Conquer Back and Neck Pain - Walk It Off! (17 page)

A specialist should perform the epidural injection using fluoroscopy (moving x-ray picture) to accurately place the steroid in the exact region of the painful nerve. I refer my patients to another specialist (anesthesiologist or physiatrist) to perform epidural injections. Your doctor may perform the epidural or may refer you to another specialist to have it performed.

First, a disclaimer: Unlike an MRI scan, I have personally never had an epidural, therefore I am relating to you what patients have told me about their experience with the procedure. Most patients say that it is not a very painful procedure, but a few patients do complain of experiencing a temporary increase in pain at the time of the injection. This is particularly true when the steroid is injected into the area of an irritated nerve. You can request sedation when it is being performed, but some patients do not want it. The injection includes a local anesthetic along with the steroid medication, which should give you some immediate pain relief. Immediate pain relief from the local anesthetic is an indication that the correct area was injected. I write a prescription stating the exact level and side of the herniated disc so that the doctor who is performing the procedure will know exactly where I want the injection to be placed. Accurate placement of the steroid is confirmed when the patient has immediate relief of pain from the local anesthetic in the injection. Immediate relief of your pain at the time of the epidural injection also helps to confirm the diagnosis that the disc herniation seen on your MRI scan is the actual cause of your pain.

Diabetic patients may see a temporary increase in their blood sugar following an epidural. They should monitor their blood sugar closely for a few days following the injection. However, I have not seen a diabetic patient develop any permanent trouble from the transient elevation of blood sugar following an epidural.

Rarely, a patient may experience a spinal headache. A spinal headache results from leakage of spinal fluid when the needle causes a hole in the sac (dura) that contains the nerves. Years ago I had a spinal headache following spinal anesthesia for knee surgery. I experienced intense pain behind my eyes when I stood up and it went away immediately when I lay down. This is typically how patients describe a spinal headache. It usually goes away after a few days, but it can be very disturbing to say the least. At times a blood patch is required to stop the leak and relieve the headache (blood is taken from a vein in your arm and then injected into the epidural space to seal the spinal fluid leak). Spinal headache from spinal fluid leakage is seen more often in patients who have had more than three epidural injections. This is one of the reasons I limit the number of epidurals I will prescribe to my patients to three in a six-month period. The other reason for limiting the number of epidural steroid injections is that if three injections that lessen local inflammation do not give lasting relief of pain, then the irritating source of the problem is not being taken care of. So, if the nerve in your back continues to be irritated and painful despite three epidurals within a six-month period, then it is time to consider other options, such as surgery.

In over 35 years of practice, I have seen only two patients who developed an infection following an epidural steroid injection. Both patients were heavy smokers; smokers are susceptible to infection, so I ask my patients to stop smoking before they have an epidural. The risk of infection from an epidural is very low. In order to prevent this complication, I do not recommend that a patient with an active infection, such as acne around the site of injection, have an epidural steroid injection until the infection is treated first. If you have had a recent urinary tract infection, fever, earache, toothache, periodontal disease, foot ulcer, or other source of infection in your body, you should not have an epidural. Active infections somewhere in your body must be treated before having an epidural steroid injection because of the risk of the infection spreading to your spine as the result of the procedure. You should warn your doctor of any active or recent infections that you have experienced, even a common cold, before allowing yourself to have an epidural steroid injection.

Increased nerve damage may result from an epidural injection if the needle penetrates the nerve. A skillful doctor who performs the injection will take precautions while performing the procedure to prevent this from happening.

When appropriate precautions are taken, I have found that epidural steroid injections are a safe and effective way of relieving pain caused by a herniated disc. Many of my patients have been satisfied with the pain relief experienced from an epidural steroid for a painful herniated disc.

If your disc herniation causes weakness of a major muscle in your arm or leg along with the pain, if you have changes in your bowel and bladder function, or if you experience loss of balance, you need surgery as soon as possible. If the pain is unrelenting and you are having difficulty walking and sleeping, you should have surgery. If you have had the pain for more than three months and it has not been relieved by one or more epidural steroid injections and you need narcotics to function, you should seriously consider surgery.

The top figure illustrates a spine cross section showing a compressed nerve from a herniated disc. The lower figure shows that a portion of the disc has been removed to decompress the nerve.

The standard surgical procedure for a disc herniation in your low back is called a laminectomy (removing part of the roof of the spinal canal in order to see the herniated disc) and disc excision (removing that part of the disc that is pressing on the nerve). The incision is between two and four inches long, depending on how large you are, and the surgeon wears magnifying glasses to perform the procedure. The procedure takes between 45 minutes and an hour and a half, depending on how adherent the herniated disc is to the nerve. Most patients are able to walk the same day of surgery and leave the hospital the following day. You can expect to be able to get out of bed by yourself and walk without pain before you leave the hospital. The procedure is not very painful, and most of my patients take narcotics for no more than a day or two following surgery. You can expect to be back at work within 10 days.

I once removed a herniated disc in the low back on a bone fisherman. Bone fishermen are the ones who stand on an elevated platform in the back of a skiff and push the boat through the water with a long pole. The surgery was on a Monday, and he returned to the Florida Keys the following morning. He never came back to see me in the clinic, so I contacted his wife and she told me that he was out fishing and had been since two days following his surgery! It was bone fishing season and he wasn’t going to miss any more time than was necessary. He was pushing his boat with his clients around the salt-water flats of the Florida Keys in hot pursuit of bonefish.

Though I would not advocate that you try to do what he did two days following disc surgery, this story illustrates that recovery from a standard open disc excision in the low back can be that fast. My doctor colleagues have gone back to work within a week of disc surgery. But for someone who performs heavy work requiring lifting and bending, I do not recommend returning to work until six weeks following the surgery. I do not recommend golf or tennis, both of which require twisting — a particularly stressful motion for a degenerated disc — for a period of three months following a disc excision. I recommend walking exercises for the first six weeks following surgery. I have found that most people can return to the activity level they were at prior to suffering from the herniated disc. A tennis player should be able to resume playing tennis, and a golfer should be able to golf following disc surgery.

What about micro-discectomy? What is it and does it have any advantage over a standard discectomy? Micro-discectomy is the removal of the disc through a small incision (less than two inches) with the aid of a microscope. It requires more time to perform the surgery through a small surgical incision compared to a standard surgical incision. I can see no real advantage, other than cosmetic, to have the surgery performed through a small incision. The proponents of the smaller incision claim that patients leave the hospital sooner and require less pain medication following micro-discectomy compared to a standard disc excision. This has not been my observation. Patients who have a standard incision versus a micro disc incision both leave the hospital within 23 hours and are back to work within 10 days. I do not recommend the microscopic procedure to my patients unless they specifically ask for the procedure. The length of time spent in the hospital and the amount of pain medication required following surgery, including discectomy, is related to the health and fitness of the patient, not the length of the skin incision.

I saw an advertisement in a flight magazine with three ladies lying on a beach; one had a band-aid on her back from surgery the same day! How about band-aid surgery? Band-aid surgery refers to a technique in which a scope is used to remove the disc, similar to the well-known arthroscopic surgery for the knee. The incision for the scope is presumably small enough to be covered by a band-aid, albeit a large one! Over many years I have seen many failed attempts to perfect arthroscopic surgery for the spine. The method has not gained acceptance by most spinal surgeons for several reasons. The most common disc that herniates is the L5-S1 disc, which is a difficult level in the low back to safely reach through a scope. The second reason is that almost every disc herniation that doesn’t get better with time is associated with a small, misshapen spine canal, spinal stenosis, which is difficult to correct through a scope. I have also seen some serious complications from this technique. There is a higher incidence of spinal-fluid leakage, infections, and nerve damage using this technique compared to standard disc surgery. I do not recommend or perform arthroscopic disc surgery for these reasons.

Only that part of the disc that is out of place is removed in the low back, and a spinal fusion (page 93) is hardly ever performed at the same time. The discs in the low back are eight to 10 times larger than the discs in your neck, and only a small part of the discs in your low back herniates out of place. The remainder of the disc is still adequate to function normally with rare exceptions, which I will explain to you in the chapters on spinal fusion and disc replacements.

Your neck discs are small, and the area of the disc that herniates can be difficult to reach because your spinal cord is in the way. Therefore, most herniated discs in the neck are taken out by a front approach to the spine. Almost the entire disc in your neck must be removed to reach the displaced fragment in front of the spinal cord. Therefore a spinal fusion with a block of bone from your pelvis or from a bone bank is used to fill the space between the vertebrae following a disc excision in the neck. The other alternative is to have an artificial disc replacement instead of a fusion following a neck-disc removal. I will explain the pros and cons of both procedures in depth in
Chapter 12
.

Some disc herniations in the neck can be removed through a small incision in the back of your neck. When the procedure can be performed from this approach, a spinal fusion is not necessary because the whole disc is not removed, only the fragment that is pressing on the nerve. This is a good alternative approach to the standard front approach, which requires that the entire disc be removed and that something be put into its place.

Disc herniations in the thoracic spine, or back of the chest area, are the rarest, and they are the most difficult and dangerous to remove of any of the discs in your spine. There are two ways to remove a disc from the thoracic spine; one is from behind, just alongside the spine, and the more common way, and I think the safer way, is through the chest. This is one area of your spine where some discs can be safely taken out through a scope. Most of the disc is taken out, and a fusion is usually performed at the same time. Because there is very little normal motion in thoracic discs, unlike the neck, artificial discs are not used following the removal of a thoracic disc.

What are the benefits of having a disc removed if it is not an emergency, and is it okay to wait? If you are faced with chronic disc pain that is not threatening life or limb and for whatever reason need to have quick relief, then there is an advantage to having a disc excision. You can expect at least 80 percent relief of pain almost immediately upon awakening from anesthesia. You may experience immediate partial relief of muscle weakness and improvement in sensory loss following a disc excision. According to studies reported in the medical literature, more people are happier the first year following surgery compared to people who wait it out. The studies also show that somewhere between the first year and 10 years following onset of the symptoms of a low-back disc herniation, the people who wait it out have the same overall relief as those who have surgery. Why have the surgery then? Many people cannot wait it out for various reasons. My neighbor had such severe pain that he wanted immediate surgery. The bone fisherman needed quick relief from his disc herniation so that he would lose as little time as possible from fishing season. Others have reached a plateau and have gotten better with time, and some patients who are gradually getting worse elect surgery. After learning from your doctor the alternatives, nature, benefits, and risks of disc surgery, you need to make the final decision about whether the surgery is right for you