Question: "I have terrible pain going down my leg that they say is radiculopathy from disc disease. What can I do about it?"

Answer:

• Unfortunately, this is a very common problem.
• I recently posted a blog about the mechanics of nerve impingement and radiculopathy (see Feb 2nd posting for details).
• With your question, I will expand on information from the prior posting and go through some potential treatment options. This should give you a good foundation from which to discuss treatment strategies with your PCP.

Surgery:

• Surgery can be a definitive treatment for pain arising from degenerative disc disease. When appropriate, surgery can be a miracle cure.
• However, even when the cause of pain is clear on MRI and physical exam, surgery is not always successful at alleviating symptoms. Up to 40% of patients have persistent and sometimes worse pain after surgery. This is the so called “failed back syndrome”.

Surgery risks

• There are many different types of back surgery. Regardless of the approach, spinal surgery is not a minor endeavor.
• There are short term risks with surgery such as anesthesia complications, bleeding, nerve injury, infection, and death. These risk factors are exaggerated with concomitant health problems such as heart disease and diabetes.
• There are also potential long term complications with surgery such as chronic pain, recurrent or worsening pain from surgical scar tissue, decreased mobility, fracture, infection, etc.
• Because of these factors and because radiculopathy symptoms may subside on their own, surgery may be delayed.
• However, there are times when surgery is the only solution to avoid potential paralysis. Qualified medical examination and MRI will be needed to direct appropriate clinical care. Don’t try to do this on your own. If you have paralysis or other problems such as trouble urinating this may indicate a more serious problem such as cord compression. This blog entry information is for radiculopathy and not for the more serious problem of severe spinal stenosis, cord compression and/or cauda equina syndrome. See your doctor regarding your back pain or other related symptoms because without appropriate medical care it may lead to permanent disability.  

Primum non nocere (first do no harm):

• After a disc has ruptured, several specific immune cells (such as macrophages) will arrive at the scene to start to remove the diseased material. These immune cells are small and therefore the removal of disc material is slow. If there is not an additional or recurrent disc rupture, then over time the diseased disc often gets smaller and the amount of inflammatory mediators will decrease. This process will lead to a marked improvement or resolution of symptoms for many patients. There are some papers that suggest the long term outcome for radiculopathy is similar for patients who wait to have surgery compared to patients who have immediate surgery.

Finding out about other pain treatment options: 

• It is important to know your audience. Don’t expect to get a full list of nonsurgical pain treatment options from your surgeon.  Surgeons like to do surgery and they get paid to do surgery. Most surgeons think about surgery all the time and do it very well. In general, surgeons like to face a problem head on with the tools they know. Another words, everything looks like a nail if you only have a hammer.  There are other less invasive options to consider for back pain that your surgeon or PCP may not even know about (see below).

Noninvasive or minimally invasive treatment options for radiculopathy:

• In general, radiculopathy is not an easy problem because is not a normal kind of pain and does not respond to well to standard pain treatments. In addition, pain is only part of the story because nerve injury also affects muscle function.

I am in favor of:

1. Pain Clinic: Many major hospitals have a dedicated “pain clinic” or “pain center.” There you will find people who are trained specifically in the art of treating different specific types of pain. These are usually run by or in conjunction with anesthesiologists. They should know the subtleties of pain treatment better than an average surgeon or PCP. This is a relatively new field and sometimes you won’t know about this option unless you ask about it specifically. If I were in your position I would definitely explore this alternative.
2. Diet and reasonable exercise with the goal of reaching a healthy weight and developing strong back supporting muscles. This should be done under the supervision of a medical professional. 
3. Neurontin (gabapentin): This is an underused medication that has a low side-effect profile and is particularly good at neuropathic pain. The only major problem with neurontin is that it takes a long time to start working and doesn’t work for everyone.
4. Acetaminophen: Low side effects and works fairly well for neuropathic pain.
5. Capsaicin cream: This is a relatively new one on the market and I like it for several reasons. First it is effective. Second it has a low side effect profile and third it is the active hot ingredient in chili peppers. Muy caliente! It is used topically. When it is applied to the skin, capsaicin cream has been found to deplete the pain neurochemical known as substance P.  Less substance P = less pain. Use gloves when applying because this stuff is hot and can burn sensitive parts.
6. Lidocaine patch: This is also applied topically and will numb the skin. This is basically the stuff the dentist injects but is used topically with the patch, so no injection pain.
7. Nontraditional approaches: These include acupuncture, biofeedback, meditation, etc. Acupuncture is covered by many insurance plans for the indication of pain. These options have no real side-effects and in some journal articles, the positive results for acupuncture have been reported to be up to 90%. They can be used in conjunction with other pharmacologic treatments without cross side effects.
8. Physical therapy: A dedicated medical physical therapy program is important for long term function and may also help in the short term, but should only be done by qualified individuals with specific knowledge of the nature and extent of disease.
9. Nerve root blocks: This can be helpful in some patients. Some studies have reported success as high as 60%.  However, in some patient's symptom relief can be short lived. The procedure is semi-invasive and the risks are less common than surgery. Risks include bleeding, nerve damage, vascular damage, infection, transient weakness/paralysis, spinal cord infarction and stroke. Most physicians will limit the procedure to a total of 3 separate treatments attempts because of potential steroid side effects, however this limit is controversial.

Options that I have mixed feelings about (treatment will depend on your specific clinical situation):

1. NSAID’s (such as aspirin) are better than opiates for this type of pain, but chronic use increases the risk for side effects such as a bleeding stomach ulcer. This is risk is exaggerated for someone like yourself who should already be on NSAID’s for heart disease or with chronic illness.
2. I am not a fan of narcotics but when the pain is intolerable it may be an option. Vicodin is a better option than oxycontin and oxycodone because Vicodin is a mixed drug containing both acetaminophen and hydrocodone. The mixture allows a lower dose of hydrocodone (narcotic) but long term use can result in similar problems (cause constipation, can alter level of awareness, and are addictive). In general, narcotics are not particularly good at this type of pain.

I am unsure about these options:

1. I have heard that electrical stimulation has been helpful in some uncontrolled studies; however, I have no experience with this myself.
2. Mechanical traction seems archaic, but it apparently works for some.

Treatment options that I would view with caution:

1. I am not a fan of a chiropractor. I have seen some unnecessarily bad outcomes, particularly after manipulation if the neck. However, some people swear by it.
2. I would avoid stronger opiates such as oxycontin and oxycodone. Opiates are not particularly good at this type of pain; they cause constipation, can alter your level of awareness, and are addictive.
3. Some people advocate bed rest. I do not think this is a viable option because in the long term this will weaken already compromised muscles. Weakened muscles will not be able to support your spine and therefore accelerate the degenerative process. Disuse will also lead to limited motion from muscle/tendon tightening. Extended bed rest will also lead to accelerated osteoporosis, potential spinal/hip fracture, pneumonia and other bad things.