Surgical vs Conservative Tx for L5 S1 Disc Herniation

By Chelsey Toney

Basic Anatomy

SOAP NoteJanuary 27, 2014 21 y/o male patient came in c/o sciatic nerve pain. PMH of nerve pain in High School when participating on the wrestling team. Pain has been ongoing on and off since then. November the pain came back again and patient mentioned it being the worst it had ever been. Pain was located in the lower back through the plantar aspect of the left ankle. No tingling or numbness. Minimal weakness once pain started. Pain with movement 6-8/10. Numbing pain without movement. Sharp pain with movement. Hard sitting through classes all day. Sitting ↑ pain. Movement to lie down caused pain, but once there supine no pain was noted. Sitting down to standing up and vice versa ↑ pain. Bending over caused pain. Patient had X-rays taken which were negative. No MRI was taken. Pain keeps patient up at night and wakes up from deep sleep. Was given muscle relaxers and takes them every night. Patient mentioned that the muscle relaxers were the only thing that takes away the pain. Not running, but doing upper body workouts. No allergies. Given Motrin by the Infirmary, but hadn’t taken any. He had been foam rolling the upper hamstring with minimal pain. He had also been foam rolling some quads and IT bands. Patient noted as the foam roller moved closer to the knee, as well as the gastrocnemius and soleus, it caused too much pain. Gait and body alignment were observed. Assessed beginning at the top of the spine and progressed down to the shoulders, mid back, hips, knees, and ankles. Trunk flexion was 45 degrees. Revealed no pain, but movement of extending his torso back to the anatomical position caused pain. Balance was also assessed. Patient was able to do this w/o pain. Gait revealed pain when transferring weight. Stationary squat which caused minimal pain. RROM hip flexion no pain, RROM knee extension was not able to perform because of pain bilaterally. RROM internal rotation revealed pain. RROM ankle dorsiflexion and great toe extension = WNL. Quad reflex = WNL. Achilles reflex = no left reflex . Slump test +. 90/90 test for hamstrings couldn’t complete because of pain. SLR test right leg 35-40 degrees pain started on left side. Left leg 20 degrees for pain. Both muscle and nerve pain felt when sciatic nerve was palpated, but the patient noted that the pain was felt proximal to where he was being palpated. Palpation over the lower lumbar was point tender. Left hamstring and calf were sore, but patient noted that he wasn’t sure if the pain was just from muscle soreness or from not being able to contract them for a long amount of time from pain. Visually you could tell patient was in discomfort when moving to lying supine.

TreatmentExercises were given so he could perform them at home as well. Exercise 1 – Ankle flexion while lying supine. With his left ankle he was to flex it to the point where he experienced some tension then relax the ankle back to neutral. This was to “floss” the sciatic nerve through his tissues to make the nerve move. Note: Patient can perform this even while sitting in class. Exercise 2 - Sitting upright, slight knee extension from 90 degrees. Tension on tension off 30-40 reps. This wouldn’t begin to decrease the pain immediately. Exercise 3 – Sitting on a tennis ball under gluteus muscles with some rolling. Better to just sit on tennis ball to let it “sink into” the muscles. Exercise 4 – Continue foam rolling. Focus on proper foam rolling techniques to not stretch out the sciatic nerve too much. Needed to be lying flat to avoid the sciatic nerve.

Recommended to avoid bending and touching toes. Heat may help with comfort. Standing puts the least amount of pressure on it as possible.

MRI

MRI revealed L5 S1 Disc Extrusion onto the Sciatic Nerve

Patient MRI

Conservative Treatment- SNRB (Thackeray, et. al., 2010)

- Minimal research, but has been shown to be effective- 16 year study (Iwamoto, et. al., 2011)

Surgical Treatment

- Study consisting of 743 patients- 528 received surgery - 191 received non-operative care

- Tubular Retractor System

Risk Factors

A study performed by Shimia et. al. 2013, showed that gender (male), taller height, heavy works, and being a smoker can predict lumbar

disc herniation recurrence. Height: 6 ft

Weight: 185 lbSmoker: No

Patient Preference

- Patient wants surgery for long term healing- Tired of the constant pain- Wants to be able to tie his shoes like a “normal” person- Wants to get this over with so he can follow

his dream to become a Navy Seal- He will be meeting with his doctor back home

to go over his options

Works CitedChotigavanichaya C1, Korwutthikulrangsri E, Suratkarndawadee S, Ruangchainikom M, Watthanaapisith T, Tanapipatsiri S, and Chotivichit A. Minimally invasive lumbar disectomy with the tubular retractor system: 4-7 years follow-up. J Med Assoc Thai. 2012; 9: 82-6. Available at: http://www.ncbi.nlm.nih.gov/pubmed/23326987. Accessed April 15, 2014.

Iwamoto, J., Sato, Y., Takeda, T., and Matsumoto, H. Return to play after conservative treatment in athletes with symptomatic lumbar disc herniation: a practice-based observational study. Open access Journal of Sports Medicine. 2011; 2: 25-31. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3781879. Accessed January 30, 2014.

Shimia, M., Babaei-Ghazani, A., Sadat, B., Habibi, B., and Habibzadeh, A. Risk factors of recurrent lumbar disk herniation. Asian Journal of Neurosurgery. 2013; 8(2): 93-96. Available at:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3775189. Accessed April 15, 2014.

Takahashi, H., Okuni, I., Ushiqome, N., Harada, T., Tsuruoka, H., Ohshiro, T., et. al. Low level laser therapy for patients with cervical disk hernia. Laser Therapy. 2012; 21(3): 193-197. Available at:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3882355. Accessed April 15, 2014.

Thackeray, A., Fritz, J., Brennan, G., Zaman, F., and Willick, S. A pilot study examining the effectiveness of physical therapy as an adjunct to selective nerve root block in the treatment of lumbar radicular pain from disk herniation: a randomized controlled trial. Physical Therapy Journal.2010; 90(12): 1717-1729. Available at: http://ptjournal.apta.org/content/90/12/1717.long. Accessed April 15, 2014.

Weinstein, J., Lurie, J., Tosteson, T., Skinner, J., Hanscom, B., Tosteson, A., et. al. Surgical vs nonoperative treatment for lumbar disk hernation. JAMA. 2006; 296(20): 2451-2459. Available at:http://www.ncbi/nlm/nih.gov/pmc/articles/PMC2562254. Accessed April 15, 2014.