural injections before and after failed surgery for radiculopathy, only with stronger and more frequent doses.
Epidural steroid injections ease pain temporarily by reducing the size of stressed nerve roots. However concerns over short-term gain long-term costs in the use of epidural steroid injection side-effects have been noted.
Epidurals are part of the common treatments for light cases of lumbar radiculopathy which usually include NSAIDs (non-steroidal anti-inflammatory drugs), physical therapy, or chiropractic treatment. Although many patients respond very well to these treatments, they are only temporary fixes that can help ease the pain and only relieve some symptoms of the condition.
Further, research in the Journal of the American Medical Association, JAMA said that oral steroids as compared to placebo, offered minor improvement in function but did not improve pain conditions.6
Diagnosis and Treatment of Lumbar Radiculopathy
Many patients will be sent off for physical therapy. These patients often see mixed results.
- Research in the medical journal Spine reported: “Physical therapy is commonly sought by people with lumbar disc herniation and associated radiculopathy. It is unclear whether physical therapy is effective for this population.” The research did find that for up to 10 weeks physical therapy provided symptom relief, but the effects were not long-lasting.7
In utilizing Prolotherapy as a treatment, diagnosing lumbar radiculopathy as a transient pain, as mentioned above, requires a physical examination, manipulation, and palpitation of the suspect area.
Most often individuals, as we discussed, who are diagnosed with lumbar radiculopathy, really have more of a radicular pain that comes and goes with changes in activity or changes in position.
This means the nerve gets pinched intermittently possibly caused by an underlying ligament injury to the lumbar spine. The ligaments become weaker and allow for more movement than normal. The vertebrae then move excessively, and the nerve can get pinched. This pinching causes extreme pain down the legs and feet. If the lumbar radiculopathy is intermittent, then the leg pain will be occasional or intermittent. Prolotherapy to the injured and weakened areas will stabilize the lumbar vertebrae. Intermittent radiculopathy generally responds very well to Prolotherapy.
How does Prolotherapy help radiculopathy?
Radiculopathy by definition means a nerve is being compromised leading to symptoms in the extremity. We find that 90% of people coming in with the diagnosis of radiculopathy do not have a pinched nerve. The majority has referred pain down the extremity (leg or arm) from a ligament injury in their pelvis, lower back, neck, or upper back. Three to six Prolotherapy sessions and the majority of these pains subside. For the other 10 percent that have a true radiculopathy the following is typically present:
- Crippling pain.
- The MRI shows an acute herniated disc
- The MRI finding is consistent with the person’s symptoms and exams
- The EMG collaborates the MRI
In the case of a true pinched nerve, most Prolotherapists will get the person some pain control while the Prolotherapy is working. The person with a true radiculopathy needs to decrease the inflammation of the disc material pressing on the nerve while the Prolotherapy helps stabilize the herniated areas.
- The best approach, in our opinion, is to give a steroid injections right around where the disc herniation is located. This is called a nerve block.
- Sometimes an epidural is done, but we like putting the medication directly where the problem is located.
- The person is also prescribed muscle relaxers and rarely oral steroids. These steps are only immediate-level treatments.
- Simultaneously Prolotherapy works on the long-term cure. Yes the steroids block some of the Prolotherapy effect, but the person needs immediate pain relief.
- A medication to help sleep is also warranted sometimes.
Obviously, the person gets Prolotherapy to the areas. The person is seen in follow-up in one week. At this time if they still have a lot of pain, then another steroid injection is given to the painful area.
At the two-week point, sometimes another Prolotherapy session is done.
Up to four Prolotherapy sessions are sometimes needed. The above approach has been used at Caring Medical Rehabilitation Services for years. It has kept a lot of people out of surgery.
In our experience the above approach even with herniated discs is around 90% successful. Of course, we have our handful of cases that have needed surgical consultation and surgery. We are grateful the surgeons are there for back-up. Even for an acute herniated disc the surgeon is second line therapy, or the person with a pseudo- or true radiculopathy the treatment of choice is Prolotherapy.
1 Onyia CU, Menon SK. The debate on most ideal technique for managing recurrent lumbar disc herniation: a short review. British Journal of Neurosurgery. 2017 Aug 22:1-8.
2. Corniola MV, Tessitore E, Schaller K, Gautschi OP. Lumbar disc herniation–diagnosis and treatment. Rev Med Suisse. 2014 Dec 10;10(454):2376-82.
3 Villavicencio AT, Nelson EL, Rajpal S, Burneikiene S. The Timing of Surgery and Symptom Resolution in Patients Undergoing Transforaminal Lumbar Interbody Fusion for Lumbar Degenerative Disk Disease and Radiculopathy. Clinical spine surgery. 2016 May.
4 Billy GG, Lin J, Gao M, Chow MX. Predictive Factors of the Effectiveness of Caudal Epidural Steroid Injections in Managing Patients With Chronic Low Back Pain and Radiculopathy. Clinical spine surgery. 2017 Jul 1;30(6):E833-8.
5 Taskaynatan MA, Tezel K, Yavuz F. The effectiveness of transforaminal epidural steroid injection in patients with radicular low back pain due to lumbar disc herniation two years after treatment. J Back Musculoskelet Rehabil. 2014 Oct 15.
6 Goldberg H, Firtch W, Tyburski M, Pressman A, Ackerson L, Hamilton L, Smith W, Carver R, Maratukulam A, Won LA, Carragee E, Avins AL. Oral steroids for acute radiculopathy due to a herniated lumbar disk: a randomized clinical trial. JAMA. 2015 May 19;313(19):1915-23. doi: 10.1001/jama.2015.4468.
7. Hahne AJ, Ford JJ, Hinman RS, Richards MC, Surkitt LD, Chan AY, Slater SL, Taylor NF. Individualized functional restoration as an adjunct to advice for lumbar disc herniation with associated radiculopathy. A pre-planned subgroup analysis of a randomized controlled trial. Spine J. 2016 Oct 17.
This article was taken from Prolotherapy for lumbar radiculopathy, Ross Hauser, MD