Social and medical history

The patient with discogenic low back pain often relates his pain to posture and motion associated with occupation, sports or other recreational activities, recent trauma, or repetitive microtrauma. There are important parameters in the patient’s history which help to guide us in deciding who might need surgery. The patient’s occupation and likelihood of return to that occupation without surgery needs to be assessed. Patient’s prior and future sports participation are important to consider. The patient’s financial security, dependence of others on the patient’s ability to earn a living, and important scheduled upcoming events may play a role as well.

In terms of medical history, the degree of recent neurological progression and location of the pain are important. If the pains seems to be centralizing, being felt less in the leg but more in the back or buttock, this often may represent resolution even when the severity has increased temporarily. On the other hand, increasing pain down the leg or associated sensory or motor complaints are of greater concern. In addition, relating the pain to specific activities is important. For example, progression during bed rest is quite concerning; recurrence of symptoms during a tennis tournament would, of course, be fairly unconcerning.

Other more indirect information which can be of value in taking a history is a sense of the patient’s tolerance for pain or coping skills for disability. In addition, any favorable response thus far to any other therapeutic measures which have been tried carries a non-specific favorable prognosis for response to more aggressive treatment.

Physical examination

In terms of physical examination, if through the course of passive extension or attempted lateral shift correction techniques, the patient’s gain can be to centralize, this is a favorable prognostic sign. Any evidence of progressive neurological deficits is, of course, unfavorable; depending upon degree, this might lead one to consider surgery promptly. Straight leg raise maneuver alone is not very specific and carries relatively little prognostic value; however, crossed straight leg raise and worsening straight leg raise are prognostically grim signs for success with conservative management. Also, as mentioned, any findings which suggest a more diffuse or non-disc process should lead one to greater concern and, therefore, require additional diagnostic measures. Likewise, inconsistency in examination or exaggeration of pain response to simple maneuvers should make one skeptical about the patient’s ultimate response.

Effectiveness of treatment course

Finally, in considering the possibility that conservative measures have failed, it is vital that careful attention be paid to the conservative treatment course. Have all non-operative, aggressive, treatment modalities been considered and tried if possible? Often patients are given both flexion and extension techniques and the benefits are diluted by the harm caused through a poorly focused exercise program. Has traction been tried in appropriate position and in adequate poundage? Failure to use adequate poundage will, of course, fail to resolve the symptoms. Have epidural or selective root blocks been considered where appropriate? Often, the level or the technique is suboptimal. Blocks may be unsuccessful not because the technique is inappropriate but because the injection was poorly placed. IF this is a possibility, injection under fluroscopy needs to be considered.

Summary

In summary, Ms. L.G. responded over a six-week period to two epidural steroid injections, a brief course of anti-inflammatory medication, and aggressive physical therapy including pelvic traction, passive and then active exercise, and postural advice. She attended back school and was discharged from therapy and is continuing to exercise on her own. In all likelihood, should she have a recurrence of symptoms, she will be better equipped to handle them and to nip them in the bud.

Slipped discs: who should have surgery? A careful initial medical history and physical examination, aggressive treatment, and judicious monitoring will spare most low back sufferers the need.