How do you diagnose a disc herniation?

This seems to be a popular question so, here we go.

Disc herniations are easy to find. 30 minutes in the old MRI machine and wham, there they are (or aren’t if you don’t have any). Case closed, right? Wrong!

Many disc herniations that show up on MRI are not causing any problems. They are innocent. I know what you’re thinking. My disc is torn or ruptured or slipped or something terrible like that and you are saying that is OK??!!

Actually, sort of. Studies have shown that if you go out to your local mall and grab the first 100 people you see that don’t have back pain and never have and take them to get an MRI…………..about 30 of them will have disc herniations.

But, you say, it must be about to snap!! Like a tinder box about to go up in flames!! Not really. Disc herniations are one of those things that don’t matter…unless of course they do.

Figuring out whether they do or not is what you need a doctor and a good old physical examination for. I guess you can’t outsource the docs yet.

What kind of treatment do I need: Part II

Once we have ruled out the nasty causes of back pain (cancer, infection, etc.) and we know we are dealing with a musculoskeletal condition (disc herniation, arthritis, back sprain, etc. etc.), we can talk about treatment options. There are two main types of treatment for neck and back pain: passive care and active care.

Passive Care

Passive care includes things that are done to you. This includes massage, chiropractic adjustments, ultrasound, microcurrent, traction and more. The general rule on passive care is that it should be a bigger part of your care at the start and a smaller part of your care as you get better.

Passive care can be great. It makes you feel better! However, if you are not getting active care, more than likely you are getting less than the best treatment.

Active Care

Active care is things that you do to and for yourself. Usually active care means some type of exercise. Walking is a form of active care that everyone should do. However, general exercises like walking are not enough by themselves. Most neck and back pain needs some specific exercises to correct your specific problems.

The good news is that you almost never need any fancy or expensive equipment or a lot of time. For most, five minutes per day five days per week is enough – for your specific therapy exercises, not your exercise for general health (darn!).

An example of a specific therapy exercise that is commonly needed is in my earlier column, “The Back Pain Vaccine”.

My back hurts. What kind of treatment should I get?

It is hard to be a patient with back pain. Everywhere is conflicting advice. Surely, though, your healthcare team will give you up-to-date and unbiased advice, right?

In short, not a chance! Most (MD’s, DC’s, LMP’s, PT’s, DO’s, ABC’s, etc) are going to tell you either: a) you’ll be fine, just wait b) you need whatever it is that I do. If their treatment fails, you may get one referral to someone else that they like (personally). Otherwise, the pain is in your head…or there is nothing more to do…or just keep getting my treatment…or….

Since nobody is going to give you a straight answer, here is my guide on how to use the different providers:

Family Practitioner (MD or DO): They are going to be fairly good at ruling out a nasty cause of your pain, particularly cancer and infection. If you have an exotic arthritis, they will probably figure it out with time.

Massage Therapist (LMP): Massage is a great adjunct to other treatment, but not enough usually on it’s own. Combine with Physical therapy and/or chiropractic.

Chiropractor (DC): I wish I could say, go find a chiropractor and he will help you with what he can and manage the referrals for the other care that you need (massage, physical therapy, surgical consults, etc.). Many do this, but not most.

Chiropractic adjustments are very efficient and effective treatments for a majority of back and neck complaints. Combined with physical therapy exercises it is even better in most cases. Generally, the chiropractor should be able to guide you through the exercises that you need, which should not be too many – if so, you may need a physical therapist.

Unfortunately, many chiropractors treat everyone the same and just crack your back without good diagnosis or making sure you get the other treatment you need. Finding a good chiropractor can be difficult, but it is worth it.

Physical Therapist: For most back pain, physical therapy exercises are effective and often necessary. PT’s tend to give to many useless exercises along with the useful ones. Often a chiropractor can give you the exercises that you need more efficiently, but if it is more complicated, or your chiropractor can’t handle it, you will need a PT. You can’t throw a dart at the phone book here either and have a reasonable chance, but good PT’s are out there.

Surgeons (MD, DO): You probably should not have back surgery. Just having a herniated disk does not mean you need back surgery. However, if you do, go to a neurosurgeon that does mostly spine surgeries. You will have the best luck here.

What about cortisone injections and prolotherapy and those fancy traction machines with an “86% success rate” and…and how much treatment do I need? Next time.

Warning: This is a (very) general guide on who does what well. It is to help you find someone to treat you, not so you can diagnose yourself and ignore medical advice given to you. If you are unsure of your current treatment or diagnosis, etc, get a second opinion from a live person in the flesh, not a blog!

When should I see a doctor for low back pain?

When back pain strikes, I know your first response: It will go away. Actually, at first this is a good reaction. However, if these symptoms mean you NEED to be checked out:

1. New pain that lasts longer than 2 weeks.
2. Pain that does not improve with rest.
3. Weakness in your leg (i.e. dragging your toes on one foot, etc).
4. Fever.
5. Numbness in the areas that would touch a saddle if riding a horse, or difficulty going to the bathroom (whether unusually difficult, or coming without your intention).

So, if you have any of the above you MUST go and be checked out at least. However, what if your back pain comes and goes?

If you have 3 or more episodes of the same pain that last longer than 1-2 days, you should be treated.

Now, of course, you are wondering: who should I see? what kind of treatment do I need? how much treatment do I need? We’ll get to some of these questions in the next day or so.

Disc Herniation: What your MRI is telling you

Disc herniation can be scary. I see patients and even doctors who shudder at it’s very name! But, are all disc herniations created equal? How do I know if mine is going to get better or not?

A new study looked at this question. They followed 154 people with sciatica and disc herniation on MRI for 14 months. The main question they were interested in was: do the patients who recover have anything different on their MRI’s from the people that don’t get better?

They found that patients with broad-based disc herniations(disc that protruded most of the way across the disc from left to right) were more likely to recover than those that had disc herniations just on one side. They also found that men were more likely to recover than women.

But, the most important nugget from this study is that they patient’s recovery had no relation to whether or not the disc herniation was still present, or even if it was still pressing on the nerve.

So remember, the question is not whether the disc is still pressing on the nerve. The question is whether your pain is bothering you and/or preventing you from doing what you want to do!