Alternatives to Back Surgery and Bulging Discs
There are quite a few alternatives to back surgery for patients with bulging or herniated discs. Back surgery, in general, is one of those procedures where everyone seems to know someone who had a bad experience. Newer techniques aim to try to heal the damage to the disc rather than cutting parts of it out. So let's dig into this topic.
What is a Bulging or Herniated Disc?
The discs that live between your neck or back bones (vertebrae) are like shock absorbers and have a softer gel inside (nucleus pulposis) with a hard fibrous outside (annulus fibrosis). A bulging disc is when the outer fibers that make up the sidewalls of the disc become damaged through trauma or wear and tear and the inner stuff causes the sidewall to pooch out or bulge. This is also called a disc protrusion or prolapse. When the softer gel actually escapes the disc, this is called a disc herniation, herniated disc, or extrusion. All of this bulging or herniation can irritate the nearby spinal nerve leading to sciatica (radiculopathy).
How Successful is Lower Back Surgery?
Some research shows that patients with sciatica (symptoms down the leg) get better quicker, but after a year, there is little difference between patients who got surgery versus those who opted to do nothing (1-3). Meaning back surgery can help get rid of nerve pain faster, but if the patient waits, the pain will likely go away on its own over time.
What Kind of Surgery is Done for a Bulging Disc?
There are a number of different types of back surgery for disc bulges and herniations. All accomplish the same thing, which is cutting out the disc material (either the herniated inner part or the bulging sidewall) which is called Discectomy. The procedures basically differ in invasiveness. The traditional surgery (also called Open Discectomy) goes through the low back muscles and has many different problems including killing off the important spinal stabilizing muscles (4). A number of smaller surgical approaches have since been developed which include minimally invasive endoscopic procedures that work through smaller windows to get at the disc. The two procedures work about the same as far as outcomes and complications, but the minimally invasive procedure has a quicker recovery time (5).
What Percentage of Back Surgeries Fail?
One of the reasons patients seek alternatives to back surgery is that the failure rate of spinal surgery ranged from 10 to 50% (6-10). This means the patients were classified as having continued low back or leg pain or new disabling symptoms after the surgery which is called Failed Back Surgery Syndrome. These failure rates are very high for surgery, which is why back surgery has gained a negative public perception (11).
New Non-surgical Treatments for Disc Herniation and Bulges
A mainstay of alternatives to back surgery, introduced in the 1990s, is the use of epidural steroid injections. In this procedure, the doctor injects high dose steroids between the nerve and the disc by using x-ray guidance. These generally work in many patients (14). Having said that, the steroid and anesthetics used can be toxic to local nerves and disc cells (15-17).
Two new alternatives to back surgery have emerged using autologous orthobiologics, or the patient's own platelets or stem cells. The first is an Orthobiologic Epidural which differs from an epidural steroid injection in the following ways:
- Growth factors are used which are obtained from the patient's own blood platelets that have been shown to be beneficial to nerve health (19,20).
- A nanogram dose of steroid which is tissue friendly is used instead of the 1,000,000 times higher dose currently used in epidural steroid injections
- The anesthetic used is tissue friendly (ropivacaine instead of toxic bupivacaine) (24)
Our clinic published on a large case series of patients treated with these Orthobiologic Epidurals with excellent results (18). Many of these patients avoided surgery, hence for them, an Orthobiologic Epidural fit into the category of alternatives to back surgery.
Another new treatment for disc bulges is called Percutaneous Spinal Annuloplasty and takes a different approach as well. Instead of cutting out chunks of disc material that can weaken the sidewall and set the patient up for re-herniation (21), the goal is to get the tears in the disc to heal through an injection of the patient's own stem cells. We have published several papers on the effectiveness of this procedure to reduce disc bulge sizes and symptoms without surgery (22,23), making this also fit into the alternatives to back surgery category.
The upshot? There are several new alternatives to back surgery that have a different approach. Namely to use your body's platelets or stem cells to heal try to the damage rather than cut important structures out.