The purpose of this work is not to obsessively evaluate the merits of all the available therapies with exhaustive statistics and intricate details; however, it would not be complete unless I gave some direction to those who's back pain is not alleviated by The O'Connor Technique (tm) and are forced to seek other relief from disc herniation pain. I am not so arrogant as to believe that my method will solve everyone's pain; so, for those situations, I believe I have a duty to give some of my perspectives so that at least some pitfalls can be avoided. In keeping with that "duty" I would also refer anyone seeking alternative therapies to try Back Pain Information from SpineUniverse since it gives an exceptionally complete offering of other methodologies which I have no problem recommending because if I can't help your condition, there is no reason why you shouldn't try elsewhere. I just happen to produce the best therapeutic option for the overwhelming majority of back and neck pain sufferers.
TENS (TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION)
This methodology relies upon a small pulsating current of electricity to basically confuse the nerve impulses going up the spinal cord to the brain. It is possibly functioning on the same level as acupuncture, the effect of which is poorly understood and explained; however, in some people it works. What probably is happening is that a small amount of stimulation is carried in the fast fibers that carry information to the brain related to the position of the body, touch, and vibration. These fibers' connections have a hierarchy of order in which they pass on to the brain as if there were a "gate" that only lets one nerve impulse at a time pass through. This is called the gating theory of pain proposed by Melzack and Wall. It explains why when a person slams their knee into an object, it helps to rub it when one would logically assume that further stimulation of damaged tissue would increase the pain. The rubbing stimulates sensory nerve impulses which seem to beat the pain impulses to the "gate;" and the pain is reduced when the pain impulses do not travel up the spinal cord to the brain. I have found that, initially, it can help the pain; but, after awhile, the nervous system accommodates to the electrical impulses and the pain breaks through. Therefore, they may help in an acute situation for a short time, but do not look to these devices for anything approaching long-term relief in the presence of a disc herniation.
ICE AND HEAT
This does not deny that when a piece of ice is rubbed on your back that the disc pain won't go away temporarily, because it does. Sometimes, if the pain is extremely severe, this is not an unreasonable alternative so long as you are willing to sustain the ice touching your skin, getting you wet, and you accept the fact that when you stop rubbing with ice the pain will return. However, if you have been out of pain for the minutes to hours that the ice or heat was applied, at least you did get some relief during the most severe component of the episode, which in some cases, can be a great relief.
TRIGGER POINT INJECTIONS
I rank this therapy within the realm of last resorts and believe it
is treating only the symptoms, not the source of the pain. Of course,
if you want to take the risk of someone putting a needle into your spine
only millimeters away from the nerves that work your legs or arms, you
are welcome to use your discretion. Early in the injury, the steroids
will certainly reduce the inflammatory component, and the anesthetic (novocaine
like drugs) will immediately eliminate the pain for the few hours that
local anesthetic acts. However, the beneficial effect (if received at
all) is reported to be not long-lived; and I fear that the steroids well-established
propensity to weaken ligamentous tissues makes it less than an optimal
therapy. I can see little point in permanently weakening a containment
structure for the short term, transient, gain of pain relief. If the mechanical
source of the pain is not eliminated, the result is probably equivalent
to acupuncture or TENS--No cure, just a time-limited treatment. Be certain
that, if you do resort to this therapy, you choose a physician highly
skilled in this technique and the proposed benefits vs risks be clearly
An additional thought is that, over the long term, even a poorly functional disc is better than no disc. Without the disc, the vertebral bones would rub together or shift due to the lack of support inherent in the concentric structure. In the case of a posteriorly damaged disc, one still has the anterior component to provide some shock-absorbtion. There is little ability once the chemical is injected to differentiate good disc material from bad disc material. Everything is digested the same. For this reason, I really cannot recommend the therapy. In fact, I am not knowledgeable of a physician who performs this in my area; and I have practiced medicine for 15 years without making a single referral for this modality. Moreover, I have never attended upon a patient who has had the procedure. Therefore, I would say be very careful if this option is considered and become fully-informed prior to your decision.
Everyone with severe back pain is confronted by the inevitable concern--Will I need surgery? Too often, the decision is not well-thought out, made in desperation, or undertaken with unreasonable expectations. It is encouraging to note that only 5-10% of patients with radicular pain end up with surgery. Surgery should be strongly considered in the presence of demonstrable neurological compromise (that is if you have lost strength or absence of sensation in an extremity) that remains for more than a couple of days immediately after injury. This loss should be consistent and documentable by objective means such as NMRI and EMG (Electo-MyeloGraphy: a diagnostic technique wherein electrical impulses are measured from the spinal cord to the muscles to determine if the nerve is damaged.) It should be considered if intolerable symptoms have not been significantly alleviated after six weeks of failed non-surgical alternatives. The length of time elapsed without relief is probably the best indicator that the pain will not resolve without surgery.
Removal of the herniated disc material or "diskectomy" is warranted when the annulus fibrosus shows unmistakable signs of a prolapsed or extruded disc material. All of the surgical approaches to disc disease have one defining characteristic in common. They involve the removal of the offending nucleus pulposus or disc material from what ever abnormal anatomical space it finds itself, including the intervertebral space, the foramina (space where the spinal nerve root courses on its way out of the spinal canal), or the spinal canal.
When deciding whether to undergo a procedure in which someone is going to enter deep into the structural part of your body and remove some material wherein an error or bad luck can leave you a paraplegic, make every effort to determine the advisability of the technique and the qualifications of the physician. Don't go uninformed into one of the most important decisions of your life. Don't let your HMO intimidate you into accepting only the procedure they decided to pay for and don't fear doing research outside of your community to find the best institution in which to have the most appropriate procedure done by the most competent surgeon you can afford.
Of tantamount importance, if an immediate and persistent loss of function in an extremity occurs with a spinal injury or a progressive loss of neurological function occurs, surgery should be strongly considered to prevent permanent damage from compression of a nerve root. The presence of a foot drop (weakness such that you cannot lift the weight of your foot at the ankle) or a definite loss of sensation (that is, if you can stick a pin in the affected area and not feel it) constitutes a medical emergency. Weakness should not be defined as just a "giving out" with pain, and tingling feelings like the area is "asleep" (a paresthesia) are usually not signs of nerve damage that necessarily require surgical intervention. A significant weakness constitutes a profound failure of strength that doesn't allow normal movement, usually resulting in an inability to walk on your heels or toes or hold yourself up on the painful leg with a bent knee.
Surgery is said to not be indicated and should not be performed for a disc herniation without symptoms even if it appears to be compressing a nerve root on an imaging study. Surgery is also said to be not worth the pain, risk, and assumed benefit in syndromes of back pain without accompanying radicular pain (pain shooting down the extremity) or simply changes in sensation. If there is no loss of neurological function, surgery exposes the patient to the dangers of surgery without any predictable benefit. However, I have seen patients with such bad discs, that so continuously de-centralize and are so unstable that their only hope for a reasonably normal life would be to undergo surgical fusion of the offending disc unit. I even accept the reality that I may someday be forced to make this surgical decision for my own back.
If you are uncertain whether you need surgery or not, don't fear alienating your medical providers by asking sufficient questions to insure that you are making a fully informed decision. If they take any offense at your attempt to truly understand the risks, benefits, and alternatives, reconsider your decision to put your trust in that individual. They should never be too busy to adequately explain the merits and rationale for their particular approach to your problem. If you get the same anxious feeling as if when someone selling you aluminum siding is becoming visibly irritated when you attempt to actually read the fine print of the contract, hold off on your decision until you feel better about it.
Think about it, even if the success rate of percutaneous diskectomy is only fifty percent, it is only the equivalent of a large needle going into your back. The recovery from that is relatively minuscule compared to a spinal fusion or laminectomy in which the skin, muscle and sinew are splayed open, cut, torn, stretched and dried out by bright lights and every blood vessel that makes the fatal mistake of bleeding is electrically burned by a small smoking probe. Then, in the laminectomy, portions of the spinal bones are chipped away so that access can be gained to the posterior aspect of the disc. In the case of a spinal fusion, portions of the hip bone are harvested and used to build a plate of bone to make the formerly mobile spine, immobile.
Deciding to have anything like that done should only come after an attempt is made to exhaust all other opportunities for remedy and to acquire all the information possible to make an informed decision. A decision should be based upon the degree of symptoms compared to the alteration of lifestyle necessary without it as well as after it is done. There are people who have had the surgery and are glad they did because they were effectively healed. There are others who were surgically treated appropriately; but nevertheless got worse as well as those who got no appreciable benefit.
In my opinion, if it is determined on the basis of an imaging study (either CAT, NMRI, and/or Myelogram) that shows a compressed nerve in combination with an EMG (Electro-Myography=a test involving the use of tiny needles to measure electrical impulses reaching the muscles) that proves nerve damage, and the methods described in this book fail to help, then surgery is the only alternative to losing the neurological function of the extremity. Having a paralyzed leg or arm is no small matter and surgery is probably the only chance one has of preventing that complication. Usually, now-a-days, most surgeons won't proceed without satisfying those criteria; however, I still occasionally interview patients who have gone to surgery without actual documentable nerve damage, but this is rare lately in this litigious environment.
An important consideration that is sometimes over-looked in deciding to perform surgery is whether or not the nerve is permanently damaged to some degree when the disc is not actually compressing it. I don't feel that this situation is well treated or understood in the "black-and-white" world in which modern medicine sometimes paints itself. There are, you may be surprized to learn, grey areas of medicine still out there. I have seen several cases in which, immediately following the injury, there is definite nerve impairment that later resolves because a disc fragment at the instant of the injury transiently compresses the spinal nerve root then recoils back into a position closer to the center of the vertebral disc. This instantaneous collision with the nerve root can produce permanent nerve damage yet not be seen to be actively compressing the nerve on an imaging study. In this case, surgery probably cannot be expected to restore nerve function lost as a result of that happening. The nerve is permanently damaged, yet there is no continual compression by a piece of disc material. Even though the person may experience repetitive pain, the surgery probably isn't going to be that productive in the long run and, following the back pain management techniques delineated in this book is probably a superior plan.
There is good reason to believe that if one can keep the disc material centralized and prevent it from further impacting upon the nerve root, the body's healing process will fill in and scar down the area where the peripheral ligamentous structures were damaged and the granulomatous material that the body uses to fill in damaged spaces will additionally help prevent the disc from migrating to a position wherein it impacts upon the nerves.
In this event, operative diskectomy that does not remove the entire nucleus pulposus (as opposed to percutaneous needle diskectomy) would have been of no real, long-term benefit because, if anything, the process of taking out the disc material would only have made a larger opening in the ligamentous capsule of the disc unit which, over time and with continued flexion forces, would allow additional degenerating disc material to migrate out through the pathway created by a combination of the injury and the surgery.
However, if the imaging study shows continued compression that can't be helped by the techniques in this book and, the patient has neurological damage, there may be no genuine advantage to waiting. In this case, the nerve damage can be reduced or prevented by physically removing the putative piece of disc material. Here, the decision is not whether surgery is indicated, it is a matter of what type of surgery is best. I would favor percutaneous diskectomy; but if the disc material is so close to the nerve that the diskectomy needle might damage the nerve more in the process of trying to remove it, an open procedure might be the only alternative that makes sense.
There are several gradations of diskectomy which are arranged here in order of least to maximum trauma.
Of all the available therapies for degenerative disc disease the most promising and least traumatic involves the use of a large needle-like device that enters the disc space and removes the painful disc material in a piecemeal fashion with a cutting device on the tip (or a laser which vaporizes the offending disc material) allowing it to be vacuumed out. This is called percutaneous diskectomy. One current and hopefully temporary drawback with this method is that there are too few competently trained and expertly experienced physicians who are capable of meeting the demand for the procedure. Consequently, a lot of patients who would be best served by this method approach the neurosurgeon contracted by their HMO and are convinced that an open procedure is necessary. Not being totally aware of the alternatives, they can be easily convinced that the open procedure is the only alternative because the HMO would otherwise have to pay a special neurosurgeon with whom they do not have an existing reduced fee contract.
Understandably a surgeon that has become competent and familiar with laminectomies and fusions is unlikely to abandon these procedures in favor of an alternative until forced by the marketplace. On the other hand, the "consumer" in pain has little opportunity or ability to truly evaluate the merits of a medical procedure and is only interested in relieving it. Pain and disability tend to make people dependent and trusting. That is not to say that one should decline to place trust in physicians, but if this alternative is not offered, then I would suggest that you ask if the procedure is "contraindicated" in your particular case. That will put the surgeon on notice that you know what you are talking about and, if his decision is legitimate, he will give a reasonable answer. If not, find out "why not?" with further exploration before going under the scalpel.
Some of the reasons why a percutaneous discectomy may not be appropriate are those cases wherein the disc material has pushed completely through the annulus fibrosus's capsule and/or the posterior longitudinal ligament and entered the spinal canal. In that case, it would be too dangerous to put a microtome into potential contact with the spinal cord or nerve roots. As long as the displaced disc material is shown (by imaging study such as NMRI, CT, Discogram, or Myelogram) to be definitely within the capsule and well away from the spinal nerve elements, this technique can be used, provided (of course) that The O'Connor Technique (tm) has failed
Although I clearly can't match my surgical credentials with those of the neurosurgeons and this book constitutes the only forum in which my opinion on how surgical procedures should be performed can, currently, be voiced, I would argue that the most lateral and anterior approach would serve patients best. Any procedure that compromises the integrity of the disc capsule should be performed such that it minimizes the future probability of disc material ultimately migrating through the surgically weakened capsule. During surgical manipulation, a pathway should not be created in the disc's capsule to allow pieces of disc material to travel outside of the disc space when future WEIGHT-BEARING FLEXION resumes.
In percutaneous diskectomy, disk material is removed through essentially a large bore needle. There is a reasonable probability that the nerve root decompression could be incomplete, more nucleus pulposus material could herniate in the future through the hole made, infection could occur, or facet joint damage could result. The success rate is highly dependent upon the expertise of the physician and by 1991 it was as high as 70% and as low as 50%.(3) In patients with classical herniated disc findings, its success rate is 85%.(4) It is described as an extremely safe technique, with over 20,000 of these procedures having been accomplished without a major nerve or vessel complication.(5) Advances in optics which allow for direct visualization of the intervertebral anatomy have recently improved upon these success rates.
The most recent advance employing a laser to vaporize the disc material holds some greater promise once its use becomes more widespread. In this method, the same approach is used as in the microtome-facilitated diskectomy, but a laser removes the material by vaporization and suctioning. Even if all the herniated disc material cannot be removed, by removing a substantial portion of the disc, this method can create a larger cavity into which the most peripherally (furthest from the center) protruding nucleus pulposus can re-centralize and thus relieve pressure on the affected nerve root. It remains to be seen whether removing non-herniating disc material does not prematurely predispose the disc to degeneration and ultimately requiring a fusion later in life due to instability of the disc unit.
Not everyone is suited for this method, only about 15-20% of patients requiring back surgery qualify, and it is ideally suited for individuals who have a largely intact disk with only a small protrusion. Candidates for this procedure should meet the same criteria for standard diskectomy: 1) a positive imaging study evidencing Lumbar disc herniation, consistent with clinical findings, such as no significant pain relief following 6 months of conservative treatment, 2) significant unilateral leg pain greater than back pain, 3) demonstrated specific paresthetic complaints, 4) demonstrated indications from a physical examination, and 5) demonstration of neurologic findings indicating a herniated disc.(6)
It is contraindicated for those with broken off pieces of discs, previously operated on discs, failed chemonucleosis, spinal stenosis, or the elderly with chronic degenerative, bulging discs.
Often, adequate decompression of the spinal cord or nerve root can be achieved by microdiskectomy. In this procedure, a hemilaminotomy (partial removal of the disc) is done through a tiny skin incision, and herniated disk material is removed with the aid of an operating microscope.
Microdiskectomy is basically the same procedure as a laminotomy, but an operating microscope with special small tools are used. With this method, the soft tissue damage and trauma of surgically approaching the herniated disc is significantly reduced, which also reduces the post-operative morbidity. It usually only requires one or two days in the hospital. The drawback of both this method and the laminectomy is that in order to remove the protruding disc material, the protective posterior ligamentous portion of the annulus fibrosus (the capsule) and posterior longitudinal ligaments usually must be surgically cut. In that case, there is a weakness created that can allow for future degenerated disc material to re-enter the spinal canal space through the surgically cut ligaments. For that reason, I would advocate these procedures only for those instances when the disc material has actually already herniated through the posterior ligamentous capsule, which can be determined when a discogram reveals the dye escaping through the torn capsule. If it hasn't, then a logically better approach might be to attempt a percutaneous diskectomy because that will better maintain the integrity of the capsule. It that fails, then an open approach might prove necessary, later; but, the trial with the percutaneous route stands a much greater probability of never requiring open surgery especially if the PRINCIPLES in this book are adhered to post-surgically because The O'Connor Technique (tm) reduces the pressure and consequently the probability that disc material will put enough pressure on the posterior ligamentous structures to result in a herniation.
One of the alternatives to diskectomy include laminectomy (or more properly termed a laminotomy) in which a portion of the vertebral bone directly posterior to the site of herniation called the lamina is removed. This allows direct visualization of the herniated disc material and facilitates its removal with grasping instruments. Sometimes this may be the best alternative, as in situations described above, wherein the herniated or sequestered disc material is too close to the spinal nerves to risk going in with a "blind" needle.
A new option that is currently undergoing clinical trials involves replacing the problem disc with an artificial prosthetic disc. It is currently too early to tell if these will be successful; but they apparently hold promise. They have been used in Europe for a number of years and should be generating some valid statistics soon. I would recommend making a thorough search of the complications and long term results before agreeing to this therapy. If it turns out that it is a very successful modality, then it would probably rank as the ideal surgical approach. In this choice, if it fails, you can always resort to the surgical fusion. However, if you have the surgical fusion, it is probably unlikely that a prosthetic disc would be able to be inserted afterwards since the bones have been so altered by fusion.
The more disc material that is removed or the more simple
discectomy surgery that is done increases the instability of the spine,
often necessitating fusion surgery later as the disc continues to degenerate.
It is no small feat to direct a needle into a space deep within the body. Nor is it easy to perform an operation deep within the spine. I ask the reader not to interpret my assertions as failing to respect the skills of spinal or neuro-surgeons in general. I have the utmost respect and frank awe of their skills and dedication to their patients. The neurosurgeons I have had occasion to know work so hard and get unfairly sued so often, that I often wonder what could compel a person to subject themselves to such abuse. Sure, the money is good; but, in reality, they are probably underpaid when you take into consideration the sacrifices they undergo by choosing that career (This probably could apply to any physician, and does to most that I have had occasion to work with). I'm glad someone does it. My back would not have tolerated that laborious a career. Imagine bending over for hours upon hours without a break, night after night, day after day.
Those doctors deserve the utmost respect by their colleagues and the public in general; however, their decisions should not go without scrutiny, because they are human, too, and not all of them make decisions solely based upon what is best for the patient. Often, their needs and training impact upon their decision process. For instance, if a surgeon is up in his years, doesn't feel the need to acquire the skill of percutaneous diskectomy, and prefers to stick with the procedure he feels most comfortable with, he may be inclined to convince a patient to go with an open operative procedure when a percutaneous solution would have been better.
Given this scenario, it would require of him the largess to refer the patient to another neurosurgeon. If it just so happens that he hasn't been too"busy" (which in medical parlance means making money), he may be reluctant to offer that as an alternative. This is a consideration which the wise patient should be aware of, yet not assume to be the case unless definitive evidence exists to demonstrate it. If you suspect yourself being put in such a situation, it would behoove you to obtain a second opinion or a third opinion from a different neurosurgeon who does both procedures. It is unnecessary to be confrontational or accusatory, but in the same vein, do not assume a totally submissive role.
My intent is not to alienate neurosurgeons by this choice of words; however, if they are honest with their patients and themselves--they have nothing to be offended by because they are not of whom I make reference. Yet, they know, as well as I do, that there are some surgeons out there (the decided minority) that are motivated by something less than altruism.
Nevertheless, if, after you have devoted a legitimate and conscientious effort to rehabilitating and protecting your back, studied and practiced The O'Connor Technique (tm) on a daily basis, and you unfortunately are caused to resort to surgery, then you cannot be seen to have sold yourself short. Be aware, too, that often a surgeon's decision to operate or not depends upon the pressure put on the surgeon to operate. Patients who unrealistically believe that surgery is the answer, can influence a physician to decide in favor of surgery simply due to the patient's plaintive encouragement.
If you accidentally fall in flexion and your condition worsens, of course, no one can blame you; however, putting yourself in a position that would cause you to be in flexion when you fall can be seen as a failed opportunity to prevent future pain and problems. If you are constantly conscious about the mechanisms of injury, you will judiciously avoid situations in which you put yourself at risk of a flexed fall that could result in a disc herniation. If you fall while playing football, its not exactly an "accident" because, if you have a bad back, you shouldn't be engaging in a sport that has such a high probability of flexion falls.
An equivalent situation would be if one were to leave home without one's glasses and drive to the store. Not being able to read a one-way sign causes one to get into an "accident." Well, sure, it was an auto "accident," but by putting oneself knowledgeably into that circumstance, the person actually can be seen to have caused the "accident". Same with the bad back, if you carry packages up wet steps knowing that if you lose your balance you will be unable to grab the hand rail to prevent a backwards fall in flexion, you have just set yourself up for a prolonged period of pain. Sure, the fall was an "accident" in that you didn't plan it to happen, but you have pushed the probabilities that if something untoward did happen, the worse possible consequence for you would occur. It is better to think about these considerations in advance, and make several trips up and down the stairs so that you have a free hand to catch yourself in case you fall backwards. It may sound like an imposition, but if you ever have to experience the grinding agony of a surgical fusion procedure, looking back on whether you would have desired to sustain that inconvenience if you knew you could prevent it, I'm willing to bet you would choose the less traumatic option.
Finally, if you undergo a surgical procedure, you are at just as much risk of damaging the same disc unit as you were before surgery if you don't intentionally change the mechanical forces on your back. A diskectomy usually only removes the herniated volume or a portion thereof. There probably is loose disc material remaining, that with the same forces applied, will probably eventually migrate along the path the other material took on its exiting of the central area. This residual material has a good chance of returning you to the same pain you were in before the surgery. I believe that the above described mechanisms are the major cause of surgeries that do well in the immediate post operative period but, later, end up as long-term failures.
One concept that must be understood following surgery, a fusion or, for that matter, the prolonged wearing of a back brace to stabilize a painful segment of the spine, is that the damaging flexion forces that originally caused the affected discs to deteriorate will be communicated to the adjacent disc if you continue to commit the same flexion mistakes. If you persist in making the same mechanical mistakes as before the surgery, put damage inducing stresses on the disc level that had to be surgically or mechanically corrected, and you do not alter your motion behavior, you can expect the same herniations to happen again at either the repaired level (if it is not fused) or the level above or below the fusion. If for no other reason, knowledge of the operant mechanical forces and the protective measures elaborated in The O'Connor Technique (tm) is of value for any stage of disc disease or repair because it manages the problem on a minute-to-minute basis to prevent further damage from occurring. It is this ongoing damage that contributes to the surgical failure rates and, I believe, is largely preventable.
The point to remember is that, even if you have to resort to surgery, the basic mechanical problems are still lifelong and still have a profound effect up the surgically treated unit and other adjacent discs. Surgery does not alleviate that reality. Surgery may temporarily end the pain, but it has a good chance of returning unless you actively work to prevent it. The O'Connor Technique (tm) is, in part, designed to eliminate that event or at least forestall the eventuality if it should exist as your ultimate predictable destiny.
2. Vlok, GJ, Hendrix MR, The lumbar disc: evaluating the causes of pain. Orthopedics, 1991;14:419-25.
3. Spencer DL, Lumbar intervertebral disc surgery In: Bridwell KH, De Wald RI, eds. The Textbook of Spinal Surgery. Vol 2. Philadelphia, Lippincott, 1991:675-93.
4. Kambin P, Gellman H. Percutaneous lateral discectomy of the lumbar spine; a preliminary report. Clin Orthop. 1983;174:127-129.
5. Mooney V, Percutaneous discectomy. Spine, State of the Art Reviews. 1989;3:103-112.
6. Overmyer R, Herniated disk: New laser therapy is more efficient and rapid than standard technique, Modern Medicine, June 1990;58:32-34.
7. Turner JA, Ersek MN, Herron L, et al., Patient outcomes after lumbar
spinal fusions. The Journal of the American Medical Association, 1992;268:907-11.