Lumbosacral Disc Injuries Treatment & Management

  • Author: Robert E Windsor, MD, FAAPMR, FAAEM, FAAPM; Chief Editor: Craig C Young, MD   more...
 
Updated: Nov 28, 2011
 

Acute Phase

Rehabilitation Program

Physical Therapy

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.

Surgical Intervention

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.[39, 40] 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.

Other Treatment

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.[32] 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.[41] 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.[42] This procedure has provided an alternative to major spinal surgery in the treatment of chronic LBP related to IDD.

Proceed to Medication
 
 
Contributor Information and Disclosures
Author

Robert E Windsor, MD, FAAPMR, FAAEM, FAAPM  President and Director, Georgia Pain Physicians, PC; Clinical Associate Professor, Department of Physical Medicine and Rehabilitation, Emory University School of Medicine

Robert E Windsor, MD, FAAPMR, FAAEM, FAAPM is a member of the following medical societies: American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine, American Medical Association, International Association for the Study of Pain, and Texas Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Kevin P Sullivan, MD  Consulting Staff, The Boston Spine Group

Kevin P Sullivan, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, International Spine Intervention Society, and North American Spine Society

Disclosure: BioAssets Development Corp Consulting fee Consulting

Erik D Hiester, DO  Fellow in Interventional Pain Management, Emory Medical School/Georgia Pain Physicians

Erik D Hiester, DO is a member of the following medical societies: American Academy of Family Physicians, American Medical Association, American Osteopathic Association, and American Pain Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Andrew D Perron, MD  Residency Director, Department of Emergency Medicine, Maine Medical Center

Andrew D Perron, MD is a member of the following medical societies: American College of Emergency Physicians, American College of Sports Medicine, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Henry T Goitz, MD  Academic Chair and Associate Director, Detroit Medical Center Sports Medicine Institute; Director, Education, Research, and Injury Prevention Center; Co-Director, Orthopaedic Sports Medicine Fellowship

Henry T Goitz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons and American Orthopaedic Society for Sports Medicine

Disclosure: Nothing to disclose.

Jon B Whitehurst, MD  Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner, Rockford Orthopedic Associates; Orthopedic Chairman, Rockford Memorial Hospital

Jon B Whitehurst, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America

Disclosure: Nothing to disclose.

Chief Editor

Craig C Young, MD  Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Director of Primary Care Sports Medicine Fellowship, Medical College of Wisconsin

Craig C Young, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous coauthor Dr Dennis P White to the development and writing of this article.

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