Conservative Treatment

Spontaneous improvement of low back discomfort has allowed ineffective treatments to

perpetuate, because benefits have been ascribed to them when they are prescribed while the
patient is still symptomatic but otherwise improving. Hippocrates expected improvement in
sciatica in 40 days, and the customary and contemporary guideline is 6 weeks. An often-quoted
study suggests near-resolution improvement of 90% of patients within 6 weeks, but this study
has been faulted because the criterion for patient recovery was failure to return to the observing
physician. The prevalence of back problems is consistent with the failure of a subgroup of
patients to improve and to have periodic recurrent episodes of disability.
Analysis of the effectiveness of treatments and attempts to restrict treatment to those modalities
that have demonstrated efficacy are evidence-based medical practice. Bedrest has a long
history of use but has not been shown to be effective beyond the initial 1 or 2 days; after this
period, bedrest is counterproductive. All conservative treatments are essentially efforts to
reduce inflammation; therefore, only a very short period of rest is appropriate, antiinflammatories are of some benefit (because the pain is from inflammation of the nerve), and
warm, moist heat or modalities may be helpful. Activities should be resumed as early as
tolerated. Exercises and physical therapy mobilize muscles and joints to facilitate the removal of
edema and promote recovery. Muscle relaxants may offer symptomatic relief of the acute
muscle spasms but only in the early stages; however, all are central acting, there is no direct
relaxation of skeletal muscle, and they are also sedating.
For back pain without radiculopathy, chiropractic care has high patient satisfaction when
performed within the first 6 weeks, and it has been shown to have good efficacy acutely from an
evidence-based standpoint.[22] Injections (eg, epidural) may be particularly helpful in patients with
radiculopathy by providing symptom relief, which allows the patient to increase activities and
helps facilitate rehabilitation.[23, 24] Any nuclear material that is herniated may shrink as the
proteoglycan deteriorates, loses its water-retaining ability, and turns from a grapelike object to a
raisinlike object.
Arbitrary time schedules for improvement are inappropriate in any patient who continues to
improve and whose function is relatively maintained. Traction in the acute setting may help
muscle spasms, but it does not reduce the HNP and has no good evidence of efficacy. The use
of traction does not justify hospital admission, as it is not cost-effective and can be administered
on an outpatient basis.
Long-term use of physical therapy modalities is no more effective than hot showers or hot packs
are at home. A transcutaneous electrical nerve stimulation (TENS) unit may be subjectively
helpful in some patients with chronic conditions. Encourage patients to essentially compensate
for intervertebral disk incompetence, as possible, by muscular stabilization, and to maintain
flexibility by initiating life-long exercise regimens, including aerobic conditioning, particularly
swimming, which allows gravity relief.
Assess the body mechanics of every patient who is disabled from work. Educate all patients
about body mechanics, and discuss the risk factors for faulty body mechanics, so that
applications can be incorporated into individual work settings, including appropriate seating (eg,
lumbar support). The lumbar facet joints are oriented relatively vertically, thus allowing forward
flexion, but the joints impact each other when a person bends and then rotates. Repetitive
bending and twisting have been noted to be epidemiologic problems in workers, and may be
associated with chronic pain and disability.[25] Attention to lifting techniques and ergonomic
modification at workstations may be very appropriate.

Surgical Intervention
The classic presentation of an herniated nucleus pulposus includes the complaint of sciatica,
with associated objective neurologic findings of weakness, reflex change, and dermatomal
numbness. Various surgical procedures have been reported and share the common goal of
decompressing the neural elements to relieve the leg pain. These procedures are most
appropriate for patients with minimal or tolerable back pain, with an essentially intact and
clinically stable disk. However, the hope of permanently relieving the back pain is a fantasy, a
false hope.
The most common procedure for a herniated or ruptured intervertebral disk is a
microdiscectomy, in which a small incision is made, aided by an operating microscope, and a
hemilaminotomy is performed to remove the disk fragment that is impinging on the nerves.
Many patients who undergo microdiscectomy can be discharged with minimal soreness and
complete relief of leg pain after an overnight admission and observation. Same-day procedures
are in the process of cautious development; patients with dominant back pain have a different
problem, even if HNP is present, and would require stabilization by fusion if unresponsive to
well-managed appropriate therapy or arthroplasty (if there is an isolated level with good facet
joints).
Minimally invasive techniques have not replaced this standard microdiscectomy procedure but
can be summarized in 2 categories: central decompression of the disk and directed
fragmentectomy. Outpatient treatment has been reported.[26]
Central decompression of the disk can be performed chemically or enzymatically with
chymopapain, by laser or plasma (ionized gas) ablation and vaporization, or mechanically by
aspiration and suction with a shaver such as the nucleotome or percutaneous lateral
decompression (arthroscopic microdiscectomy).
The Food and Drug Administration (FDA) initially released and then withheld chymopapain for
injection into lumbar disks because of adverse allergic reactions in patients; skin tests
subsequently were used to determine sensitivity. However, the procedure continued to induce
severe muscle spasms that could be far worse than those of an open operation and thus
required hospitalization and bedrest for up to 50% of patients.[27] This morbidity must be

considered a contradiction to the assertion by proponents that the enzyme is limited to the disk
in the chemical digestion of the nucleus pulposus, because the muscles are severely affected,
which would not be expected if the enzyme were contained. In addition, severe scarring in the
spinal canal is noted routinely after this procedure.
The nucleotome and laser central decompressions have been shown only to equal placebo in
effectiveness, and their use has declined. Superiority has not been demonstrated; patient
selection is crucial, with a steep learning curve.[28]
Further development of alternatives, such as nucleoplasty, and efforts to reduce disk pressure
remain under study. The incidence of recurent herniation is small but may be irreducible. Efforts
to seal the annulus are under investigation.
Directed fragmentectomy is similar to an open microdiscectomy and has demonstrated greater
effectiveness than placebo. This procedure uses an arthroscopic approach and a probe that
directs a flexible pituitary rongeur from the center of the intervertebral disk toward the posterior
annulus. Endoscopic techniques to perform a directed fragmentectomy and to minimize
disruption of normal structures continue in development, but superiority has not been
demonstrated despite this minimally invasive approach.
Concerning the cervical spine, HNP customarily is treated anteriorly, because the pathology is
anterior and manipulation of the cervical cord is not tolerated by the patient. The posterior
approach is reserved for disk herniation that is confined to the foramen and for foraminal
stenosis. An alternative to the anterior cervical spine approach is minimal disk excision; clinical
stability following this procedure is dependent upon the residual disk, which is also true in cases
where there is lumbar spine involvement with back pain. Removal of neural compression
dramatically relieves radiculopathy; however, residual axial neck pain may result in significant
impairment.
Anterior cervical interbody fusion is another intervention. Proponents of discectomy alone assert
equivalent results, but the adequacy of follow-up in those case reports is a significant concern.
Patients with more severe disk degeneration, particularly myelopathy, would more uniformly
undergo fusion. Anterior instrumentation is being used more commonly, and interbody cages are
under consideration as a means of attaining more rapid rehabilitation and more consistent
results.

http://emedicine.medscape.com/article/1263961-overview#aw2aab6b8

Herniated Nucleus Pulposus

Author: Mark R Foster, MD, PhD, FACS; Chief Editor: Mary Ann E Keenan, MD

Foster

M.

Herniated

Nucleus

Pulposus

di

akses

http://emedicine.medscape.com/article/1263961-overview#aw2aab6b8 3 desember
2012