Non-Operative Treatments, Discectomy and Spinal Decompression

Conservative management of spinal conditions includes physical therapy, activity modification, medications (including anti-inflammatories, muscle relaxants, and analgesics), modalities such as ice and heat, selective use of supportive devices (braces and corsets), and injections such as epidural steroids and selective nerve root blocks. Physical therapy approaches, in the hands of an appropriately trained spine therapist, are aimed at helping patients correct postural deviations contributing to symptoms, strengthening the trunk support muscles, teaching safe body mechanics, and enabling patients to self-treat pain through the use of stretching and exercise.

The McKenzie method, a distinct philosophic approach, is based on the premise that patients can be taught to self-treat, and through the use of repeated directional movements, patients can centralize or abolish pain. (64) Centralization of pain refers to the movement of pain out of the extremity toward the spine, and in the case of back pain, move toward the midline. This assessment method has been found to have some predictive value in identifying patients who will be able to improve or abolish their symptoms without surgery, or those who will likely require surgical intervention. (65-67) The majority of patients with disc herniations resolve symptoms over time with conservative therapy. (68-70)

Surgical Management

Discectomy/Decompression
The goals of surgical intervention include preserving or restoring neurologic function, stabilizing unstable spinal segments, improving functional status, and relieving pain. Surgery for herniated discs is considered when radicular pain has persisted beyond 8-12 weeks and has been refractory to conservative therapy (including physical therapy, activity modification, and medications).

The presence of progressive or profound neurologic dysfunction is another indication that surgery is necessary. (20,28,71) The goal of surgery to treat disc herniations is to relieve radicular pain and prevent or reverse progression of neurologic deficit. Depending on the degree and location of disc herniations, and the progression of neurologic impairment, surgery may become urgent or emergent, as in the case of cauda equina syndrome.

Because the biomechanics differ in the cervical, thoracic, and lumbar spine, disc herniation surgery is often approached differently in each of these areas. In the cervical spine, disc herniations are often approached anteriorly and accompanied by arthrodesis (fusion). In certain clinical situations, cervical disc herniations can be approached posteriorly without arthrodesis. In the thoracic spine, disc herniations are usually approached anteriorly with arthrodesis, depending on patient characteristics and clinical findings. Epidural lesions or intradural tumors in the thoracic spine may be approached posteriorly by laminectomy. (72) Disc herniations are approached posteriorly in the lumbar spine and generally do not require arthrodesis.

The motion forces in the spine differ between the cervical, thoracic, and lumbar regions. The cervical and lumbar areas are more susceptible to degenerative changes that contribute to spinal stenosis than the thoracic spine, which is protected by the stabilizing effects of the ribs and chest cage in the thoracic region.

Decompression surgery to treat lumbar stenosis is considered if neurologic symptoms and functional limitations become severe, and are no longer responsive to conservative therapies such as physical therapy and epidural steroid injections. Surgical intervention is directed at relieving the pressure on the spinal cord and nerve roots by removing part of the posterior structures. This includes the lamina and ligamentum flavum, and may include resecting osteophytes, and removing portions of the facet joints if necessary. In the cervical spine, stenosis can be treated by posterior cervical decompression or laminoplasty.