Does Disc Herniation Size Affect Conservative Care Success? | Podcast Ep. 254

Foreign. Hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langmay. Today we are answering maybe the oldest question the world has ever known. Does size matter? We're taking a look at a paper, does size matter? An analysis of the effect of lumbar disc herniation size of on the success of non operative treatment. This paper has my attention. It got my attention. It's brand new. I think it's gonna get your attention. There is a lot of good information to glean from this study and a lot of different ways we can put it into clinical practice. So that's what we'll be breaking down today. Before we get started, if you have not left this podcast feedback or a rating on itunes, please do so. If you're listening on your iPhone, you can scroll on down, slide that thumb and you will be able to leave us feedback or a rating that helps more and more docs find out about this podcast. We are, I think we've blown through 12,000 downloads and listeners each and every week. So thank you a ton for tuning in. We're going to keep doing our best to deliver the goods. And this week we are back with the research. As I said at the top, we're talking about does size matter? An analysis of the effect of lumbar disc herniation size on the success of non operative treatment. So couple things to break down first. This is on success of non operative treatment, right? We have seen a story be told time and time again and that is of the patient who has some sort of light radiculopathy. They get taken care of, quote, unquote, treated with medication that doesn't work. Maybe they get an injection that doesn't work. An MRI is ordered by their primary care physician or pain management doctor and a disc herniation is present which would have been expected on a thorough exam to start with. And lo and behold, oh my goodness, there is a big disc herniation. That means you need to talk to Mr. Or Mrs. Surgeon. This is something that happens hundreds of thousands of times per year. It's happening probably in your town this week, if not today, where somebody is being pushed into surgical consultants based upon the size of a herniation or they're being pulled out of your practice. An MRI's order, patient starts care, they actually start improving and then they go back to see their primary care doctor who see or pain management doctor who see or surgeon who sees a big herniation. Oh my gosh, you got to stop going to the chiropractor. There's a, you have a huge herniation. We have all. If you've been in practice more than a month, you've seen this happen in this study. That's why this study is so incredibly important, because it's looking at, hey, does that really matter at all? Does the size of a lumbar disc herniation matter? And does it have any impact on whether conservative or non operative care will work? And that's what we're gonna break down. So the researchers start out by citing previous trials that showed significant improvement with the non operative management in patients suffering from lumbar disc. So this wasn't size. Right. But we've seen numerous studies throughout time that have showcased there's significant improvement that can be had nonoperatively with people that have lumbar disc herniations and surgical disc herniations for that matter. So this study, they took a look, they measured everything. So let's break down. There was about 400 patients that met the inclusion criteria. 14. So about 4% had herniations at L3, L4, about 50% at L4, L5 and about 50% at L5S1. So give and take a little bit there, about 45% at L5S1.So majority of the disc herniations, literally the highest number and over 50%, we're at L4, L5, close second place. L5 S1 lagging behind very few, 3 out of 100 at L3, L4. So overall, 8.7% of the patients required surgical treatment after failing conservative management for at least six weeks. So let me reverse that. 8.7% required surgical intervention after failing conservative. Which means the other side of that, over 91% did not need surgical treatment. So now let's start breaking this down even more. The researchers say, quote, in particular, the size of a disc herniation had an odds ratio of 1.003, implying no correlation between between disc herniation size as a percentage of the canal area and the likelihood a patient would require surgical intervention after six weeks of conservative care. So even when the canal was greatly occluded, if there were no red flags, there was no saddle paresthesia, there was no loss of bowel bladder, none of those classic red flags. People still were 90 plus percent likely to to get well. Even with huge disc herniations, they were still exceptionally likely, overwhelmingly likely, 90% plus likely to get well. Conservatively, researchers found, quote, results from this study show that there is no statistical association between the size of a lumbar disc herniation and the likelihood that a patient will fail conservative treatment and ultimately require surgery. Quote, on several occasions in this study, patients with nearly complete dural sac stenosis, some as great as 85.1%, were successfully managed without surgery. So let's break that down a little bit. The canal in the lumbar spine, an ideal canal size is 10 millimeters in width. So if they are occluded, 85.1%, that'd be 8.5 millimeters of that canal were taken up. That means a canal diameter was 1.5 millimeters. And those individuals, several people in this study were occluded up to. I mean, that is severe central cord stenosis starts at like 4 to 5 millimeters. They had 1.5 millimeters of space for the nerve roots to travel through, for the cauda equina to travel through. That's incredible. Think about how resilient and dynamic our bodies are when there's 1.5 millimeters of space left. Out of 10 millimeters, 85% occluded. And the researchers are like, hey, they had a pretty darn good likelihood of getting well. Conservatively, research has also found, quote, literature shows that over 90% of lumbar disc herniations will resolve on their own. So this goes right in line with conservative management. Right? Over 90% get well without surgery. 90% will resolve on their own. So our job is to really help that along. So theories such as retraction from posterior longitudinal ligament, tension, resorption by macrophage, phagocytosis, lymphatic drainage has been named, an immune reaction, dehydration. These things have all been proposed as theories on the natural history with disc herniations and why so many resolve on their own. A lot of them are still theories, really trying to. People are still trying to figure that out. As with most things, it's probably a combination of a variety of them, but this is really, really important. And why is this so important? Yes, it's important for your practice, as we'll talk about in a moment. But this is also very practical and important because studies have shown that over the long term, the difference between having surgery and not having surgery diminishes. We just touched on a few weeks ago the paper that was about either spinal manipulation, conservative care, or a microdiscectomy. And the results pretty much favor not going through the microdiscectomy. And it's only if you fail conservative care that a microdiscectomy should even be entertained. And additionally, the rate of spine surgery in the United States is at the highest in the world. It's five times that of England or Scotland. Now, why is that? I'm gonna go out on an unbelievable limb here. I might sound like a complete conspiracy theorist. There's a lot of money to be made in spine surgery, right? So countries that have socialized medicine, there's not as much of a carrot. When we have out of network benefits paying $20,000 plus for microdiscectomies, when you have out of network benefits, paying, paying six figures plus for fusions and bill charges in the tens of thousands and hundreds of thousands of dollars, you start to, you know, it's the. The hammer and the nail type of situation. Everything starts to look like a nail when you have that much of a hammer. And additionally, when you see structural issues that can easily be described to a patient, that's a normal canal. I mean, and I did this not to push surgery, but. But to guide people away from surgery, if possible, for quite a long time. When reviewing images and when you can say, hey, this is what your canal normally looks like. See all that white? It's a huge white circle. And then you scroll down and there's a disc herniation, you say, see what that looks like there? And the patient literally gasps and loses their breath. It makes sense to a patient at that point in time if they're uninformed in healthcare. I gotta go in there and cut that out. You have almost no room left. We gotta go in there and chop that out. We'll seal it off, you'll be in great shape. And that's very easy, quote, unquote, sell. I hate to say it that way, but that's an easy sell for hundreds of thousands of people each and every year, over a million people having spine surgery each and every year of all types, makes and models. So why is this important? Let's bring it back to practical steps that you can take. Practical steps that you can take is now that you have this information, you can guide and direct your patients. So when you have a patient that comes in and they get an MRI after they started care, maybe they have an MRI before they started care and they have a disc herniation. Oh, doc, I don't know. I have two disc bulges and one really bad herniation, and you look at it and you've seen something worse ten times earlier in the day already. But to a patient, their MRI is their story. And when they see a disc herniation, a structural abnormality, that freaks people out. So being able to describe to them the truth, which is, hey, your disc herniation size has very little to do with the outcome of your case. As a matter of fact, you could have almost 90%. You see how yours is, whatever the truth is, right? Yours is only less than halfway taken up. You still have more than half of the space of your canal. Even if it was 90% occluded, you'd still have about a 90% chance of getting well conservatively, without the need for dangerous drugs and risky surgeries. When you can really break it down to a patient, empower them or let them know, let's say they started care and then they went and got an MRI because their primary care ordered it. This happens all the time. Being able to preemptively say, I'd love to take a look at it, and then let them know, hey, when we see this, here's what the literature says. Now, your primary care doctor might not be up to date on that, and they might believe that it's in your best interest to have surgery very quickly because of the size of your disc herniation. But we've seen in brand new studies, I like to keep up on this stuff. So in brand new studies, we've showcased the fact that the size of the disc herniation does not play a role in whether or not you'll get well. As a matter of fact, you can see where I'm going this 90% of people will get well without the need for surgical intervention. And there's nothing, you know, Bob, Jimmy, Karen, you know, there's nothing here in your clinical record that showcases it would be any different. So let's get some care. Let's, let's see if we can get you on the right track without needing those drugs and surgery. So breaking it down to them in a way that makes sense, playing a little bit of offense and defense based upon a patient centric model. And the clinical truth, I think, is one of the best things that we can ultimately do as chiropractors because there's so much disinformation out there. There's so much misinformation out there. And again, we've all seen patients that come in. I used to say patients would come in and their MRI report, you know, practically a normal MRI report is four pages long. And patients freaked. I have arthritis, I have dun, dun, dun, dun, degenerative disc disease. And they're 70 years old. And you're like, you've been having that for 20 years, just as every single human being on planet earth has, right? But they don't know the difference. And it's your job, it's our job as chiropractors to be able to explain to them the truth about what's going on. Now papers like this help us out a ton. This is brand new study Global Spine Journal. I'm gonna link it down in the show notes. Bottom line, the percentage of the spinal canal occupied by a herniated disc does not predict which patients will fail non operative care and require surgery within a two year window after undergoing that lumbar mri. So take this information, get out there, tell the story, empower your patients, feel good about what you're doing. Don't get I've seen, sometimes I've even seen chiropractors where there's a little bit of disc. Oh my goodness, I can't believe the disc herniation. I've talked to docs on the phone and I'm looking at it saying golly, that's no big deal whatsoever. So don't get skittish. 90% occlusion can still be come back from over 90% of the time. Keep an eye out for those red flags. Make those referrals when they're appropriate, but do the care that's in the best interest of the patient in your practice until proven otherwise. If you have any questions about this, hit me up. Jeffeedencebasedchiropractor.com make it a fantastic week in practice and I'll talk to you soon.

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