“Though cold sciatica cripple our senators and make their limbs halt as lamely as their manners” -William Shakespeare
Intervertebral discs or simply the ‘discs’ are cushion like structures present normally between adjacent vertebrae (bones of the back).
These discs serve many functions like shock absorption and help in motion between the vertebrae. It is by the virtue of these discs that we are able to bend forwards and sideways, lean backwards and turn sideways.
Without these, our spine would just be an immobile segment of bone.
A Prolapsed Intervertebral Disc (PIVD) or in common terms a ‘disc disease’ is said to occur when a disc moves from its normal place and gets closer to the spinal cord or nerve roots, thereby compressing these natural electric wires.
PIVDs are very common worldwide as is true of Kashmir. However, in our part of the world, many myths are prevalent in common masses regarding natural history and treatment of disc disease. This article will try to bust those myths and present forth the true facts related to it, as supported by literature.
Myth 1: Discs are abnormal structures present in some people
Fact: Intervertebral discs are normally present in every person, 23 in number from neck to lower back. Discs are normal structures and it’s not the disc itself but the abnormal position of discs in some people that is the problem.
Myth 2: Every back pain is due to ‘disc’
Fact: Not every back pain can be attributed to disc. There are hundreds of other causes of back pain, like simple strain, to osteoporosis, to trauma, to abdominal problems, to urinary problems, to infection including TB, to cancer, to name a few. So every back pain needs to be evaluated by an expert before labelling the pain as ‘discogenic’.
Myth 3: Only overweight individuals are at risk of having ‘disc disease’
Fact: No. Although overweight individuals are at a slightly higher risk but even lean individuals can suffer from this ailment. Losing weight will reduce your chances of having a PIVD but it wont eliminate the chances.
Myth 4: People doing heavy work are susceptible
Fact: Yes, but people with sedentary lifestyle or those doing no work at all can have ‘disc disease’. In a recent study conducted at Bone & Joint Hospital Barzulla, it was found that among kashmiri people with MRI documented discs, only 53% were heavy workers. So sitting idle can’t save you from the ‘disc disease’. Besides sedentary lifestyle may weaken your muscles and bones thereby predisposing you to misery. Whether heavy work is a direct cause of PIVD, is not yet fully established.
Myth 5: X-rays are necessary
Fact: Not every back pain patient needs an X-ray. There are well mentioned guidelines in literature on which patients need X-rays and which not. I find it out of scope of this article to quote those guidelines.
Myth 6: X-rays can diagnose a ‘disc’
Fact: Although X-rays are somewhat helpful but a prolapsed disc can be diagnosed for sure only by clinical assessment supported by an MRI.
Myth 7: Treatment is done based on MRI reports
Fact: We have seen patients with huge discs on MRI but only mild symptoms and those with small disc bulges on MRI but with excruciating symptoms. Moreover, all discs that are seen on MRI are not culprits. Some are innocent. MRIs should just be taken as a guide and one should treat patients, not MRIs as suggested by McNab and other pioneers in the field. Moreover, MRIs being expensive and not readily available should be used judiciously in this part of the world. Only few patients with back pain and/or sciatica need X ray, fewer need MRI and a lot fewer need surgery.
Myth 8: Bed rest is the main treatment
Fact: So far, this is the most prevalent myth in Kashmir that people with discs needs to take absolute rest and abstain from any sort of physical work. False is this claim, as literature recommends only few days (3-5), at the most a week of bedrest, that too in acute incapacitating back pain or sciatica. Too long a bedrest weakens one’s back muscles and predisposes him/her to further misery. Although some precautions need to be taken like avoiding abnormal posture and prolonged bending in some, patients can resume normal work once the acute stage is over. Persons with prolapsed discs should avoid those specific activities which predispose them to pain.
Myth 9: Disc patients never get rid of it
Fact: Again false. Typical history of PIVD include back and lower limb symptoms for few days or weeks followed by almost complete relief. Although mild pain can remain for few months but that is not incapacitating and patients do well in between the exacerbations. Nature has bestowed our bodies with immense healing capacities and it can heal anything if it gets enough time.
Myth 10: Spinal anesthesia during child-birth surgery and other surgeries leads to disc disease later on
Fact: On of the common myths that our patients, especially females, present to us is that they suffered a disc disease after a surgery for child birth for which an injection was given in the back. Spinal anesthesia has its own known complications but I could not find any substantial solid literature suggesting it to be the cause of PIVD. Even if it leads to back pain later, the chances must be remote.
Myth 11: Discs go into legs
Fact: Discs do not go into your legs. Instead, they compress the nerve roots that supply your buttocks, thighs, calves, and feet. So you feel pain in these body parts although nothing is wrong with them. It is a similar thing like a fault at a far off grid station would lead to power cut-off at your home.
Myth 12: Some medications dissolve the disc
Fact: Medications like analgesics, neuro-tropics (pregabalin, gabapentin), muscle relaxants, steroids are known to relieve the symptoms but none of these drugs can dissolve the disc in true sense. Some drugs like steroids can reduce the edema around nerve roots and disc. Disc dissolving injections (chymopapain) are however available but their risks and benefits are still debatable.
Myth 13: Injections in the back lead to problems
Fact: Epidural steroid injections are a mainstay of treatment of disc disease with excellent results and a very rare complication rate. Literature says so. Nothing is without complications, not even the food we eat. But we do not stop eating. Do we? Some people have problems after having milk but that does not rule out milk as a good food.
Myth 14: Most people with discs need surgery
Fact: Wrong. Most patients with discs recover without surgery. Only 1-2 % of patients require surgery. There are well defined indications before labeling a patient as a surgical candidate. If you feel sudden difficulty in moving your feet or toes, have difficulty passing urine or stool, cannot feel flip-flops (chappals) in your feet, your flip-flops slip out of your feet due to loss of sensation, you might need a surgery. Besides if you are not getting any relief after months of treatment, that might become an indication of surgery. Having said that, surgery should always be kept as a last resort.
Myth 15: Disc surgery has high failure rates
Fact: As mentioned earlier, everything has its complications.Like every drug and every procedure out there, disc surgery also has its complications, but most patients if selected properly will have a dramatic recovery after surgery. The patient, however, should deserve a surgery in the first place. Disc failure surgeries can be attributed to patient, surgeon or nature. Giving false history, concealing the facts and exaggerating the symptoms by a patient might end him on an operation table which was otherwise not required. Wrong level surgery, inadequate removal and surgery only for financial gains on part of a surgeon will only add to the patients misery. If you cannot help, please don’t harm. Even if everything goes well, patient can have disc prolapse at another level months or years after surgery which is beyond the control of the surgeon and patient. However, surgery when properly indicated and done, will ease the patient of his sufferings.
Myth 16: Depression leads to back pain
Fact: This statement is not a myth per se. Bad mental health can lead to back pain but back pain can also lead to mental health issues. Whether bad mental health leads to back pain or vice-versa, it needs to be evaluated in each and every patient individually. Besides, familial support, be it physical, emotional, or financial is a cornerstone in dealing with these patients. This is the most common loophole in the management of patients in our society. If a patient suffers from a back pain or sciatica for a long time and all investigations couldn’t pin point a cause, he/she needs a psychiatrist and emotional support more than an orthopedic surgeon.
This article is intended to enlighten common masses about this disease and should not be used as a guide for treatment. Every patient is different and demands different treatment. Always consult an expert whenever you have back or leg pain. I have intentionally avoided using medical jargons and terms in this article so common people may understand. I may be disagreed with.
(Dr Akhtar Rasool is Senior Resident, Orthopedics at GMC Baramulla and can be mailed at [email protected])