Talk:Disc herniation/Archive 3

I think both source articles could be merged into this article.--Steven Fruitsmaak (Reply) 23:00, 28 August 2006 (UTC)

It shouldn't be any problem, since Dematt and myself, Fyslee, used all of their content to make this article, and then we developed it even further to make it more complete. If any small changes have been made since then, anyone is welcome to add them to this article. -- Fyslee 19:58, 29 August 2006 (UTC)

If you're sure your article completely supersedes the other two, then you could install a redirect from both pages to yours, and check for any double redirects.--Steven Fruitsmaak (Reply) 22:47, 29 August 2006 (UTC)

A check should be made of both articles for any changes in the last week or so. If they are good, they should be incorporated here before deleting those articles.

Would it be a good idea to place archived copies of the discussion pages from both articles here? -- Fyslee 04:50, 30 August 2006 (UTC)

Yes that would be a good idea.--Steven Fruitsmaak (Reply) 06:25, 31 August 2006 (UTC)

I have checked both articles, and there is nothing more to move, so they can both be blanked and replaced by redirects.

Before blanking the talk pages, what about archiving them here, as suggested above? -- Fyslee 05:20, 30 August 2006 (UTC)

I think it would be a good idea to archive the articles just in case. --Dematt 11:53, 30 August 2006 (UTC)

Archives are now made, and all contents are copied to them. Now the old contents and the articles themselves can be blanked, and substituted with redirects. -- Fyslee 14:22, 30 August 2006 (UTC)

Redirects are now in place, and all content is blanked. Now the edit histories need to be blanked as well, but I don't know how that's done. -- Fyslee 16:38, 30 August 2006 (UTC)

No, they don't need to be blanked. Also, archives weren't necessary. The page histories already contain that.

What you should do is check for double redirect like Lumbar disc prolapse, by going to the redirect page and clicking: what links here. Look for redirect pages there and replace those.--Steven Fruitsmaak (Reply) 06:25, 31 August 2006 (UTC)

I think I've succeeded in tracking down and changing all instances of "slipped disc," except of course on talk pages. -- Fyslee 18:16, 30 August 2006 (UTC)

Is the term "Spinal disc herniation" the same as or sysnonymous with Lumbar Radiculopathy? If so, it would be nice to have a redirct for searches for Lumbar Radiculopathy to this wiki topic. YORD-the-unknown 15:44, 27 September 2006 (UTC)

The radicular portion of the nerve is that part of the nerve that is within the spinal canal before it leaves the spinal column. When that part of the nerve is diseased it will cause pain into the leg along with some other symptoms. This is called Lumbar radiculopathy. By far the most common reason for Lumbar Radiculopathy is disc herniation, but there may be other reasons as well, especially space occupying lesions (called SOLs) like tumors, vascular anomalies and some types of cysts as well as primary conditions such as diabetes that may affect blood supply to the nerve itself as well as cause nerve damage. IOW, spinal disc herniations can cause lumbar radiculopathy, but not all lumbar radiculopathies are the result of spinal disc herniations. It should have an article of its own. It should also be linked here. I'll take a better look at it. Thanks for the heads up! --Dematt 04:06, 28 September 2006 (UTC)

Lumbar Radiculopathy is more synonymous with sciatica. If we're going to redirect, that is the one to redirect to. Any input?--Dematt 04:11, 28 September 2006 (UTC)

Dematt is correct. "Lumbar radiculopathy" and "sciatica" say something about symptoms arising from certain structures, which often give rise to the same symptoms. Lumbar radiculopathy involves the spinal nerve roots and can cause sciatica, while sciatica doesn't necessarily involve the spine at all, often being caused by piriformis syndrome. -- Fyslee 04:28, 28 September 2006 (UTC)

Maybe what we need to do is redirect all of the nerve diagnoses to sciatica where we can differentiate and explain each of them. Then we can link them to potential causes such as spinal disc herniation, piriformis syndrome, etc.. --Dematt 11:47, 28 September 2006 (UTC)

Okay, I redirected Lumbar Radiculopathy and Radiculitis to Sciatica. If any problems with this, let me know. --Dematt 23:27, 1 October 2006 (UTC)

The opening sentence as is, "A spinal disc herniation is a pathological condition in which a tear in the outer, fibrous ring (annulus fibrosus) of an intervertebral disc allows the soft, central portion (nucleus pulposus) to be extruded (herniated) to the outside of the disc.", I would suggest is entirely not understandable to the average non medically qualified person and needs a re-write so that it can be explained in layman's terms. --Rebroad 11:06, 28 January 2007 (UTC)

We need to distinguish between a true herniation and the condition that precedes it -- a disc protrusion. Now terminology can differ from country to country. I'm an American PT in Denmark, and Midgley is an MD in the UK. What's the proper English terminology. Right now (in the lead) "bulging" is not the same as the former "allows the soft, central portion (nucleus pulposus) to be extruded (herniated) to the outside of the disc." Can we find acceptable language to make sure we describe the subject of the article, and not the subject of some (potential) other article (Spinal disc protrusion). -- Fyslee 21:49, 28 January 2007 (UTC)

Extrusion suggests to me detachment - as in plastic components and models made by extrusion of plastic into or though a mould or template. We tend to call the discs between the spinal vertebrae "intervertebral discs" as well. Midgley 13:56, 29 January 2007 (UTC)

Agree, for us, protrusion can be any stage that "bulges" until that actual "prolapse" when the pulposus "extrudes" through the outer fibers of the annulus. The prolapsed material could still be directly behind the disc and basically behave in the same manner as just a bulge. When they acturally seperate and "float" to other areas, they are then "sequestered". --Dematt 14:06, 29 January 2007 (UTC)

That's also my understanding of the three stages that can occur: protrusion, prolapse, sequestration (bulge, herniation, separation). -- Fyslee 18:49, 29 January 2007 (UTC)

I have added a refs section with code, and turned all internal links into embedded references. I also found a few references that debunk the "slipped disc" terminology. For plenty more, try this search: "slipped disc" not slip

The references need better descriptions and uniform formatting. More references and more content would also be welcomed.

The three stages described above could be developed into a paragraph. -- Fyslee 18:59, 2 February 2007 (UTC)

I just moved lumbar disc herniation content from the surgery sections of back pain and low back pain. See rationale.Badgettrg 15:55, 31 May 2007 (UTC)

The article says "The majority of herniated discs will heal themselves in about six weeks and do not require surgery." To me, that seems to say that the herniation goes away without treatment. I don't think that's true. Would it be more accurate to say, "In the majority of cases in which a herniated disc causes pain, the pain goes away within six weeks without treament."? Dwasserm 02:01, 26 July 2007 (UTC)

The entire treatment section is poorly referenced. I think your question is a good one, and a good start to set the example by including whatever a reliable source says about the issue. Sancho 05:04, 24 September 2007 (UTC)

Number 1 on the list is "bed rest" and I don't think that really is the best treatment. Many patients complain saying the most severe pain they experience is after having slept for 3-4 hours. As such, treatment should emphasize mobility of the affected areas, to the extent possible and comfortable. —Preceding unsigned comment added by 69.113.126.46 (talk) 03:00, 1 May 2008 (UTC)

Bed rest is not advised. My parents suggest they were advised bed rest when they had slipped discs 15+ years ago, but today the advice is certainly to remain active. Including walking, cycling, swimming in conjunction with therapeutic stretches and exercise. Virtualt333 (talk) 00:21, 19 July 2008 (UTC)

In the conservative segment of the treatment section, it says "Osteopathic/Chiropractic manipulation". It then goes on to say how dangerous it can be... Let me just say, that as a student osteopath, that even I know that manipulating a segment with a prolapse is a radiculous and stupid thing to do. I dont think any chiropracter or osteopath in their right mind would do that... —Preceding unsigned comment added by 217.207.114.194 (talk) 12:30, 26 June 2008 (UTC)

Never say that a warning of a danger is unnecessary because you know it; it is needed to save others who may not know. Unfortunately, one cannot blindly trust any practitioner in these areas... Including such warnings in wikipedia helps to educate, not just the professional, but the patient, which is important AmirOnWiki (talk) 16:00, 28 June 2008 (UTC)

Osteopaths are often cited as a 'quick fix' for back troubles, though sometimes the results are only transient. However, even a GP will refer a patient to an osteopath in the early days of a prolapsed disc, as it is often significantly quicker than physiotherapy. I have expereinced manipulation from very experienced professionals in both of these disciplines. Virtualt333 (talk) 00:21, 19 July 2008 (UTC)

I have a protrusion myself and found that Valium reduced my pain very effectively (which anti-inflammatories didn't). The doctor explained that this is due to its muscle-relaxing effects. I would be grateful if a knowledgeable editor would introduce to this section an explanation of this phenomenon. AmirOnWiki (talk) 16:00, 28 June 2008 (UTC)

I won't profess to explain exactly your situation, but as a sufferer myself, I can provide some insight through my own observations and personal advice from medical practitioners. Most people will have experienced lower back pain in the form of tense muscles, and this is certainly often a complicating factor in prolapsed discs. Often with a prolapsed disc the back muscles are forced to spasm in order to protect the body from pain and damage induced by flexing the weak vertebra, which itself aches. But if sciatica is your problem, then there is probably a coincidence of piriformis syndrome, where the piriformis (a small 'pear-shaped' muscle under the large flat gluteus maximus in your buttock) spasms around the sciatic nerve causing shooting pains down your leg. Valium relieves this spasm, relieving sciatica and back ache. Unfortunately, I have neither the expertise, nor the references, to begin to write this section! Virtualt333 (talk) 00:21, 19 July 2008 (UTC)

I'm very skeptical about this link, given at the bottom of the page :

http://www.herniateddischell.com/herniated-disc-order-faq.html (herniated disk order FAQ)

It's for a specific product and doesn't seem to have any medical references whatsoever... It's just a webpage to buy a videotape (?)

I'm not to familiar with Wiki editing but I thought I'd just let people know... 74.122.211.152 05:57, 26 September 2007 (UTC) Anya 74.122.211.152 05:57, 26 September 2007 (UTC)

Good catch. I removed that link along with most of the others. Sancho 22:47, 26 September 2007 (UTC)

You can read Wikipedia:External links to see what links should be avoided, and feel free to improve the encyclopedia by making these types of edits yourself :-) Sancho 22:48, 26 September 2007 (UTC)

I believe the last reference is also a commercial link. It links to a youtube video which shows the director of the regenexx clinic talking about the benefits of regenexx. It does not provide any solid science or more information except as an advertisement for the clinic. --Abbaroodle (talk) 20:15, 23 April 2009 (UTC)

I would like to suggest a note regarding this treatment:

• IDET (a minimally invasive surgery for disc pain)

"Patients with severe radicular symptoms due to a herniated disk or patients with severe spinal stenosis are not good candidates [for IDET]." http://emedicine.medscape.com/article/1145641-overview

Go for it. -- Brangifer (talk) 02:00, 17 December 2009 (UTC)

Again, better sources would be better, but this statement from the Chicago Institute of Neurosurgery and Neuroresearch seems like it should be worked into the summary of this section:

The treatment of lumbar disc herniations can be divided into two categories, conservative (or non-surgical) and surgical. One exception would be in the cases of cauda equina syndrome, sudden loss of foot strength or urinary problems. In these cases, surgery would be considered the conservative approach

. DigitalC (talk) 16:02, 30 January 2010 (UTC)

The terminology section seems to focus extensively on the "slipped disc" term, and why it's incorrect. Laudable as this is, there are a lot more terminology problems that need to be sorted with herniated discs... more specifically perhaps a discussion as to why "herniation" may be considered a too imprecise term nowadays. Also, discussing the wide variation in terminology might be worthwhile as well; bulge, tear, fissure, prolapse, protrusion, extrusion, herniation, etc. —/Mendaliv/^2¢/_Δ's/ 13:02, 17 May 2010 (UTC)

Recent edits have highlighted dissent amonst editors regarding the validity, safety and efficacy of chriopractic treatment of spinal disc herniation. An anonymous IP editor who claims they are a chiropractor has indicated in their edit summaries that they are able to provide references to support the use of chiropractic treatment for this condition. Another editor, whom I believe also has professional qualifications in healthcare, has suggested that people providing chiropractic treatment for spinal disc herniation in the US have been subject to sanction under FDA related laws for doing so. Therefore, I have tagged the entry of "Chiropractic" in the treatment section of the article as dubious, and requiring citations. I accordingly invited interested editors to present the cited evidence for and against chiropractic treatment for spinal disc herniation in the article, for the benefit of all who may read it. I will further suggest that should reliable sources not be provided for the use of chiropractic in this setting within a reasonable time frame, say 1 week, that chiro may be removed as a treatment option from the article. Mattopaedia ^{Have a yarn} 01:06, 30 January 2010 (UTC)

An even more informative option is the one suggested in the section above. Treatments that have been studied and found wanting can be listed with that information and the references to back it up. There is a range of treatments in use, some of which have been studied, others which may seem plausible, but which haven't been studied very well, and still others which are implausible and have actually been disproven. The spectrum from proven to unproven, from experimental to nonsensical, and from disproven to outright quackery can be dealt with. My point is that we don't have to list only proven methods, but can also create a list where the references reveal the state of the evidence for each one. Some will of course be unproven but in use, others will be slightly studied and used based on empirical evidence (IOW further evidence is needed to clarify the true value). -- Brangifer (talk) 01:37, 30 January 2010 (UTC)

I agree with Mattopaedia, citations are always important, and uncited information should be removed if dubious. I would also like to ask for a quote from Senstad et al. (is this the best source we can come up with, it is over 13 years old) that Spinal Manipulation is a relative contraindication. From my knowledge, a disc bulge/herniation can present as non-specific low back pain in its beginning stages, and progress to having radiating symptoms. Obivously if this progressio occured after treatment, it would appear that it was a "potential side effect" of the treatment. I will look for more sources, but I think it is worth nothing that the Clinical Practice Guideline from the American College of Physicians and the American Pain Society recommends spinal manipulation for people with acute, subacute, and chronic low back pain that have not improved with self-care methods. It also says "The evidence is insufficient to conclude that benefits of manipulation vary according to [...] presence or absence of radiating pain (108)." I will try to dig for sources, but I have also read that it is not physiologically possible to herniate a disc with the forces of spinal manipulation, and that one would have to shear the facet joints first. DigitalC (talk) 15:12, 30 January 2010 (UTC)

• Source for natural history of a herniated disc progressing to myelopathy - Murphy DR, Beres JL "Herniated disk in the cervical spine can progress to myelopathy as part of the natural history of this condition. Because of this, any interpretation of myelopathy that occurs after cervical manipulation, or any other procedure, must be made with caution."
• Another relevant source: Safety of spinal manipulation in the treatment of lumbar disk herniations: a systematic review and risk assessment. "The apparent safety of spinal manipulation, especially when compared with other "medically accepted" treatments for [Lumbar Disc Herniation (LDH)], should stimulate its use in the conservative treatment plan of LDH." Oliphant D, 2004
• "Serious complications from lumbar spinal manipulation are extremely rare, estimated to be 1 case per 100 million manipulations" Meeker & Haldeman, 2004

DigitalC (talk) 16:24, 30 January 2010 (UTC)

• "There is limited evidence that spinal manipulative therapy is superior to sham therapy in the short term and superior to chemonucleolysis for disc herniation in the long term." Efficacy of Spinal Manipulation, Bronfort et al., in Complementary medicine in clinical practice. 2006. Rakel D, Fass N.

This is a higher quality source than the one used for other indicated treatments, and as such should pass for listing spinal manipulation under indicated treatments. Note that this does not refer to chiropractic therapy. DigitalC (talk) 15:55, 30 January 2010 (UTC)

• FamilyDoctor.org (American Association of Family Physicians) states "Sometimes stretching of the spine, by your doctor or a chiropractor, can help the pain.". Again, this isn't a high quality source for the inclusion of Chiropractic, but it is better than the reference used for the other treatments. DigitalC (talk) 15:58, 30 January 2010 (UTC)

Part of what we may be seeing though is people with asymptomatic disc protrusions whose pain comes from some soft tissue problem or facet joint arthropathy garnering some benefit. I don't have a source to support that, but it may provide a hint as to where to look next. I will say though that chiropractic manipulation, regardless of what medical evidence we have for or against it, should be mentioned as it does enjoy significant popularity as a treatment for spinal disorders like this. It's also important to distinguish pure chiropractic manipulation from the chirotherapy programs you see (which may be more like passive PT + manipulation). —/Mendaliv/^2¢/_Δ's/ 13:11, 17 May 2010 (UTC)

Dear Colleagues work of Dr. Harry Gouvas, MD, PhD (Draws, Photos, Texts), it is ready to see the Greek version o Lumbar Disk Herniation. Please see it http://el.wikipedia.org/wiki/%CE%9A%CE%AE%CE%BB%CE%B7_%CE%94%CE%AF%CF%83%CE%BA%CE%BF%CF%85_%CE%9F%CF%83%CF%86%CF%8D%CE%BF%CF%82 and i you want COPY + PASTE + TRANSLATE. Best regards from Greece Dr. Harry GouvasHarrygouvas (talk) 20:14, 25 February 2011 (UTC)

The current "treatments" section is heavily reliant on one online medical source that is no longer available. Other listed 'therapies' had no source at all. It seems that this list has not been 'clleaned-up' in a while. Also, I mentioned above the problems with the spine manipulation text (ie: source does not support contraindicated claim and other sources actually say the opposite). Thus, I have re-done the evidence section (excluding the surgery section). My poposed revision is below, please comment.Puhlaa (talk) 04:23, 7 December 2011 (UTC)

I have a few thoughts to express, some of them "in principle"....

1. I welcome improvements to this section. It's never been totally satisfactory and it has been the target of various attempts to promote certain methods.
2. Has the original source been tracked down and the new URL found? The content is usually still available.
3. We need to keep in my the MEDRS guidelines, which strongly discourage the use of primary sources. We need to use reviews of many primary sources. Picking and choosing primary sources is a common form of OR which those guidelines discourage.
4. Strictly speaking (and we should be careful about this point), the article is about herniations, and the treatments mentioned should stick to that point, not to LBP and other forms of back pain, even when provably caused by a herniation.
   Back pain and sciatica in the presence of a herniation is still a multifaceted problem, with primary and secondary aspects all blended together and causing symptoms. Many treatment methods and techniques may lend themselves to reduction of various symptoms, even if they have no proven effect on the herniation. In such cases, we should not be using such sources or mentioning such methods. That would be more appropriate for the Low back pain article. Stick to the subject. That will severely limit what is mentioned, and so it should be. Other articles deal with the other methods used for back pain and symptoms.

In light of these thoughts, I hope you radically rethink your proposal. -- Brangifer (talk) 03:11, 8 December 2011 (UTC)

Hey BR, thanks for the input. Of course I will consider your comments, however, some of them seem to just be 'generic' advice? For example, your comment about primary sources? If you look at the reflist below, I am pretty sure that none of the souces I have proposed are primary sources, they are all reviews or systematic reviews that are MEDRS compliant (please correct me if I am wrong).

With regard to your comment about herniation Tx specifically, I could not find a systematic review that has discussed the Tx of herniation without a discussion of radiculopathy. Even articles titled "Tx of herniation", when I pull full text, the discussion is all about neurological symptoms...as this is a tangible measure for doctors and patients. For example, a person is rarely a surgical candidate without neurological symptoms present... does this mean that a discussion of surgery is innapropriate here, as they all use neurological symptoms as indication and outcome, not herniation alone? Am i missing the point? These topics are inseparable IMO, If they were separable, then the peer-reviewed literature would indicate this by having reviews discussing each individually. However, I have found the best sources I could that discuss herniation and unfortunately, every one puts lumbar radiculopathy as a part of their review and discussion. Even cochrane reviews look at LBP or LBP with radiculopathy; there is no review on 'individual causes of LBP'. Thus, while I understand your concern here, I feel that we have an option of having no discussion of Tx in this article, or mixing in some discussion of related morbidities like radiculopathy. If we are too stringint, then not even the surgery text could be included, as it all uses neurological signs as an indication for surgery and as an outcome measure for surgical success. So, which is preferable in your opinion, to include Tx here that may be more relevant for Tx of radiculopathy than herniation specifically, or to have no Tx listed? If you can recommend high-quality sources that discuss herniation Tx alone, without a mix with radicular symptoms, I am happy to use them :)

Anyways, can you please be more specific? What parts of the proposal do you think are needing a 'radical re-think'? I am hearing that you think that the list of TX is too inclusive? Which items in the list are innapropriate? You will note that my list is shorter than what everyone has been ok with for the past 2 years (at least by my check), and my version actually has sources :) Thus, I am not sure how exactly to interpret your advice to `radically rethink my proposal'? There is no rush, lets make this article better! It should be easy as there is little controversy here, just a dilemma over how to differentiate herniation from back pain from radiculopathy in wikipedia when the peer-reviewed literature is not so good at making this distinction.

In the meantime, I will have a look for the current source single source that is used for the entire Tx section that seems unavailable.Puhlaa (talk) 04:15, 8 December 2011 (UTC)

I am still hopeful that there will be some specific feedback given to help me improve the treatment sectin of this article. The proposed new text is impartial (no specific professions are listed, only treatments) and it is well-sourced to multiple systematic reviews, making it IMO, much better than the current text in the treatment section. Puhlaa (talk) 15:32, 10 December 2011 (UTC)

I see that there was a brief discussion of this above, but no resolution. Currently, the article says that spinal manipulation is contraindicated for lumbar disk herniation, however, the source does not support this claim. The source says:"It is likely to be safe when used by appropriately-trained practitioners, however some of the reports discussed highlight the importance of a thorough case history and physical examination." Moreover, other recent sources seem to suggest that it is relatively safe and effective:

• "Moderate evidence favors....manipulation over sham manipulation...." and "These reviews suggest that some concerns remain over the potential for manipulation to cause or exacerbate a LDH, although no adverse events related to manipulation were reported by the trials in our review." []
• "There is moderate quality evidence that spinal manipulation is effective for the treatment of acute lumbar radiculopathy" []
• "Active manipulation is more effective than sham manipulation..." and "Concerns exist regarding possible further herniation from spinal manipulation in people with severe herniation who are surgical candidates." (They state concerns, but unfortunately provide no refs to support those concerns) []
• "The apparent safety of spinal manipulation, especially when compared with other "medically accepted" treatments for LDH, should stimulate its use in the conservative treatment plan of LDH" []

The WHO does state that "frank herniation with progressive neurological signs" is a contraindication to manipulation, however, I cannot find a source that suggests manipulation is outright contraindicated for simple LDH, or for LDH with radiculopathy.Puhlaa (talk) 16:14, 6 December 2011 (UTC)

It seems that this entire section needs a re-write and some sources (right now 1 common online source is used for all Tx, but the source is no longer available). I am going to work on a revision of the treatment section, I will post it heref for review soon.Puhlaa (talk) 19:23, 6 December 2011 (UTC)

I have fixed the wrongful 'contraindicated' label for spinal manipulation, as mentioned above.Puhlaa (talk) 15:43, 10 December 2011 (UTC)