Managing Herniated Discs

DIAGNOSING A HERNIATED DISC

The diagnosis of a Herniated Disc is made upon history and examination.  Use of imaging and pathology is discouraged unless there is cause to think that the patient is suffering a serious complication [1].

MANAGING A HERNIATED DISC

The majority of adults with low back pain are effectively managed in primary care. Routine imaging and bed rest are best avoided. Instead, patients should initially be provided with advice and simple analgesics and encouraged to remain as physically active as possible. If this initial approach provides insufficient pain relief, stronger analgesics and referral for physical therapies may be considered. Interdisciplinary rehabilitation is an option for those with persistent low back pain that does not respond to initial measures[2].

Care pathway for low back pain C/- MJA 2018

Do not routinely order imaging or pathology

Patients with non-specific low back pain of less than six weeks duration should not routinely be sent for imaging or pathology tests. However, in Australian primary care about one quarter of patients with acute back pain are sent for imaging and 5% are sent for pathology. This practice is hard to justify as the findings on imaging, electromyography, nerve conduction studies and pathology tests are not correlated with symptoms of back pain. These investigations do not help establish a diagnosis or help with selection of therapy in patients with non-specific low back pain. International clinical practice guidelines uniformly recommend that investigations should be reserved for patients with suspected serious pathology or those with radiculopathy who are being considered for surgery. A systematic review of trials revealed that routine imaging does not improve clinical outcomes, compared to imaging only when indicated, and therefore it is not recommended.

The majority of patients with a short duration of symptoms will recover.

Management of acute non-specific low back pain (up to six weeks duration)

First-line care

  • Advice
  • Review in 1–2 weeks
  • Consider physiotherapy and psychological therapy

Second-line care

  • Use of analgesia e.g. non-steroidal anti-inflammatory drugs (paracetamol no longer recommended)
  • Spinal manipulative therapy
  • Hot packs, heat wraps

Advice to Patients

  • Reassure that there is no evidence of serious damage or disease
  • Avoid labelling as injury, disc trouble, degeneration or wear and tear
  • Reassure about good natural history, providing you stay active, but with accurate information about recurrent symptoms and how to deal with them
  • Advise the use of simple safe treatments to control symptoms
  • Encourage staying active, continuing daily activities as normally as possible, and staying at work. This gives the most rapid and complete recovery and less risk of recurrent problems.
  • Avoid saying 'let pain be your guide'
  • Encourage taking responsibility for their own continued management

ROLE OF SURGERY

Surgery has a limited role in the management of low back pain. Discectomy has been shown to be effective in patients with radiculopathy due to a herniated lumbar disc, and decompressive surgery is suitable for patients with spinal stenosis. As both conditions may improve on their own, a trial of conservative management should be offered first. Patients should be advised that discectomy for radiculopathy provides more rapid relief of pain, however, the long-term outcomes are similar to those for conservative care.

For patients with degenerative disc disease with presumed discogenic back pain, the surgical options include fusion and artificial disc replacement. Both UK and US guidelines noted that fusion is no more effective than interdisciplinary rehabilitation. The UK guideline suggests that referral for surgery be reserved for those who do not respond to interdisciplinary rehabilitation. The US guideline reported that presently there are insufficient long-term data to judge the benefits and harms of artificial disc replacement, and did not recommend the treatment.

References:

[1] Maher CG, Williams C, Lin C, Latimer J. Managing low back pain in primary care. Austr Prescr 2011;34:128-321 DOI: 10.18773/austpresc.2011.069

[2] Goergen S, Maher C, Leech M, Kuang R. Acute Low Back Pain. Education Modules for Appropriate Imaging Referrals: Royal Australian and New Zealand College of Radiologists; 2015.

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