Lumbosacral Disc Injuries Treatment & Management
- Author: Robert E Windsor, MD, FAAPMR, FAAEM, FAAPM; Chief Editor: Craig C Young, MD more...
Physical therapy for acute radiculopathy should emphasize analgesia through passive modalities, stretching activities, and soft-tissue mobilization initially, and then the therapy should advance to McKenzie-type activities to regain segmental motion. Once segmental activity has been normalized or improved and the patient's pain has been reduced, then the patient may begin a walking program and a progressive lumbar stabilization program. The stabilization program should be steadily advanced, and the patient should have a generalized conditioning program initiated as well.
The treatment of radiculopathy depends upon the pain severity, degree of functional limitation, and neurologic status. Surgical emergencies include cauda equina syndrome and a rapidly progressive neurologic deficit. Relative surgical emergencies include painless weakness with or without numbness, less than antigravity strength, or extreme leg pain that is unresponsive to a selective nerve root block (SNRB). The above clinical scenarios are thought to be biomechanical rather than biochemical in origin; thus, they are amenable to immediate surgical intervention. All other conditions require a minimum of 6-12 weeks of adequate nonsurgical care before the consideration of surgery. Treatment is directed toward alleviating pain.
For those patients with chronic LBP that is unresponsive to nonsurgical management, lumbar fusion remains the surgical procedure of choice. Unfortunately, suboptimal clinical results are obtained by a significant proportion of patients. Lumbar disc arthroplasty has been developed as a potential means to improve the long-term outcome of these patients.[41, 42] Although these devices have had relatively good early clinical results, questions still remain about their long-term efficacy in the maintenance of motion and relief of pain, the life span of the devices, and the results of randomized comparative trials with fusion.
Early in the care of radiculopathy, interventional procedures may be employed in cases of severe pain, lack of progress, or significant functional impairment. In a position statement, the NASS recommended the use of epidural steroid injections in lumbar radicular pain caused by structural abnormalities such as disc herniation and spinal stenosis.[33, 43] If no improvement occurs, confirmation of the diagnosis is required. MRI is the study of choice, but it is important for the lesion, as seen on MRI, to corroborate with the location of symptoms. In borderline or ambiguous cases, electrodiagnostic testing can be helpful. If the diagnosis remains uncertain, a fluoroscopically guided SNRB may be employed as a diagnostic aid.
Appropriate nonsurgical rehabilitative interventions include oral nonsteroidal anti-inflammatory drugs (NSAIDs), spine-specific physical therapy, avoidance of provocative influences, and a fluoroscopically guided steroid injection. If a comprehensive conservative program fails, an open surgical or other less invasive procedure (chemonucleolysis or percutaneous discectomy) is offered. Long-term analyses have not shown surgical intervention to be superior to a more conservative approach. Less invasive treatments may be successful in up to 80% of persons thought to be appropriate surgical candidates.
Intradiscal electrothermy (IDET) is perhaps one of the newest and most innovative treatments aimed at chronic LBP resulting from IDD. Targeted thermal therapy with the IDET procedure is designed to modify annular collagen, thermocoagulate annular nociceptive nerve fibers, and cauterize ingrowth granulation tissue. These effects promote collagen remodeling and changes in the annular integrity (causes contraction and thickening of the annulus collagen, thereby stabilizing annulus fissures). A study evaluating the outcome after IDET has shown success rates of 70-80% based upon an improvement of 2 points on a 10-point visual analog score (VAS) and sitting tolerance. This procedure has provided an alternative to major spinal surgery in the treatment of chronic LBP related to IDD.
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