DEAR MAYO CLINIC: I am in my late 50s and have an active lifestyle. I have had two prior surgeries for a herniated lumbar disk. Recently, I began to have leg pain, which occurred previously, so I believe I must have another herniated disk. I have tried pain medicines and injections in the past, and I’ve taken up swimming to remain active. Is there anything else I can do to treat this except undergoing surgery again?

ANSWER: Pain can be a significant source of frustration for many people, negatively affecting quality of life. For most, the pain from a herniated disk often subsides with time as the condition gradually improves on its own. But in the interim, utilizing nonsurgical treatment options can help alleviate the discomfort. A decision to have additional back surgery typically is made in those who fail with nonsurgical treatments or those rare patients with progressive or severe weakness from the nerve irritation.

First, before you pursue additional treatment, I recommend that you get a second opinion about what’s causing your pain — if you haven’t done so already. Even if an MRI or CT scan shows disk abnormalities, they may not be the root of the problem. Several musculoskeletal sources of leg pain can mimic nerve irritation pain.

A herniated disk can result from the natural wear and tear on the spine as you age. The spine consists of vertebrae, which are bones, and disks of cartilage between the bones. The cartilage cushions the spine and allows for spinal motion. The disks have a tough outer layer, called the annulus, that surrounds a softer inner core, called the nucleus. As the body ages, the annulus stiffens, dehydrates and develops cracks. Over time, some of the nucleus can leak through a crack, creating a herniated disk — sometimes called a slipped, protruding, extruding or ruptured disk.

In some cases, a herniated disk can become inflamed or put pressure on a spinal nerve, causing leg pain, numbness or weakness if the disk is in the low back — or those same symptoms in the arm if the disk is in the neck.

The initial pain caused by a herniated disk can be severe, as you likely have experienced previously. However, the most severe pain usually subsides within a week or two. Over time, the portion of the disk protruding through the annulus tends to shrink, and the pain eases.

A combination of medications and physical therapy can be effective in relieving discomfort. Over-the-counter and prescription pain relievers may help discomfort that is mild to moderate. Prescription drugs that can effectively relieve nerve pain include gabapentin, pregabalin, duloxetine or tricyclic antidepressants. A muscle relaxant sometimes is prescribed when discomfort is accompanied by back muscle spasms.

Corticosteroid injections may be prescribed for nerve pain that is intense or is not relieved by other medications. Corticosteroids work by reducing inflammation and often are given via an injection into the area around one or more spinal nerves. This is called an epidural injection.

Physical therapy also can have a role in reducing the pain of a herniated disk. You mention that you’ve tried swimming. It’s important to stay active with heart-healthy exercises, such as swimming, walking or biking. Choose exercises that do not flare up your leg and back pain, as everyone will have a different tolerance for specific types of exercise. Swimming may be valuable in that it takes the weight off your legs, allowing you good range of motion without as much discomfort.

You also should work with a recognized physical medicine group and physical therapist who can provide education on spine biomechanics, posture and other back care principles, and show you exercises designed to stabilize and strengthen back muscles, as well as help increase flexibility. These exercises can help reduce future back pain flare-ups. A physical therapist often teaches stretching exercises, called McKenzie maneuvers, which decrease or eliminate leg and back pain for a few minutes to several hours.

Understandably, you may find the need to modify daily routines to avoid activities that cause pain to flare and to take breaks as needed. Recurring back-related pain is less likely in people who exercise regularly and have otherwise strong, healthy spine muscles. Normal activities shouldn’t cause nerve injury for someone who has a herniated disk.

Time is an important factor in healing. The symptoms of a herniated disk can take four to six weeks or longer to improve significantly. After six weeks, if you’ve tried medications and followed exercise and physical therapy and still have seen no improvement, talk to your health care team about more aggressive therapies.

I also recommend that you consult a spine specialist who is familiar with nonsurgical treatment options for herniated disks. If your new problem is in the same area as the two previous procedures, another surgical intervention may have a higher risk of failure or may require spinal fusion. You would be wise to explore all medical options before considering additional surgery. — Dr. Randy Shelerud, Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minnesota

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The post Mayo Clinic Q and A: Additional opinions helpful in treating back pain appeared first on Mayo Clinic News Network.

ANSWER: You are correct that the discs in the low back change in appearance over time in almost all adults. This includes loss of disc height and loss of water content that makes the discs appear darker on an MRI scan. The discs also may bulge into the spinal canal. These changes often affect more than one disc.

Whether these disc changes, as seen on an MRI scan, have anything to do with your hip pain or back pain in general can be a challenging question. The fact that healthy adults without hip or back pain have the same changes suggests that, much of the time, these disc changes are not associated with pain.

In your case, without further evaluation, it’s not clear whether the bulging discs are causing your pain. The process of determining whether the discs are causing your hip pain would start with a face-to-face evaluation with your health care provider, along with a detailed back examination. There are several other structures in the low back, buttock and hip region that can cause hip pain. These structures are unrelated to age-related disc changes.

Most hip pain is related to muscle, tendon, joint or ligament issues, or to irritation or degeneration of the small fluid-filled sacs (bursa) that cushion the bones, tendons and muscles near your joints. Less frequently, nerve irritation at the spine can cause hip pain. A methodical health care provider usually can identify these problems with a thorough examination in addition to possibly other testing, such as X-rays, an electromyogram, a joint injection or a diagnostic nerve block.

Restoration of discs is an active area of research. Animal studies have shown that restoring disc height, water content and structure can occur with stem cell injections or injections of other products into the discs. Human studies are assessing whether these same changes can be achieved in people with back pain. Although many health care providers offer such treatments, injection of stem cells or other substances into the discs should only be done if you are a participant in a research study, because it is not yet known if the treatment is completely safe or effective.

At this time, the best management for chronic back pain, whether it’s from a painful disc or another source, is to get the muscles that support your low back as fit, functional and strong as possible. It’s also important to use proper body mechanics and care for your back. A physical therapist who specializes in spine care can create a physical therapy treatment plan to fit your needs.

In addition to physical therapy, the American College of Physicians recently published a guideline for chronic low back pain treatment, including other therapies to consider that are supported by solid scientific evidence. They include mindfulness-based stress reduction, multidisciplinary rehabilitation and acupuncture. There is less evidence but growing support for other treatments, such as biofeedback training, manipulation, yoga and tai chi therapy.

Though I cannot be more definitive regarding specific treatment for your problem until a diagnosis is made, realize that simple measures are almost always preferable to injections and surgery. These might include the use of heat, ice or pain creams for pain control. Stretches and over-the-counter agents, as well as modifying your activity to types of movement patterns that you tolerate best, typically are recommended as first-line pain treatments. — Dr. Randy Shelerud, Spine Center, Mayo Clinic, Rochester, Minnesota

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DEAR MAYO CLINIC: Three weeks ago I was diagnosed with sciatica. I didn’t have much pain initially, but it has been extremely painful the past few days — usually when I’m sitting. Would physical therapy be an option for treatment? I don’t like to take medications for pain. Are there other treatments I should try? Could surgery help?

ANSWER: Sciatica can cause significant discomfort. The good news is that time and treatment often successfully resolve this condition. In most cases, surgery is not necessary to treat sciatica.

Sciatica typically refers to pain from irritation of one of the spinal nerves in your low back. Although the source of the irritation is in your back, you feel the pain of sciatica along the affected nerve where it is located in your leg after it exits the spine, typically in the buttock and leg. Sciatica usually affects only one side of the body.

Sciatica pain is often a dull pain, but it also can be sharp and, at times, you may feel the pain travel or “shoot” down your leg. Symptoms of sciatica may include numbness, tingling or weakness along with the pain.

Sciatica develops due to a change in one of the cartilage pads in your spine, called discs.  A small component of the disc pokes into the spinal canal, creating inflammation, or swelling. That, in turn, leads to inflammation of the nerve and triggers the symptoms of sciatica. Pressure on the nerve from the disc may contribute to sciatica, as well. Other less likely causes of nerve irritation include bone spurs, cysts or other lesions in the spine that grow near a nerve.

Physical therapy can be an excellent treatment option for sciatica. It often involves learning stretches to improve your flexibility, techniques for pain control and exercises to strengthen and condition the muscles that support your back. This type of physical therapy helps reduce sciatica pain and lowers your risk for future injuries. In addition to physical therapy, staying active in whatever type of physical activity you best tolerate can help ease pain and other symptoms, too.

Though you mention that you prefer to avoid medications, newer drugs are available that can work quite well for pain caused by sciatica. They are not potentially habit-forming like narcotic drugs, or opioids, can be. Drugs like gabapentin, duloxetine, nortriptyline and pregabalin can be useful for managing severe pain or pain that makes it hard to sleep.

Corticosteroids are another treatment option. These potent anti-inflammatory drugs are delivered via an injection that places the medication just where it is needed. You have an imaging exam, such as a CT scan or an MRI, before a corticosteroid injection, so your health care provider can see where the medication should go. Imaging also is used to guide the injection as it’s being delivered to ensure safety and accuracy.

In about 90 to 95 percent of sciatica cases, the problem is successfully resolved with time and conservative, non-surgical treatments. If sciatica persists despite these treatments, though, surgery may be considered.

Although uncommon, surgery may be recommended as a first step in treatment if weakness associated with sciatica is moderate to severe, if weakness gets worse over time, if symptoms affect both legs or if you are experiencing incontinence due to sciatica. Very rarely, sciatica can lead to extensive numbness in the buttocks and pelvic floor. When that happens, prompt surgical intervention is often required.

When sciatica is the result of a disc problem — as it is in most typical cases — and surgery is required, it can be quite effective. The procedure involves removing the portion of the disc that’s affecting the nerve. This surgery usually takes about 75 minutes and requires only one day in the hospital. — Dr. Randy Shelerud, Spine Center, Mayo Clinic, Rochester, Minnesota

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On Saturday, June 29, Randy Shelerud, M.D., will join us to discuss  back pain. Who’s a candidate for surgery?  Why are smoking and obesity bad for your back?  We’ll learn the correct way to lift heavy objects and find out about the best back pain medication.

MYTH OR MATTER OF FACT:  Firmer mattresses are better for your back.

Listen Saturday 9-10 a.m. CDT http://radio.mayoclinic.org/ or on I Heart Radio.

Follow #mayoradio and tweet your questions during the show.

Listen to this week’s Medical News Headlines at News Segment June 29, 2013 (right click MP3).

Mayo Clinic Radio is a weekly one-hour radio program highlighting health and medical information from Mayo Clinic.

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