Surgery can help, but is usually not required
As a neurosurgeon, I am surprised at the number of patients who undergo spine surgery when conservative management is more appropriate. My goal has always been to avoid surgery whenever possible. To that end, I offer the following clinical synopsis to assist with primary care management of low back and leg pain secondary to lumbar degenerative disease and to aid in decision making regarding surgical referral.
Managing patients with lower back and leg pain can be elemental or can be complex.
Decision making evolves around the following needs:
- Reaching a clinical diagnosis
- Monitor for neurologic dysfunction
- Diagnose underlying malignant or dangerous pathology
- Treat the patient’s pain
- Determine need for diagnostic testing
- Determine when surgical referral is appropriate
Key points on the history and physical include an understanding of the onset of the pain and its pattern. Leg pain from a herniated disc will usually radiate in a clear cut pattern, usually below the knee for the most commonly a ected discs of L4/5 and L5/S1. Patients with lumbar stenosis typically manifest neurogenic claudication.They will experience leg pain (usually bilateral) with walking that is relieved with sitting. They frequently walk forward in a stooped fashion. Patients with back pain may be suffering from lumbosacral strains, irritation of arthritic joints or, less commonly, from degenerated discs. Interestingly, 30% of the population have degenerative discs on an MRI with no symptoms.
Mr. Phil Graham was experiencing a recurrent episode of leg pain that had previously resolved with conservative management. MRI’s showed a herniated disk at L4/5 and Dr. McKalip performed a microdiscectomy at St. Anthony’s hospital. The patient was discharged the next day with an incision less than 3 cm in length and is now traveling and working in his landscape design rm, Phil Graham Studio. This case is an example of conservative therapy working at the right time and surgery then being timed appropriately to provide great pain relief and functional restoration for the patient.
Clinical diagnosis
If leg pain disappears during that time, there is no need for an MRI in the absence of neurologic dysfunction. Recurrent episodes of leg and back pain should prompt an MRI. Patients with severe and debilitating leg and back pain that is unresponsive to conservative management may warrant earlier scanning to determine if a surgically treatable lesion is present.
It is also appropriate to order an early scan in patients who are highly functional and seek timely return to employment or activity and may seek early surgery for this purpose. Patients often respond to non-steroidal anti-in ammatory drugs and mild narcotics, which can be escalated. Short-acting opiates are preferred versus the early use of long-acting agents like Oxycontin. Medrol dose packs (6 day) can be very useful, but should not be used frequently.
Physical therapy can help with pain control through heat and massage and sometimes traction. Patient should not be given bed rest for more than 2-3 days and should be encouraged to move. Any time a neurologic motor de cit is present, a neurosurgeon should be contacted urgently, usually within an hour of determining such. Sensory changes are less worrisome, but incontinence should be considered an emergency. Urgent scanning is appropriate in these settings. Referral to a surgeon should occur in the patient with unrelenting pain after 4-6 weeks or pain that is disabling early on. Typically, surgeons will wait at least 6-8 weeks before operating to ensure spontaneous resolution can’t occur unless the patient insists on early surgery. Surgical strategies available include simple discectomy (microscopic, or endoscopic) or hemilaminectomy/ foraminotomy for radiculopathy. A laminectomy is typically performed for lumbar stenosis associated with neurogenic claudication.
Diagnose underlying malignant or dangerous pathology
One must be aware of the possibility of renal colic, abdominal aortic aneurysms or other visceral causes of spinal pain. In addition, one should be aware of the possibility of discitis which may occur following a UTI, lower extremity infection or recent spine surgery.
An associated epidural abscess can manifest as neurologic de cits. Early laboratory and radiologic testing may be merited (see below) in certain cases. In patients with other clinical signs for non-spinal pain, radiographic or laboratory study appropriate for those presentations should be considered (e.g. renal colic, AAA). An ESR and CBC may be helpful to rule out discitis. Advanced discitis will manifest eroded end plates on a plain lm, but early discitis will have negative lms. A lumbar MRI can be appropriate at the right time. Early on, they should be reserved for patients who have neurologic dysfunction (weakness, incontinence). If leg pain doesn’t ease after 4-6 weeks, then an MRI would be appropriate.
Determine need for diagnostic testing
In patients with other clinical signs for non-spinal pain, radiographic or laboratory study appropriate for those presentations should be considered (e.g. renal colic, AAA). An ESR and CBC may be helpful to rule out discitis. Advanced discitis will manifest eroded endplates on a plain lm, but early discitis will have negative lms. A lumbar MRI can be appropriate at the right time. Early on, they should be reserved for patients who have neurologic dysfunction (weakness, incontinence). If leg pain doesn’t ease after 4-6 weeks, then an MRI would be appropriate.
Pain Management
Patients often respond to non-steroidal anti-in flammatory drugs and mild narcotics, which can be escalated. Short-acting opiates are preferred versus the early use of long-acting agents like OxyContin. Medrol dose packs (6 day) can be very useful, but should not be used frequently. Physical therapy can help with pain control through heat and massage and sometimes traction. Patients should not be given bed rest for more than 2-3 days and should be encouraged to move.
Determine when surgical referral is appropriate
Any time a neurologic motor de cit is present, a neurosurgeon should be contacted urgently, usually within an hour of determining such. Sensory changes are less worrisome, but incontinence should be considered an emergency. Urgent scanning is appropriate in these settings. Referral to a surgeon should occur in the patient with unrelenting pain after 4-6 weeks or pain that is disabling early on.
Typically, surgeons will wait at least 6-8 weeks before operating to ensure
spontaneous resolution can’t occur unless the patient insists on early surgery.
Surgical strategies available include simple discectomy (microscopic, or endoscopic) or hemilaminectomy/foraminotomy for radiculopathy. A laminectomy is typically performed for lumbar stenosis associated with neurogenic claudication.
