Herniated disc :-( whinging

Yeah, it's a huge controversy now, primarily because there are plenty of people who really are helped by these surgeries. And there are plenty of people whose imaging results exactly correspond to the symptoms, and who are completely recovered by correcting those anatomical issues. This is just the ONE SINGLE THING that literally makes me angry about my profession (and medicine in general) on a day to day basis…and here it is on a forum! So apologies for ranting, but the points are valid. What I'd like to convey most tho is that everyone needs to be a very critical medical consumer and realize that with so much money at stake, there are tons of people who will try to sell you all kinds of things and claim it's going to fix your problem. And after more than a decade of treating orthopedics and 1.5 doctorates in my back pocket, I will say that anyone who says they know exactly why you hurt is totally lying; we really can only guess. I'm going hiking. :)

"So apologies for ranting, but the points are valid." Aw , don't get all apologetic, Jen. I love it when you get your dander up. And besides, you're spot on most of the time. ;0))

for 16 yearsI have had "Moderately large" herniations in my L4 and L5 discs . The very best thing that initially relieved my pain was a motorized stretching table at my physical therapists 2X a week for the first two months. After that back exercises and STRENGTHENING MY ABDOMINAL MUSCLES continued to help. Now I feel only occasional slight pain in that area and my left hip (sciatic nerve area) PLUS, my backpacks have been a bit longer in the torso than "recommended". (Ex. size L Osprey EXOS instead of size M) This keeps the shoulder straps from wrapping around my shoulders where they attach to the pack and putting any downward pressure on them- and it helps a lot by the end of a day. ** If you continue to have pain after trying everything BUT SURGERY then I suggest you look into The LASER SPINE INSTITUTE. Normally they use laser to cut off the offending part of the disc that irritates the spinal nerve(s). This process usually can cauterize the remaining disc enough that it will not bulge out again. But remember, medicine is a practice, not a certain science.

"for 16 yearsI have had "Moderately large" herniations in my L4 and L5 discs " Well, this is exactly what I'm talking about. Would you expect a cut on your arm to last 16 years? Of course not. It heals. Your discs heal. You may have back pain (and hip/buttock pain is NOT sciatica – that's the burning/tingling/numbness that goes to your foot. No foot issues, no sciatic issues!), but at this point those discs are probably not at all an issue. When the discs dry out (as they do in ALL of us as we get older…just like our skin gets wrinkly, and our hair goes grey…) then you can end up putting more pressure on your facet joints – which can hurt. That also means there may too much force that your muscles have to deal with – also can hurt. The ligaments can hurt. The synovial lining of the joints can hurt….I don't have time to keep listing all this stuff. If you keep getting MRIs then they may still show the disc herniation, or bulge, or arthritis…think of it like the scar you make after you cut your arm. It doesn't keep hurting like the cut did, does it?? You don't have pain every second of every day, right? yet if you think it's your arthritis, or your bulging or herniated discs, etc etc, then why doesn't it always hurt?? Those things don't change, right? EXACTLY. pain is NOT what you see on an image. But for the love of all things holy, stop thinking that you have "bad discs" and that that is what is causing your pain.

Great post, Jen. Excellent, actually.

I had a C6 C7 operation almost ten years ago. The disc was removed, a titanium plate placed, the vertebrae were fused. I have had no other problems with it since. I have no regrets having this operation. Since then lower back pain was diagnosed as a L5 S1 stenosis. A laminectomy was performed, but I have lingering problems. MRI's were taken each time with positive results. I had PT before and after each operation.

> as they do in ALL of us as we get older…just like our skin gets wrinkly, and our > hair goes grey… 'Ere – Watch It! I resemble that remark … Cheers

;)

When I was younger and dumber I put my paraglider into a flat spin and corkscrewed into the ground from about 50ft. It happened so fast I had no time to react. I was pretty sore for the next few days, but I was on a once in a lifetime trip in South Africa and so I popped a few pills and shrugged it off. Fifteen years later, I was sleeping just 2-3 hours a night and couldn't understand why I wasn't finding a comfortable position. One day my newly adopted dog crashed into me, sweeping my legs out from underneath . After a few days of knee pain I finally went to a chiropractor who diagnosed the knee pain was due to my hip being out of alignment. That resulted from compensating for upper and lower spinal compression. The trauma dated back to my paragliding accident, and had worsened through poor workplace ergonomics and hauling laptops through airports weekly. I spent the next six months off the road, visited my chiropractor up to three times a week. She addressed the spinal compression and hip alignment, and I regained most of my lost range of motion. Sleep came easily once again. That was three years ago, and after the course of treatment I stopped visiting her. I haven't needed to return.

Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations Link Table 2 Age-specific prevalence estimates of degenerative spine imaging findings in asymptomatic patients Link

The PT I saw when I "threw my back out" must have thought he died and when to heaven when, in answer to his question of what my expectations where, I told him "I wanted to strengthen my back so I didn't issues every time I did something without perfect posture." I also said I wasn't interested in medications for pain, etc. I ended going to what Kaiser calls a Back Clinic, which really was three PT sessions. As long as I do just one specific core strengthening exercise I am fine. You'd think that wouldn't be too hard, wouldn't you!?! And BTW, have you finished that blog post yet? ;^)

As it happens, I'm a mental health counselor who works in a chronic pain clinic. I support 100% the assertions made by Jen above regarding both the fact that an X-ray/MRI cannot predict whether someone experiences pain, and also the long-term ineffectiveness of Chiropractic. However, I did want to offer some suggestions of things that do help. Chronic pain is defined as any pain the persists 6 months or more (some say 3 months), which makes sense because, anything that is going to heal, will likely have done so after 6 months. Every day, I see people (most often with back pain) who have suffered from chronic pain, typically from 3 years up to 20+! In the first session, I always ask, "what non-medical things have you learned to help with the pain?" I'm amazed at how often the answer is "nothing," however, once in a while, I run across someone who was taught pain management skills years ago, and that's a great opportunity for me to ask, "what are you still using?" I've been working with this population for 8 years now, and have noticed a clear trend in the answers to that question. The most frequent responses fall in two general catagories: 1) some type of gentle movement, either light yoga or PT stretches, and 2) some type of deep breathing/meditation practice. The benefits of PT have already been offered above, so I just wanted to add meditation to the list of things that actually do help back pain. Please believe, I'm not a 'new age' type, and place my trust firmly in empirically-based treatment. Meditation is one of the most researched and best documented methods of treating pain. The benefits are too many to list in an already long post, so I'll just mention two here: first, when we meditate, the brain releases endorphins, which you probably already know are that positive brain chemical produced when exercising ('runner's high') or eating chocolate. Endorphins not only make us feel calm and peaceful though, they also anesthetize pain. If you've even had an injury and noticed you were numb for the first 20 minutes or so, that was because the brain was flooded with endorphins; they actually fit the same receptors in the brain that opiates do. The second benefit of meditation for chronic pain has to do with something called neuroplasticity (neuro=brain + plastic=pliable). The short version is that we build neural pathways by doing anything repetitively — think habits. Tying your shoes or playing a musical instrument are examples of neural pathways; things that you do without having to think about it, but only got that way through massive repetition. Here's the deal: pain becomes a neural pathway too when people have being 'doing pain' for a long time. Meditation is one of the best ways to change that by creating a new neural pathway of being in less pain (since meditation triggers endorphins, endorphins tamp down the pain), as well relaxing the muscles, thereby reducing tension on the source of injury. Unfortunately, although this is a potentially major benefit, few people make consistent enough use of meditation to get the full effect. It takes somewhere between 30-60 days to create a new neural pathway, so medication has to be a daily practice for a long time to reap the harvest and few people stick with it that far. But even a little bit will help a little; just like exercise, more is better. If you're interested in learning more, just look up MBSR (mindfulness based stress reduction) on youtube. Lots of free info and guided meditations. Hope that's helpful. Dan

I love psychologists who work in chronic pain!! you guys are my absolute favorite…i just wish there were more of you! I cannot +1 this post enough…Dan is spot on.

Thanks Jen. To be clear, I'm a master's-level counselor (LCPC), not a psychologist (Ph.D); not a distinction that doesn't matter much to most of the people I work with, but I wouldn't want to be accused of misrepresentation. ;-) There's an excellent video on utube called "Understanding Pain in less that 5 minutes" which is very informative and even somewhat entertaining. Here's the link: https://www.youtube.com/watch?v=C_3phB93rvI Useful for anyone who has experienced pain, not just chronic pain.

Yes, THANK GOD for the Pain Clinic! My facility has recently managed to halve the number of pain patients on chronic narcotics through a few new initiatives, and they are justifiably proud of that. Disclaimer- I'm a general surgeon, not an orthopedic surgeon… But I'll +1 everything Jen has said. Not unsurprisingly, since we are both evidence-based practitioners (as are most docs of our generation) we often have similar opinions. I especially agree that Lori's anecdote is an outstanding example of confirmation bias. I've noticed that some posters are having trouble discriminating a back injury from back pain, especially 'ruptured discs.' And there has been some (not entirely unfounded) criticism of orthopedists. Some have questioned what the difference is between orthopedists and chiropractors. The difference is that orthopedists struggle with back issues, and they will admit that. They are looking at EVIDENCE, and changing their practice accordingly. For all of the reasons Jen mentions back pain is a damned difficult problem to treat. There has indeed been a lot of evolution on how it is treated. I disagree that surgery will be recommended any time you go to an orthopedist for back pain, as one poster asserted. Any competent orthopedist will discourage back surgery for a bulging disc unless there are documented NEUROLOGICAL symptoms. Disc impingement does not cause back pain- it causes leg or buttock pain. I do work in a different system that is not income driven (the military), and I can tell you this is very much the case in my environment, at the least. Back surgery generally speaking has great potential to make your life worse not better, so you need to be in serious pain before you consider it. The example above of having just a few days of discomfort once or twice a year is a great example- if that were me I wouldn't even be thinking about surgery. In fact that IS me, as I mange to throw my back out once every year or two- I have made this much less common by working out my core more. And not all back disorders can be lumped together. There are some very valid indications for spinal fixation (though it has historically been overused, this is changing). This does admittedly leave patients with the problem of finding an orthopedist who isn't a dinosaur and wants to fixate everything. Hint- find a young guy for back problems. Regarding meniscal tears- a lot of orthopedists take issue with the new data about repair not being effective. There may be something wrong with those studies, but the insurance companies have latched on to them and many now refuse to cover it. This is unlike discectomy, which all agree is only indicated rarely. Many, in fact, try like hell to come up with some other indicated procedure and do the meniscal repair at the same time (essentially for free, since insurance won't cover it) because they think it will help. PS- Are you a D.O., Jen?

Dean, I'm a PT, not a DO, although I am fellowship trained in "manual therapy." That is a bit of a misnomer – anyone can learn how to crack people and do hands-on treatments – but the way we approach it is very much through pain science, advanced exam diagnostic skills (we learn to diagnose based on movement, pain behavior, response to interventions, etc) – all very DO-like. And a HUGE +1 to everything you said.

What I take from the studies re meniscal tears, adding that to my own clinical experience, there really are quite a few acute meniscal tears that are in just the right spot that will not respond to conservative tx but instead do really, really well with a surgical debridement. The studies in question focused primarily on the degenerative tears – those that we all have to some degree – and that also fits with my clinical experience. I've seen way too many people with "arthritis and cartilage tears" in their knees who have a meniscectomy and come to my clinic post op with exactly the same pain they had prior to the surgery. I think those are the ones under the microscope, so to speak. The question there has to be whether that degenerative meniscus is actually a pain generator or not……

Chiropractic is based on the notion that (virtually) all human ailments result from misalignment of the spine. "Cures" then result from realignment of the spine. Since the early days, chiropractors have learned a variety of other treatments that will ease suffering, sometimes permenantly. These have been added to their repertoire. But, there is absolutely no scientific basis underlying chiropractic theory. On a personal note, I have two herniated discs and mild scoliosis in my spine. Both have been diagnosed several times by X-Ray. None of these issues has ever caused me any pain. In my 30's I was 5' 11" tall – I'm now 5' 9" tall. Do I occasionally get back pain? Sure. I will, on occasion, forget that I am 78 years old and will lift something awkward or heavy, or both. Within minutes I am reduced to a floor-crawling, whimpering semi-vegetable. None of the pain comes from existing disc hernias or scoliosis though. It is usually damage to spinal muscles that gets me and then the injured muscles seem to splint themselves, painfully, to remind me not to do that again. For me the cure is rest, pure thoughts, good works and ibuprofen. I do allow 15 minutes of cussing per day though. Vicodin and its ilk won't lay a finger on it, ibuprofen is my miricle drug. I have read that roughly 80% of humanity suffers from back pain at one time or another. Just think of yourself as a member of a large, non-exclusive club.

What Dean said. Though I had a bit of back muscle pain initially, the major pain I had was all down my leg and in my butt. That has mostly subsided now, through healing and PT. But the numbness remains, and it seems to temporarily worsen, along with what I'd call discomfort but not pain on the outside of my ankle, when I do things that my back does not like. Those things seem to be walks of over an hour, or sitting in one position for an hour or more at rehearsal supporting my instrument (I'm a classical musician). I'm not even thinking about lifting anything big at this point. If I get in a bad position I get a brief twinge down the back of my leg, but nothinf like the constant excruciating pain I had initially. I've been off the painkillers after the first few weeks, and now use an anti-inflammatory as needed. But I'm still a ways from being able to do anything like a hike, let alone backpacking. It's been 12 weeks now. I don't see day to day improvement, but I can generally say I'm better than I was a couple of weeks ago. The numbness bothers me the most, and I hate to think that it may not go away; time will tell.

First of all, I wanted to let you know that there is light at the end of the tunnel for back pain, d k. I strained/sprained/stressed my back several years ago when pulling a calf, to the point that the next day I couldn't walk, and had to crawl to the phone to call work. Healing does happen, but it can take a long time. Chiropractic helped initially, but I was having not just pain, but weakness, and a little issue with urination as well, so there were some minor neurologic manifestations. Once the neurologic issues resolved, chiropractic was no help to me. Massage therapy helped more, but in the end it was proper muscle work, stretching over strained muscles and strengthening weak muscles that did the trick. Bad advice did give me a flirtation with sciatica as well, but eventually it was all about the muscles, not the fact that I had bulging discs. That being said, I do want to say a little in defense of chiropractic. As a veterinarian, the diagnosis of the source of pain is one step more removed–as my patients are not verbal, they cannot describe what they are feeling at all, although they are certainly quick to let me know where the problem is if they are tender to the touch! I do perform chiropractic, and I use the previously maligned Activator. Prior to learning this technique, the only relief I could give my patients was to put them on oral steroids, as much pain medication as I could, and instruct the client to lock their dog up and not let them move around for 2 weeks. Since having the techniques of chiropractic, I have had patients come in with their heads low, tails down, backs humped up, gaits shortened, and they leave my clinic with their heads and tails up, backs flatter, moving quickly and with proper stride. It is doing SOMETHING, I think we may just not know WHAT, and have made a story to explain to ourselves what is going on. If it is just stretching the trigger point of the muscle, then that is a valuable thing, and my patients do not need to come back to me repeatedly. Most cases resolve within 2 treatments. Chiropractic is ALWAYS followed-up with massage using an impulse massager if the patient will tolerate it; maybe that is resulting in the improvement, not the activator use. I do sometimes combine treatment with cold laser therapy if they are so painful that they will not tolerate the massage. I am about to go back to classes to learn the Chinese discipline of Tui-na, the Traditional Chinese Medicine method of body manipulation, and I'm curious to see how that will help my patients. I think we lack the technology at this time to even make an attempt to truly understand how chiropractic works. I also practice acupuncture, and while we have a better understanding of how acupuncture operates than we used to, it is still not fully understood by any means. It's awesome that it does work, though, and I happily use it on my patients. Recently had a patient with radial nerve paralysis, the nerve that controls weight bearing in the front leg. He had gotten out, maybe been hit by a car, we don't know. He was unable to use the leg at all initially, but is now back to full use of the leg after just 3 weeks. Similar cases have resulted in permanent impairment, so I am grateful that this little guy is able to use his leg fully again. I feel that we get arrogant and assume that we already KNOW everything. We still understand so little about how the body communicates between different parts. Heck, even anatomy can be unknown–recently a new blood vessel in the head was discovered that had not previously been characterized. The role of soft tissue in pain has been seriously undervalued, because we can't image it with radiographs, and we are a visual species. When we figure out a way to understand what muscles, ligaments, fascia and tendons are saying to us, we will have a much better understanding of sources of discomfort and how to alleviate them.

I had the same or similar problem: back injury, pain, sciatica, herniated disk. I did something stupid two days in a row, and my back said "enough is enough". At first I could barely walk. We'd go to my kids soccer matches and I'd spend about an hour hobbling around the field once. It gradually got better. PT therapy helped a lot, and I came away with some exercises to help the back. Once I was walking, I found that my backpack hit me in a good place for pressure, so I could backpack without pain. Shortly after I was walking, I saw a recumbent tadpole trike. Tadpoles are the ones with 2 wheels in the front. I got one, and have ridden it to work every day since (the last 8 years). Recumbents give you back support, and trikes are fairly fast and very fun. They are hard to tip over, so you can ride in snow and ice until it builds up into ruts. They put no pressure on hands, wrists, shoulders, and neck, only working out the legs. I'd look into recumbents as a way to get some exercise. see my cycling blog: http://www.bicyclepatents.com. Bob