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Sciatica- Will The Pornography of the Disc Finally End?

March 14, 2013 by

Given all the structures in the body why has the lumbar disc continued to create zealots whose obsession with this tissue as the primary source of back and leg pain borders on a perversion?  This just published paper in the New England Journal of Medicine by Barzouhi and colleagues entitled MRI in Follow-up Assessment of Sciatica should put to rest any doubts on the predictive ability of lumbar disc “pathology” in providing diagnostic or prognostic ability when it comes to sciatica.   This paper evaluated 283 patients randomized into either surgery or prolonged conservative care for sciatica and lumbar-disk herniation and analyzed their MRIs at baseline and after 1 year.  This secondary analysis found that an MRI performed at 1-year follow-up in patients who had been treated for sciatica and lumbar-disk herniation did not distinguish between those with a favorable outcome and those with an unfavorable outcome.  This article is a treasure trove of information.  The authors also noted that distinguishing between disc protrusions and extrusions did not have diagnostic value.  We have all had patients with postoperative formation of epidural scars which is hypothesized to cause mechanical traction on the dura or nerve roots and thus “causing” the persistent back and leg pain after spinal surgery.  However, this study  did not find a positive correlation between the presence of scar tissue and symptoms.   This has far reaching implications for how we “counsel” and manage this population.

I am not suggesting we make disc pornography illegal, but we should be cautious of how providers and patients interpret it.

Tim

 

 

8 Responses

  1. I want to first say I am greatly enjoying your blog. I am new to this and am glad I found your site.

    It is great to see that evidence is still backing up what I learned in PT school 6 years ago. It is also very sad to see we are still having to continue this discussion. I feel the biggest issue here is the patients who are undergoing surgery when it was not warranted.

    When treating a patient with sciatic symptoms, I discourage the patient getting an MRI unless there is prominent myotomal involvement. Getting the MRI tends to put the “idea” in the patient’s mind that the “bulging” disc is the problem. Changing his or her mind after this is very difficult.

  2. May Kesler says:

    I just have to respond. Years of experience here, but recently had a patient violin player with clear Thoracic outlet s, pain in last 2 fingers – forehand to head duh – has been practising with last 2 fingers 3 hours a day. Restrictions myofascially at elbow too. oh also herniated disc in c spine, no pain there but if you try imitating playing a violin there’s the herniation mechanism right there for you.
    So a surgeon saw her and said she must have elbow surgery immediately to free the ulnar nerve. never looked above the elbow.
    she had the surgery. no change in original symptoms, now has pain above and below surgical site/
    Sigh

  3. tim fearon says:

    pornography
    noun: erotica, pornographic material, dirty books; smut, filth, vice; informal (hard/soft) porn, porno, girlie magazines, skin flicks.

    Really? Old news but not integrated, misinformation, anchoring bias, errant association to causation, destructive medical wives tales, false working hypothesis………..pornography?

    Sounding a little like sensationalism of the news media to get us to listen.
    I love your facts, I hate this allegorical depiction.

    tim1

  4. Burton Ford says:

    Healthcare needs people to speak up with some shock value so I’m not offended at all by this post. The terminology is an accurate reflection of the perverse love affair with opioids, MRI’s, and lumbar fusions, etc. All of which are often excessively and inappropriately used but fly under the radar as some kind of evidence based medicine. It really is unfortunate not only for the sake of our profession but for patient’s.

  5. Tim Flynn PT PhD says:

    Hey Tim1,
    Thanks for your thoughts. My use of this allegorical depiction is based on the neuroscience of addiction. Addictions create chemical changes in the brain which decrease inhibitions or in the language of the below article there is damage to the “braking system” of the brain.
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3050060/

    I am honored to have Tim1 comment on my blog post,
    Tim2

  6. Britt 1 says:

    Tim 1 & Tim 2,
    I thought the pornography allusion was right-on…..after all Cyriax talked about HARD disc lesions and SOFT disc lesions (same flavors of pornography), and it’s all about a PROTRUSION of sorts, eh? B

  7. Larry Benz says:

    I appreciate Tim1 referencing of anchoring bias as that is a huge part of many problems-part of the thinking traps rant that I am currently on. Recent work on the “nocebo effect” likewise is at play on the protruded disk and it “causing” LBP. There is a quote that says in effect “not sure what pornography is but I know it when I see it”. In my view, the word might not be strong enough to implicate the overuse of surgery, pain killers, and imaging in LBP.

  8. polymer tank says:

    I do agree with all the ideas you’ve presented in your post. They’re very convincing and will certainly work. Still, the posts are too short for newbies. May you please prolong them a little from subsequent time? Thanks for the post.

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