Letters to the Editor: Disc Herniation, SCS, Arachnoiditis, Tapering Opioids
When I was reading the article “Efficacy of Acupressure Plus Manipulation for Lumbar Disc Herniation: A Clinical Report” in the Jan/Feb issue of Practical Pain Management, I was hoping to learn a “newer” approach to herniated nucleus pulposus (HNP), but I think the authors are doing something similar to the McKenzie’s concept for contained HNP.1
Letting a patient lie in the prone position, which is the initial McKenzie position for HNP prior to repetitive lumbar extension, is usually tolerated provided you use radicular symptoms as a guide for treatment progression. Although the use of lumbar traction does not have strong double-blind studies to support it, I still use it for selective patients who show initial response to traction of their legs.
Depending on the severity of the pain, I use a generic soft lumbar brace during the initial stage of acute HNP to provide lumbar stability, but I eventually let the patient undergo progressive lumbar stabilization, extension biased, to improve active lumbar core stability so the brace can gradually be discontinued.
As a physical medicine and rehabilitation (PM&R) physician and physical therapist, my rationale for treatment is to make the patient be able to do the exercise regimen independently and be less reliant on a practitioner to provide passive care. I could see the “rolling,” as described by the authors, as enhancing the effect of lumbar extension. But you also can educate a patient to use progressive and repetitive extension of the lumbar spine to promote anterior disc displacement. In certain cases, you can provide manual assistance to promote the lumbar extension.
I prescribe medications to address the chemical irritation, nerve sensitization, and pain. Only when oral medications do not suffice to control the pain and that pain begins to interfere with a patient’s progression to an active program, then do I prescribe a lumbar epidural steroid injection.
Pedro Oliveros, MD, PT
Board Certified in PM&R
Subspecialty in Pain Medicine
Dear Dr. Oliveros,
My treatments and those used in the MacKenzie exercise are significantly different, and I would hesitate to recommend the latter for the following reasons.
In disc herniation, the posterior intervertebral gap is bigger than normal. The spinal extension of MacKenzie’s exercise decreases this gap’s size, and the result is often that the herniated disc can become even more prominent than before the treatment.
A much more effective treatment of disc herniation is acupressure. Pressure is applied on certain points according to the herniated disc’s location.
I apply pressure for 10 to 20 minutes on the right side of the erector at the L4 level, for example. Pain is usually reduced, and in some cases, it may disappear. By reducing the inflammation around the sciatic root, lower back pain and sciatic pain are significantly relieved.
The application of acupressure to points on the hip on the same side as the disc herniation can also reduce sciatic inflammation and pain in the majority of cases.
Another technique of acupressure will help patients to improve local circulation and speed up the recovery process as well as to help with cold legs and feet. Pressure is applied to the femoral artery of the groin, also on the same side as the herniated disc, for a minute or less, then a gradual release of pressure; this method causes a dramatic improvement of local circulation.
An important method that I have used with success is “knocking and rolling” plus traction in alternating cycles, which may cause the herniated disc to partially return to its normal location. At my clinic, I’ve seen many cases, especially within a short period after the disc is herniated; the point beside the erector on the same level of the herniated disc cannot tolerate pressure due to severe pain. However, after repeated “knocking and rolling” plus traction in alternating cycles for several minutes, the pain becomes significantly less; then pressure can be applied. This means the disc is partially lodged back in its original state. This being said, the inflammation and swelling cannot be reduced in just a few minutes. Other manipulation such as flexion is only an assisting technique.
The combination of all these treatments has resulted in a higher success rate.
Zesheng Wang, OD, MD
Spinal Cord Stimulation for Arachnoiditis?
I live in Sweden, and 6 years ago, I developed cauda equina syndrome (CES). After 2 surgeries, I was diagnosed with adhesive arachnoiditis (AA). I had a spinal cord stimulator (SCS) implanted 2 years ago and recently have had increased pain in both legs. My question is: What is your recommendation for patients suffering from AA? SCS: yes or no?
Your question about the merits of a SCS in AA is most pertinent at this time. First, the increased pain in your legs may not be due to your stimulator, but it obviously did not prevent what I assume is progression of your AA disease.