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Lumbago

MagazineApril 2009 (Vol. 20 Issue 1)Lumbago

Q) A friend of mine has been told he has a deteriorating disc and needs a laser operation

Q) A friend of mine has been told he has a deteriorating disc and needs a laser operation. What can be done, if anything? Are there any alternative treatments?-C.B.,

via e-mail

A)Your friend's problem sounds like a crumbling disc in the spine, called lumbar degenerative disc disease (DDD). Discs act as shock-absorbers between the spinal vertebrae but, over time, they lose their resilience. This happens to virtually everyone over the age of 40 but, for most of us, it isn't a problem. However, it can cause chronic pain in a sizeable minority. The most common symptoms are low back pain, hip pain, or aches in the buttocks or thighs. There may also be occasional tingling or weakness in the knees.

Nowadays, surgery is generally only offered as a last resort, as it's usually irreversible and invasive. Nevertheless, there's a bewildering array of surgical options, of which laser treatment is just one. Laser discectomy uses a powerful laser to 'vapourize' the crumbling bits of disc soft tissue. The laser is inserted through a small incision in the back. The operation is claimed to be minimally invasive, cost-effective and free of postoperative pain, and can be done in an outpatients setting.

However, the clinical evidence isn't all that favourable, with a recent review concluding that there's only "moderate" evidence of pain relief (Pain Physician, 2007; 10: 7-111). In fact, the official UK health watchdog NICE (National Institute for Health and Clinical Excellence) is fairly scathing, describing the procedure as having "uncertain risks and benefits". NICE warns that it may have serious complications, such as "damage to nerve roots, vertebral endplates and neighbouring structures, and disc space infection". Because of the high failure rate, many operations have had to be repeated using conventional surgery (NICE. Interventional Procedure Overview of Laser Lumbar Discectomy. 26 August 2003; http://guidance.nice.org.uk/ download.aspx? o=ip075overview).

As for other surgical options, the most common operation is to connect the two vertebrae surrounding the problem disc (spinal fusion). However, the spine inevitably becomes more rigid which, in the long term, puts extra strain on the rest of the spine and may create pain elsewhere. Other 'complications' include eating disorders, wound infection, urinary retention, 'pseudo-arthritis', blood clots in the lung and paralysis.

One of the latest surgical techniques is to replacethe damaged disc with an artificial one. There's a bionic disc that has been available for about four years. Called Charit'e, it consists of two metal plates that are attached to adjacent vertebrae, between which is inserted an artificial disc made of polyethylene. Its theoretical advantage is that it mimics a natural disc, allowing normal spinal movement. However, in practice, the bionic replacements turn out to be not nearly as tough as Nature's original. Serious wear, deformations, cracks and fractures have forced many surgeons to rip them out and resort to simple fusion-often causing further spinal damage in the process.

In the UK, one NHS hospital group recently reported that the Charit'e device barely improved spine mobility or reduced pain, leading them to abandon it (J Bone Joint Surg Br, 2007; 89: 785-9). Yet, a long-term survey in a French hospital found an 82-per-cent success rate (Spine, 2007; 32: 661-6). Success may depend on the skill of the individual surgeon as much as on the quality of the implant.

A new version of Charit'e has just been approved by the Food and Drug Administration, the US health watchdog. This uses two pieces of hinged stainless steel without the polyethylene cushion (FDA news, 19 July 2007). This may prove to be superior if only because there are fewer parts to fail.

Ideally, though, it's best to avoid back surgery altogether. The classic treatment alternatives are osteopathy/chiropractic and acupuncture. Uncon-ventional manipulative techniques have been notoriously underresearched, but there is good evidence that osteopathy can help to ease lower back pain (J Can Chiropr Assoc, 2005; 49: 270-96). However, no studies appear to have been done on DDD per se.

Acupuncture can also work and is widely used-and not only in China. German researchers have done clinical trials on herniated ('slipped') discs, and found that acupuncture is an effective pain-reliever (Am J Chin Med, 2000; 28: 25-33).

A study from Shanghai University tested two types of electroacupuncture, and demonstrated that 'single-point' acupuncture is superior to the more usual 'multi-point' methods for prolapsed lumbar intervertebral discs (Zhongguo Zhen Jiu, 2006; 26: 319-21).

Finally, percutaneous electrical nerve stimulation (PENS) uses fine needles, inserted up to 4 cm into the skin (not at acupoints), through which a mild pulsed electrical current is passed. A placebo-controlled trial of DDD showed that back pain was reduced by 50 per cent, with major improvements in mobility, sleep qualityand general wellbeing. Indeed, 81 per cent of the 60 participating patients said they would fork out their own money to pay for the treatment (Anesth Analg, 1999; 88: 841-6). Sadly, PENS is not, as yet, widely available.


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