On the Herniated Disc

Back pain and the herniated disc:

An interview with Richard Deyo, back-pain researcher and primary care physician

By Maryann Napoli of the Center for Medical Consumers

http://tiny.cc/hFnY8

Low back pain has generated thousands of published studies, so it was surprising to read that so little has been proven about the best way to diagnose something as common as a herniated disc. That was my first thought when I saw the new Cochrane review of all studies that had assessed the diagnostic accuracy of the various components of the physical exam. Sixteen studies in all, most of them old and only one conducted in primary care practice where most people start looking for help. The combined total of 2,504 study participants had back pain with leg pain, aka sciatica. The conclusion: no single test can accurately diagnose a herniated disc, so doctors should use all of them to do the initial physical exam.

To clarify a few things, I turned to one of the co-authors of the new Cochrane review, Richard A. Deyo MD, MPH, Kaiser Permanente Professor of Evidence-Based Family Medicine, Oregon Health and Science University, Portland. Dr. Deyo, arguably the country’s leading back pain expert who has co-authored over a 100 published studies about the treatment of back pain.

MN: You didn’t have much to work with in this Cochrane review. All but one of the studies weren’t that great, but it gave me an excuse to call you so I can interview you again

RD: Yes, like most Cochrane reviews about diagnostic tests, it focuses one-by-one on physical examination signs and of course, doctors never do just one physical exam test. We do several tests and combine it with a history and it all forms a picture that is more reliable than just one test. For back problems, this might include tests of strength in the lower extremities (such as flexing the foot up or down), Achilles reflexes, the straight-leg raising test, and sensory testing (touch).

MN:
How important is it to determine whether a herniated disc is the source of back pain, especially now that we know, in most cases, it will go away in time? Two landmark randomized clinical trials showed that 75% of people with the severe back and leg pain of a herniated disk got better without surgery by three months.

RD: That’s a fair question, and it is fair to say that there is usually no urgency in finding out whether the disc is the problem. But it is helpful in giving the patient a prognosis. If it’s a herniated disc we know what to expect with and without surgery.

MN: You’re referring to the two landmark studies.

RD: Yes, if the patient appears to have a herniated disc I would follow the patient a little more closely than I would the person with run-of-the mill back pain. Beyond that, if it looks like the person isn’t getting better, he or she might consider surgery. Then, using data from the studies you just cited, [I would let] the patient know that the surgery might speed up recovery but after a year or two, [he or she will] probably be in the same place with or without surgery. [And the patient] would then have to consider: how do I feel about the risks of the surgery and the urgency of resolving my symptoms?

MN: Back pain is an area rife with overtreatment. To protect yourself from overtreatment, what kind of a physician should you see first?

RD: I’m biased because I’m a primary care physician. I think the first stop should be the primary care physician, as opposed to referring yourself right off the bat to an orthopedic surgeon.

MN: Why?

RD: The primary care physician should be able to do good examination to be sure you don’t have a serious underlying problem like cancer or an infection and be able to explain a range of options without having any vested interest in any particular approach. I make a distinction between back pain alone and back pain with leg pain. If the patient has back pain alone, that suggests surgery isn’t going to help much and [steroid] injections aren’t going to help much. In most cases, the best approach is self-care and exercise after acute pain subsides and it’s probably unwise to think about the more invasive treatment. People with back and leg pain are also likely to get better without any invasive treatment, and if they don’t, they should understand what the options are.

MN: There’s a lot of evidence that MRIs and CT scans are overused and concern about the high-dose radiation exposure from CT scans.

RD: Yes, part of the problem is patients often want these tests. They say, “I want to know what’s wrong.” And the fallacy is these tests so often show abnormalities that have nothing to do with the back pain. And they might lead you down a garden path to treatments that may not help. Most people don’t realize that about a quarter of us under the age of 60 have a herniated disc, but no back pain, no leg pain, no nothing. So when a doctor sees that on a CT scan by itself, it may not mean much unless it matches up with leg pain down the same side as the disc and in the same level as the disc, etc. The history and the physical exam have to match up with findings on the scan for it to mean anything. Another thing people don’t realize is that bulging discs are normal. Bulging discs and degenerated discs are in just about everyone over the age of 60 and in people under 60, probably half of them.

MN: What are the latest fads in the overtreatment that you may want to warn us about?

RD: It seems like there’s a new one every day. Are you familiar with vertebroplasty?

MN: Yes, the injection of a cement-like substance into spinal fractures due to osteoporosis.

RD: Two studies, published in the same issue of the New England Journal of Medicine, indicate that this treatment is no more effective than a local anesthetic injection, yet it had become very popular. This is just one example of something that often happens—new technologies that are introduced and become widespread before they are carefully evaluated.

MN: What else gets your hackles up?

RD: Latest thing is artificial discs, which are now touted for patients with degenerative disc disease. It’s like a sandwich with metallic plates—it’s a sandwich with polyethyene plastic material in between to form sort of a cushion. It is inserted between the vertebrae after [the surgeons] shell out the natural material. It’s being touted for people who just have degenerated, or worn-out, discs and back pain—not necessarily a herniated disc. It’s touted for anyone with back pain and a degenerated disc, which describes just about everyone over the age of 50.

MN: And I assume this, too, has not been evaluated.

RD: In my view, it is not adequately studied. The FDA approval was based on the finding that artificial discs are “not inferior” to spinal fusion surgery. The companies did two randomized trials comparing artificial discs with spinal fusion. The problem is we don’t know how long these artificial discs last or what the long-term complications may be. And even more fundamentally, they were compared with spinal fusion, but it’s not clear that fusion is effective.

MN: What about epidural steroid injections?

RD:
There’s been an explosion in their use over the last decade. But when you look at the randomized controlled trials that compared epidural steroid injections with placebo injections [just saline], here’s what the research shows: half the trials show no difference, and half the trials show a small advantage for the steroid injections. None of these trials show that these injections help people avoid surgery. A fair conclusion is they offer some people with sciatica temporary relief, but they have no role in the treatment of back pain alone, that is without leg pain, although they are commonly used in that situation.

MN:
What have you published recently?

RD: I co-authored an acupuncture and back pain study that was published last year in Archives of Internal Medicine. All the patients were “blinded,” so they couldn’t see which of three treatments they were receiving for back pain. One group got real acupuncture; another group was poked with a toothpick [sham acupuncture]; and another group received usual care from their primary care physicians. The real acupuncture and the sham acupuncture were identical in terms of results. Both groups did better than the group that got usual care from their usual primary care physicians. One interpretation of our results could be: it’s all placebo effect. Another interpretation could be that stimulating acupuncture points stimulates some physiological response whether the skin is penetrated or not. Our results are similar to that of several German studies that also showed sham and real acupuncture are better than the usual care.

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