What should I expect on the first visit? An initial visit to the chiropractor generally lasts 30-60 minutes. The practitioner takes a case history and performs an orthopedic and neurological exam to arrive at a diagnosis and screen for conditions that require referral to another specialist. He or she also palpates the spine and other joints in search of abnormalities in joint movement and muscular imbalances, and may request x-rays and/or laboratory tests. The chiropractor’s scope of practice includes radiology; most DCs have an in-house x-ray machine, while others refer radiology work to medical or chiropractic radiologists.

Once the chiropractor reaches a diagnosis, treatment can begin. Depending on the individual case, the first treatment may be delivered at the first or second visit. The DC’s repertoire includes a variety of adjustment styles, which are tailored to the needs of the individual patient. The most common adjustments are of the classical or “osseous” type, which often elicit a cavitation, or “popping” sound. This is generally not uncomfortable, but can be surprising the first time. Many chiropractors also utilize “low force” methods which involve lighter contacts. In some cases (such as elderly patients with advanced osteoporosis), only low force methods are appropriate. In all but a few states, the chiropractor’s scope of practice includes therapies such as hot and cold applications, ultrasound, and electronic muscle stimulation. In some states it also includes acupuncture. Chiropractors teach patients corrective exercises as part of a rehabilitation program, and when appropriate may provide supportive collars, braces, support belts or shoe inserts. Within the limits of state law, chiropractors may also offer dietary counseling, which in some cases includes vitamin, mineral, or herbal supplements.

How many treatments will I need? As with any type of treatment, this varies depending on the specifics of the individual case. In acute cases, treatment may be needed 3 or more times per week for a few weeks, with the frequency of visits gradually being decreased as improvement is noted. If no easing of symptoms occurs within the first four weeks of care, current guidelines advise the chiropractor to refer the patient to another practitioner. If improvement is occurring, a longer course of care is appropriate, with a diminishing frequency of visits. If a chiropractor recommends treatment for much more than a month in the absence of improvement in symptoms, this is clear sign that you should seek a second opinion. The average chiropractic case involves approximately 10-15 visits, but this includes cases that only require relatively few visits as well as more severe cases that legitimately require extended courses of care lasting many months.

What conditions respond well to chiropractic? Treatment of musculoskeletal pain—primarily back pain, neck pain, and headaches— is the mainstay of chiropractic practice. Research supports the use of chiropractic for each of these conditions. Low back pain guidelines in many nations endorse the use of spinal manipulation, as do the 2007 guidelines jointly endorsed by the American College of Physicians and the American Pain Society.1 Pain in the shoulders and other joints of the arms and legs is also frequently responsive to manipulation and other therapies employed by chiropractors. Chiropractic is widely utilized for sports injuries, with chiropractors serving on the U.S. Olympic Committee (USOC) medical staff and on the staffs of numerous professional sports teams. As of 2011, the top two positions on the USOC medical staff are filled by chiropractors, Drs. Michael Reed and Bill Moreau.

Chiropractic success in treating internal organ problems is far less predictable and has not been thoroughly researched, though virtually all chiropractors have seen individual cases of dramatic improvement that appear to be attributable to chiropractic treatment. Conditions in this category include but are not limited to hypertension,2 infantile colic,3 and ear infections in children.4

How can I find a qualified practitioner? All 50 states license and regulate doctors of chiropractic (DC), who undergo a minimum of six years of rigorous, college-level studies to become healthcare professionals. Your doctor may refer you directly to a chiropractic physician. If you decide to consult a chiropractor on your own, you can obtain a list of practitioners in your area from the American Chiropractic Association (800-986-4636 or http://www.amerchiro.org) or International Chiropractors Association (800-423-4690 or http://www.chiropractic.org).

Will insurance cover chiropractic? In the United States, chiropractic services are covered by most group health insurance policies, including most managed care policies, although the amount of reimbursement varies widely. Automobile accident insurance generally covers chiropractic treatment. Medicare provides partial coverage. Medicaid and workers’ compensation coverage varies from state to state.

References

1. Chou R, Huffman LH. Nonpharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Intern Med. Oct 2 2007;147(7):492-504.

2. Bakris G, Dickholtz M, Sr., Meyer PM, et al. Atlas vertebra realignment and achievement of arterial pressure goal in hypertensive patients: a pilot study. J Hum Hypertens. May 2007;21(5):347-352.

3. Wiberg JM, Nordsteen J, Nilsson N. The short-term effect of spinal manipulation in the treatment of infantile colic: a randomized controlled clinical trial with a blinded observer. J Manipulative Physiol Ther. 1999;22(8):517-522.

4. Fallon J, Edelman MJ. Chiropractic Care of 401 Children With Otitis Media: A Pilot Study. Altern Ther Health Med. 1998;4(2):93.

Daniel Redwood, DC is a Professor at Cleveland Chiropractic College – Kansas City. He is editor-in-chief of Health Insights Today (www.healthinsightstoday.com) and serves on the editorial boards of the Journal of the American Chiropractic Association, Journal of Alternative and Complementary Medicine, and Topics in Integrative Healthcare.

I recently came across a study comparing glucosamine versus acetaminophen. Researchers from Madrid, Spain, compared the benefit of glucosamine sulfate versus acetaminophen (Tylenol) on the symptoms of knee osteoarthritis during a 6-month treatment course. Patients were randomly assigned to receive oral glucosamine sulfate 1,500 mg once daily, acetaminophen 3 gm a day, or placebo. There were more responders to glucosamine sulfate (39%) and acetaminophen (33%) than to placebo (21%). Safety was good, and was comparable among groups. The findings of this study indicate that glucosamine sulfate is more effective than placebo and more or as effective as acetaminophen in treating knee osteoarthritis symptoms.

Dr. Sahelian Comments: Acetaminophen works quicker to relieve pain, but can cause harm to the liver, even at doses of one gram a day. I do not think it is a good drug to be taken long term for a chronic condition such as osteoarthritis. There is a possibility that if glucosamine is combined with chondroitin and other nutrients or herbs it may be more beneficial than by itself. I wonder how many years it will take for the American Board of Family Medicine to include natural supplements as options in their multiple choice questions and answers.

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Everybody worries sometimes, but some people worry all the time. Worrying is a natural human mental function that allows us to examine problems like we might a tangled ball of yarn. We turn it over and over, looking at it from all angles until we can find a thread that loosens some knots and frees the yarn. With too many people, however, worry becomes a bad mental habit, a preoccupation, and a way of wasting mental energy that could be more much more productive.

Worry can become a form of defense against difficult feelings, and an almost magical way of feeling that we can fend off undesired events. There’s a story about an old woman who would circle her house three times every day, carrying a bundle of twigs and muttering to herself. One day a new neighbor asked her what she was doing, and she replied “I’m keeping my house safe from tigers.” The neighbor said “But we’re in Indiana. There aren’t any tigers in Indiana,” to which the crone replied “See!”

Worry is a natural function of the human mind, but it can turn from a tool into a tyrant. Worrying can become a bad habit, even an addiction, because most of the things we worry about never come true. By not coming true, we are rewarded in the neurological sense of the word, we feel good, we fee; safe, we feel like we are exerting some control over the situation, so we begin to worry about other things we’d like to be able to control. It can become a full-time occupation.

The trouble with worry is that it is mentally and physically taxing, creating unnecessary stress that is exhausting for the worrier, and for the people around her (I say “her” because while worry is certainly not exclusively a female trait, the majority of people who worry themselves sick are female.) habitual worriers often develop significant illness from insomnia to anxiety disorders, irritable bowel syndrome, headaches, back pain and fibromyalgia. Worriers aren’t happy, often get depressed and are more likely than the non-worrried to smoke, drink and get addicted to prescription drugs.

Worry is a function of the imagination and is probably the most common form of mental imagery. Without imagination, there would be no worries. Imagination is the mental function that more than any other separates us from other animals. With imagination we have been given the gift of planning, and of envisioning the possible future. Through imagination, humans have been given the gift of being mobile in time – we can remember that past, and learn from it, and we can envision many possible futures and have the opportunity to choose the one that is likely to work best for us. But this gift comes with a price – we can imagine so many possible futures that we can get paralyzed by them, and if our minds get hypnotized and stuck on fears, we can become immobilized by that function which can give us the greatest mobility. We need to learn to use our imaginations better, and in a way that supports our well-being, not our worries.

The good news is that learning to use our imaginations consciously can be of great help in lessening the grip of habitual worry. Through imagery many people can impact their psychological states, their heart rate, blood pressure, respiration, digestive function, sexual function and even their immune response.

Worry is a bad habit, a distorted use of imagination, and can be overcome by learning to use the imagination more effectively and skillfully. Through guided imagery you may not stop worrying, but you can learn how to worry better. Guided Imagery will help you eliminate unproductive worrying and focus on the issues that can benefit from worrying. It will teach you skills that will help you use your imagination more effectively so that you don’t have to worry all the time, and so that the worrying you do will really help you resolve the problems you have. If you use Guided Imagery, you can go from being a worry wart to a worry warrior.

To see for yourself how you can use your imagination to relax and reduce stress immediately, go to www.thehealingmind.org and download our free 12-minute “Stress Buster” audio. To learn even more about using your imagination to resolve problems instead of creating them, check out our CDs on Stress Relief, Anxiety Relief, or our unique Guided Imagery for Self-Healing program.

* Consider working with a fully trained and qualified, experienced chiropractor, osteopath or physiotherapist first. The Manga Report (August 1993), put together by Professor Pran Manga, former director-general of the Health and Social Policy Directorate of the Canadian government, analyzed the published evidence worldwide. His conclusion: ‘Spinal manipulation applied by chiropractors is shown to be more effective than alternative treatments for lower back pain.’ One such study (The Lancet, 28 July 1990) showed a seven-point advantage of chiropractic treatment over conventional hospital management on a Oswestry disability index.

* Don’t consent to a myelogram under any but the most desperate circumstances and only after you’ve had a second expert opinion. MRI and CT scanning have largely replaced myelograms for all but certain specific conditions.

* Surgery will potentially help only disc herniation, instability, stenosis, spondylolisthesis, and scoliosis. If you don’t have a definitive diagnosis of any of the above, don’t consent to be put under the knife.

* Find an orthopedic specialist in sympathy with the teachings of Kirkaldy-Willis. If you can afford it, get hold of Managing Low Back Pain by Kirkaldy-Willis and Burton (Churchill Livingstone, Edinburgh and New York), which will help to put you on an equal footing with your orthopedic specialist.

* Find a ‘back school’ which will educate you about the cause of your pain, good daily low back care and an early return to full functioning.

* Contact grass-roots organizations like the Action Group for Relief of Pain and Distress in the UK (Hills View, Aller Road, Dolton, Winkleigh, Devon EX19 8QP). (For information on self-manipulation, send £2.50 for their book ‘A Safety Net’.)

A groundbreaking study by the UK’s University of Birmingham Medical School (BMJ, 7 July, 1990) showed that nearly a fifth (18 per cent) of women with epidural anaesthesia during labour reported long-term backache – twice the number who report backache after labour. The report concluded that of every hundred women who have an epidural during labour, eight will `develop long-term backache as a direct consequence.’

The findings of the Birmingham study were backed by a more recent study (BMJ, 15 May 1993) and a study done by the National Childbirth Trust (Some Women’s Experiences of Epidurals, a descriptive study, The National Childbirth Trust, 1987).

The NCT study and the published medical studies suggest that the problem is a postural one – women can remain in a potentially damaging position, often for some hours, without knowing it. Nevertheless, people given epidurals for other reasons, including pain relief, also suffer backache. In a study of 9000 patients given epidurals for surgery other than childbirth, one in 50 complained of backache afterward. Pauline was given an epidural during a ` routine bladder operation:’ After a series of subsequent operations to relieve the problems caused by the first, she was left in incapacitating pain – a situation later diagnosed as LSAA.

This isn’t surprising considering the postmortem findings of 10 patients who’d had postoperative epidurals (Anaesthesia, 1990; 45: 357-61). All 10 had evidence of ‘non-specific epidural inflammatory reactions’, and seven patients showed signs of epidural infection – a recipe for spinal trauma. No similar pathology was found in a control group which did not have epidural catheters. Other studies show that a fifth of those getting epidurals have `contamination’ (Anesthesia and Analgesia, 1977; 56: 222-5).

Dr Christine MacArthur, the senior research fellow who conducted the Birmingham study, says there is virtually no investigation of the long-term problems associated with spinal anaesthesia. One study (JAMA, 161: 586-91) showed long-term back problems with spinal anaesthetic (in which the anaesthetic is injected right through the spinal membranes), but that was in 1956, and no one has really looked at it since.

Low back pain has been called the ‘Cinderella’ of medicine and with good cause. In most cases, medicine itself has shown a shocking ineptitude in diagnosing and treating back problems, often tending to make the problem worse. This terrible batting average has led a Canadian government report, which studied the available evidence to date, to conclude: ‘Many medical therapies are of questionable validity or are clearly inadequate.’

In a scathing article published in 1990 by the International Society for the Study of the Lumbar Spine, Professor Gordon Waddell, orthopaedic surgeon at Glasgow’s Western Infirmary summed up this appalling track record: ‘. . . dramatic surgical successes, unfortunately, apply to only some 1 per cent of patients with low back disorders. Our failure is in the remaining 99 per cent of patients with simple backache, for whom, despite new investigations and all our treatments, the problem has become progressively worse.’ (The Lumbar Spine, James Weinstein and Sam Wiesel, eds., WB Saunders Co, Philadelphia, 1990.)

For back patients who undergo surgery, 15 to 20 per cent will fall into the category of ‘the failed back’ – the official nomenclature for people with chronic, considerable back pain that doctors can’t fix. Some 200,000 to 400,000 patients go under the knife in the US every year. That translates into 30,000 people who will emerge from back surgery every year in considerably more pain than they were before they went to their doctor.

A special WDDTY review of the current literature about back treatment reveals that medicine has three ways of making things worse: dangerous diagnostics; inappropriate, unproven treatment and surgery; and poorly studied regional anaesthesia, often, ironically, used to relieve the pain.

In the main, back pain treatments are faddish, adopted in a flurry of enthusiasm and soon discarded in favour of the next new possibility when evidence proves they don’t work.
An editorial in the New England Journal of Medicine (3 October 1991) says that earlier in this century, sacroiliac joint disease was believed the culprit in many cases of back pain, leading to fusions (the joining of one vertebra to another) of sacroiliac joints.

This was followed by treatments including the removal of the coccyx, injections for herniated or slipped discs (in which the cushiony centre of the disc, which softens the shock of spinal movement, protrudes out of the fibrous outside), lengthy bedrest, traction and even transcutaneous electrical nerve stimulation. The latest fad to be discredited in that same issue of the journal is steroid injections in the facet joints (the cartilage covering of the bony junction of two vertebrae), showing that injecting steroids is no better than injecting saline.

General practitioners, back specialists and orthopaedic surgeons have demonstrated that many haven’t a clue as to what exactly causes most back conditions. In a general review of low back pain (BMJ, 3 April 1993), Andrew Frank, consultant physician in rheumatology and rehabilitation at Northwick Park Hospital in Harrow, England, concluded: ‘Up to 85 per cent of patients with low back pain cannot be given a definitive diagnosis because of the poor associations between symptoms, signs, imaging results and pathological findings.’

Consequently, many causes of disastrous residual pain are caused by inappropriate surgery. The most popular operations include: laminectomy, in which a disc and nearby bone are removed to give the nerve branching off the central spinal cord more space to move without getting trapped or compressed by the spine; and fusion, in which one vertebrae is surgically joined to another to minimize what has been diagnosed as too much movement between them. After the operation, this segment of the spine will be unable to move.

Henry La Rocca, clinical professor of orthopaedic surgery at Tulane University in New Orleans, examining six studies of back operations found that removing discs only relieved back pain in about half of all patients (The Lumbar Spine, as above). He quotes a study in 1980 of 105 cases of failed spinal surgery, primarily disc removal. In 68 per cent of the patients, they concluded, surgery wasn’t indicated (Spine, 1980; 5: 87-94). Three out of four studies comparing operating with or without lumbar (lower back) spinal fusion surgery found no advantage for fusion and that complications, including chronic pain, were common (JAMA, 19 August 1992).

US orthopaedic surgeon Dr Charles Burton of the Institute for Low Back Care in Minneapolis, Minnesota, in analyzing failure of surgery on the spine over 10 years, quotes from a June 1981 interinstitutional orthopaedic and neurosurgical study of ‘failed-back surgery syndrome’. In more than half of all such cases, the diagnosis missed or the surgery itself caused a condition called ‘lateral spinal stenosis’, or narrowing of a portion of the spine causing compression of the spinal cord or an abnormally tight fit.

Finally, postsurgical scarring (‘epidural fibrosis’) can itself cause failed surgery and chronic pain. La Rocca also found substantial evidence that surgeons cause nerve root injury as the nerve is being separated from herniated disc material, causing scarring and therefore long-term pain and pressure on the nerve. ‘Damage to the dura or the cauda equina [membranes covering the spinal cord] from poor surgical technique yielding possibly catastrophic results completes the list,’ he writes.

This is precisely what happened to Sarah of Woking. Her back problems developed after a hysterectomy, so she consented to further surgery on her spine. The delicate layers of the spinal cord (meninges) became inflamed, and then thickened. This thickened membrane now presses constantly on her spine, incapacitating her with unbearable pain.

At Gordon Waddell’s clinic in Glasgow in Scotland, ’60 per cent believe or have been told that they have a disc prolapse, although only 11 per cent show any evidence of nerve root involvement,’ he says. Gordon Waddell and others conclude that if there is a specific problem correctly identified, such as a spinal deformity or fracture or disc herniation, then surgery can help, but not for simple relief of unspecified back pain (Spine, 1986; 11: 712-19).

Many hundreds of thousands of cases of chronic, debilitating back pain were – and still are – caused by myelograms used purely for diagnosis. This diagnostic tool involves the use a contrast medium or dye. This is injected into the canal space and trickles into and around all the discs and nerve roots in the back, which is then x-rayed. Mounting evidence shows that a good percentage of myelogram patients will develop a condition called arachnoiditis, causing permanent, unrelenting pain and rendering many virtually unable to move.

Arachnoiditis is a little-understood condition in which the middle membrane protecting the spinal cord becomes scarred. Nerves atrophy and become enmeshed in dense scar tissue, which presses constantly on the spine. Minneapolis’ Dr Burton, one of the few medics to make a study of lumbar sacral adhesive arachnoiditis (LSAA), estimates that it accounts for 11 per cent of patients with ‘failed back surgery syndrome’.

Although LSAA results from a number of different causes, in Dr Burton’s view, it essentially reflects the introduction of foreign substances into the human subarachnoid space. Dr Burton says the foreign body most often identified in victims is iophendylate (known as Pantopaque in the US, Myodil in the UK), the oil-based dye used for myelograms. In LSAA, he says, iophendylate is often found in a cyst within the scar tissue mass. In his view, a million people worldwide suffer from arachnoiditis caused by this dye, and this view could be conservative. Until the 1980s, nearly half a million myelograms were being performed in the US every year.

Pantopaque was introduced in the US in 1944 after one study convinced the medical profession that it was safe. This was despite animal studies showing that Pantopaque caused arachnoiditis, says Burton (the Swedes banned the product from use in humans in 1948). Even though the product is no longer manufactured by Glaxo, since the onset of water-based dyes and imaging techniques, iophendylate continues to be used around the world, says Burton, and many back specialists continue to maintain that iophendylate is safe.

The US Food and Drug Administration and the British government have made no moves to ban oil-based myelograms. ‘Despite the fact that iophendylate was identified as being causally related to the production of arachnoiditis from the time of its introduction, its use in the US has never been restricted by industry, government or the medical profession,’ says Burton.
It has needed patients with myelogram-induced LSAA to bring legal suits against the manufacturers before anyone else took notice. In the UK the Arachnoiditis Society now has some 1000 members and a class-action suit is underway against Glaxo.

The water-based dyes now being used instead are not without risk. One woman being investigated for sciatic (back-caused leg) pain with iopamidol (Niopam 200), a water-soluble contrast medium, was immediately rendered paraplegic (The Lancet 27 July 1991), as was another middle-aged woman given a myelogram with iohexol (Omnipaque), another water-soluble dye (The Lancet 16 March 1991). Burton says that some new mediums have caused such pain that they had to be performed under general anaesthesia.

He concludes: ‘The medical profession has not yet succeeded in finding a benign, effective myelographic medium.’

Lynne McTaggart

Between each spinal vertebra is a shock-absorbing disc that is hard on the outside, but soft in the middle. When the jelly-like interior is squeezed out of the disc through injury or wear and tear – variously known as a ‘slipped disc’, ‘prolapsed disc’ or ‘herniated disc’ – the resultant back pain needs attention.

Lumbar surgery is used to treat this and a variety of other lower-back complaints, including a pinched nerve (spinal stenosis), sciatica or a fracture. The most common operations are:

* laminotomy: part or all of the lamina (arch formed over the back of the spinal cord) is removed to relieve pressure on the cord, or to access a bony spur or damaged disc

* discectomy: removal of the part of a disk that is pressing on a nerve and causing pain

* fusion: two vertebrae are joined together by bone grafts, sometimes with metal plates, to stabilise the spine.

Is it safe?
No. Lumbar surgery should only be a last resort as there are safer methods of pain relief without surgical intervention.

* There’s a small risk of dying from deep vein thrombosis (DVT), a bloodclot in the lungs, heart attack, blood transfusion, pneumonia or other infections, respiratory depression and kidney failure (BMJ, 2000; 321: 1493).

* Even if you don’t die, you can still develop DVT, or bloodclots in your legs, pelvis or abdomen – which can then cause death when the clots are circulated to the lungs or brain.

* You could develop complications that are seemingly unrelated to the lower back. The most common major complications affect the lungs; the most common minor complications affect the nerves of the genital and bladder regions (J Bone Joint Surg, 1996; 78: 839-47).

* There’s an overall 1-2 per cent risk of nerve damage (BMJ, 2002; 324: 1414).

* You also risk paralysis, muscle weakness and loss of bowel or bladder control (Medline Plus; http://www.nlm.nih.gov/medlineplus/ency/article/002973.htm).

* According to Spine Health 2004, the North American Spine Society’s latest campaign, spinal fusion to correct lower-back pain has a strong likelihood of failure. At best, you’ve got a one in five chances that your pain will persist.

* There’s a 2-15 per cent risk of accidental puncture of the dura mater (one of the protective layers of the spinal cord), which will require surgical repair (Acta Orthop Scand [Suppl], 1972; l42: 1-95).

These are on top of the usual risks of any operation, including reactions to the anaesthesia, and bleeding and wound infection.

What doctors don’t tell you
* Only 30-40 per cent of back surgery is considered successful, even using the most liberal criteria (J Bone Joint Surg, 1997; 6lA: 20l-7; Spine, 1984; 9: 6l4-23).

* As much as 40 per cent of patients fail to achieve satisfactory long-term relief after surgery, and 66 per cent fail to achieve relief after repeated operations – the so-called ‘failed back-surgery syndrome’ (Neurosurgery, 1991; 28: 692-9).

* Nearly three-fourths of patients who undergo back surgery still complain of back pain. In addition, 23 per cent complain of constant pain, and 35 per cent still require treatment (Spine, 1988; l3: l4l8-22).

* Surgery doesn’t improve quality of life. Most patients report no change in their ability to work or perform activities such as walking, climbing stairs, driving and sleeping, or in analgesic use. Patients felt that neurological functions such as strength, sensation, bowel or bladder control were worsened more than improved by surgery (Neurosurgery, 1991; 28: 685-9l).

* GPs are largely unaware of how to manage lower-back problems, in spite of clinical guidelines laid down by the Royal College of General Practitioners. They also tend not to recognise the warning symptoms, and fail to appreciate the benefits of manipulation techniques (such as osteopathy) for persistent symptoms (BMJ, 1996; 312: 485-8).

* Surgery is probably unnecessary. A large number of patients told they needed surgery were able to avoid it in the short term simply by doing aggressive back-strengthening exercises (Arch Phys Med Rehabil, 1999; 80: 20).

* If offered within the first six weeks of an episode of low-back pain, manipulation techniques provide better short-term improvement in pain and activity levels than conventional treatments, with minimal risk, provided patients are assessed properly by a trained practitioner (BMJ, 1999; 318: 261).

* Multidisciplinary biopsychosocial rehabilitation can produce significant improvements in pain and function in those with disabling chronic low back pain (BMJ, 2001; 322: 1511-6).

Belinda Wanis

* Only have the operation if you are under 60. A more advanced age is associated with a higher risk of complications (J Bone Joint Surg, 1996; 78: 839-47).

* Stop smoking, as this reduces blood supply and so impairs healing.

* Check out your surgeon – make sure he is experienced in the operation and has a successful track record.

* Consider taking homoeopathic Arnica before and after the operation to aid healing and minimise bruising.

* Tell your surgeon and anaesthetist about any medications – traditional or herbal – that you are taking.

* If your operation involves a prosthetic disc, it may include titanium to encourage bone ingrowth. But, as a result of normal wear, titanium debris eventually accumulates, stimulating a macrophage and cytokine immune response which may have adverse effects on spinal tissues (Spine, 1999; 24: 899-903).

* Lose weight before you go under the knife as obesity can increase the usual risks of surgery (Rev Chir Orthop Repar Appar Mot, 2004; 90: 5-15).

* Try spinal manipulation, such as osteopathy, chiropractic or physiotherapy, before opting for surgery.

* Lumbar extension exercise can strengthen back muscles, decrease pain and improve function (Spine, 1993; 18: 232-8). Indeed, exercise is especially good if you have osteoporosis as the stronger your back muscles are, the less likely you are to have a vertebral fracture (Mayo Clin Proc, 1996; 71: 951-6). However, if your chronic back pain is disabling, make sure your fitness programme is supervised (BMJ, 1995; 310: 151-4).

* Rehabilitation massage and exercise therapy can move and strengthen the spine, correct posture and educate you about your back. Consider using several therapists, particularly if ergonomic issues are contributing to your pain. Most patients with a prolapsed disc will respond to such measures. If not, surgery may be necessary. But such manipulations are not recommended if the disc is severely prolapsed and compressing the spinal cord (BMJ, 2004; 328: 1119-21).

* Make sure you pick things up correctly by bending at the knees. This can help prevent future lower-back injury.

* Learn good posture with the Alexander technique or Rolfing, which can also improve muscle tone and stability.

* Learn to relax. A 1995 US National Institutes of Health report found this a useful additional treatment for chronic back pain.

* Make sure your furniture is ergonomic. At work, your chair should have good lumbar support, and you should be able to place your feet flat on the ground, with knees at right angles to your hips. If not, use a footrest. Ensure that your computer is at eye level and that the keyboard has good wrist support. Try not to cross your legs. Uncrossed legs support your back and help you maintain good posture, so avoiding back strain or pressure.

* Treat yourself to regular massage to relieve muscle tension.

* Lose weight, as carrying excess weight can curve the spine (lordosis), pull muscles out of position and create unnecessary pressure on the back.

* Supplement with fish or evening primrose oil. In the long term, this supports bone formation, preventing problems later in life, and improves nerve function (J Nutr, 1999; 129: 207-13).

* Glucosamine can help rebuild damaged cartilage (Orthop Praxis, 1970; 9: 225) but, in excess, can cause liver/kidney damage (Lancet, 1989; i: 1275). Individuals who weigh less than 82 kg (180 lb) should take 1500 mg/day; those weighing more than that should take 2000 mg/day.

* Acupuncture is safe and effective for low-back pain, and can relieve symptoms for up to six months or more, without any adverse effects (Clin J Pain, 2001; 17: 296-305).

* Ultrasound can relax the muscles, providing some relief.

* Transcutaneous electrical nerve stimulation, or TENS, works better than a placebo for pain relief and restoring function in low-back pain. The effects can last more than eight weeks. However, this is only a painkiller, and not all patients may benefit (Cochrane Library, Issue 1. Oxford: Update Software, 1997).

* Try a radiofrequency facet nerve block, or rhizolysis, a minimally invasive neurosurgical technique using a radiowave probe to ‘cut’ (by thermocoagulation) some of the nerves surrounding the spine, thus reducing pain and spasm in certain cases. In one series of studies, the success rate at the three-year follow-up was 67 per cent (Appl Neurophysiol, 1977; 39: 80-6).

* Use opiates (such as morphine or anti-inflammatories) to relieve pain, or muscle relaxants (such as Valium or Baclofen) to reduce spasm, but only in the short term as the potential dangers of these drugs include addiction and organ damage. While taking these drugs, avoid any activities that could exacerbate your condition as any warning pain will be masked by these painkillers.

* As a last resort, you could try spinal steroid injections. In one study, patients injected with steroid into the facet joints of the vertebrae had slightly less pain and better function after six months than those injected with a placebo. However, this approach is short term and offers no sustained improvement (N Engl J Med, 1991; 325: 1002-7).

The precise pathophysiology of the condition is not completely understood, but it’s believed that pain results not only from a mechanical effect on the nerves, but also from ‘biochemical irritation’ (Ann Intern Med, 1990; 112: 598-603).

PLID is primarily a degenerative condition but, paradoxically, it does not worsen with age. If you’ve got to age 55 without getting a slipped disc, you’ll probably never have one. That’s because the annulus gradually becomes more fibrous over time, thus preventing ruptures in later life. The danger zone is the 20-year window over age 35, when the nucleus of the disc begins to dry out and lose elasticity. Adolescents can also suffer PLIDs, but these are mainly caused by specific injury.

Three main factors can bring on PLID: heavy, awkward pressure on the spine; repetitive movements of the back; and being overweight.

A slipped disc usually happens when someone bends forward while lifting a heavy weight, which puts increased pressure at the front of the spine while releasing pressure at the back. Twisting motions while lifting are particularly hazardous. Heavy manual workers are most at risk but, less obviously, so are people who do a lot of driving – thought to be due to engine vibrations compacting the spinal discs.

However, fewer than one in 20 cases of acute back pain are due to PLID. Most are the result of sprains, injuries to the ligaments and muscles or a locked facet joint between two vertebrae. As a result, PLID is frequently overdiagnosed by GPs.

What doctors tell you

Doctors often recommend surgery to excise the offending tissue. There are two main operations, one more drastic than the other.

The simpler operation is a ‘standard’ or ‘open discectomy’. This involves removing the damaged or bulging part of the ruptured disc to relieve pressure on the nerves. This is increasingly being done by ‘keyhole’ surgery and is the most common operation for PLID.

The alternative is to remove the entire disc – called a ‘laminectomy’. It’s a much bigger procedure, partly because it leaves a gap between vertebrae that must be closed. This is achieved by first removing the bony arches of the vertebrae (the laminae), then either filling the gap with bone chippings (usually taken from the patient’s leg), or screwing the vertebrae together, a procedure known as ‘fusion’.

There are a number of other, less invasive treatments such as cortisone injection, which has been a standard procedure for 30 years, and chemonucleolysis, in which the soft nucleus is dissolved away by a powerful enzyme such as chymopapain, derived from papaya. Newer procedures include electrical cauterisation of the annulus nerve endings to block pain signals (‘intradiscal electrothermal annuloplasty’), the insertion of hydrogel cushions as artificial disc substitutes, and Vax-D, a sophisticated traction device.

What doctors don’t tell you

Taken as a whole, PLID surgery has a poor track record. The most recent review of the clinical data has shown that about half the standard operations need to repeated, as are a staggering 80 per cent of keyhole surgeries (J Gen Intern Med, 1993; 8: 487-96).

When discussing your surgical options, orthopaedic surgeons rarely tell you that:

* your back is likely to heal all by itself. Surgical intervention should not be a knee-jerk response, as spontaneous remissions are seen in more than 60 per cent of cases (Schmerz, 2001; 15: 484-91).

* with an open discectomy:
– it won’t make you feel any better and, indeed, could make you feel even worse (as experienced by at least 4 per cent of patients) (Eur Spine J, 2005; 14: 49-54)
– your back pain is likely to persist. About 75 per cent of patients have residual lower-back pain, 12 per cent of which is described as ‘severe’ (Spine, 2001; 26: 652-7)
– you risk inadvertent damage to the surrounding nerves.

* with fusion:
– you’re likely to suffer surgical complications. ‘Iatrogenic soft-tissue morbidity’, as it is known, is an almost routine hazard (Orthopedics, 2002; 25: 767-71)
– common complications include excessive bleeding, nerve root lesions and recurrent disc herniation – the problem you had in the first place (Eur Spine J, 2003; 12: 239-46)
– the surgeon could damage your internal organs. Perforations of intra-abdominal structures have been reported (Neurocirug [Astur], 2004; 15: 279-84) as well as rupture of large blood vessels (Eur J Vasc Endovasc Surg, 2002; 24: 189-95)
– it may actually make the pain of PLID worse because of scarring or damage to the meninges. Henry La Rocca, clinical professor of orthopaedic surgery at Tulane University in New Orleans, points to “substantial” evidence that iatrogenic scarring of the nerve roots causes long-term pain, and that iatrogenic damage to the membranes covering the spinal cord can be “catastrophic” (Weinstein J, Wiesel S, eds. The Lumbar Spine. Philadelphia: W.B. Saunders, 1990).

In addition, spinal fusion has the highest failure rates. One reason may be that the operation puts an extra load on other parts of the spine. By locking the movement in one vertebral joint, fusion forces the adjacent joints to do 50 per cent more work than they were designed to do. This can lead to later PLIDs – as one osteopath puts it, “You simply chase the problem up the spine”.

Fusion brings other long-term medical problems such as osteoarthritis, probably due to friction between the unbuffered vertebrae. The patient is also left with a weaker spine and so a reduced quality of life.

Nevertheless, there are occasions when surgery is necessary to prevent paralysis. The tell-tale symptoms are specific – either faecal incontinence or an inability to pass urine. Both are caused by the prolapsed disc pressing on the nerves that control the bladder and/or the bowel, and indicate a potentially hazardous condition requiring emergency surgery. Secondary symptoms may be back pain or numbness in the pelvic area.

Medical alternatives to surgery

Chemonucleolysis using papaya enzymes is more effective than surgery in the long term, but may also have occasionally severe adverse consequences – in particular, a fatal allergic reaction. It can also cause severe back pain for up to three months after the procedure (Spine, 1996; 21: 1102-5). As a result, it’s now falling out of favour, especially in the US.

However, chemonucleolysis has been tried with substances other than papain such as alcohol and oxygen/ozone, which appear not to cause allergic reactions nor many side-effects. Ozone therapy claims to benefit 80 per cent of cases, although subsequent tests have shown that it fails to reduce the size of the disc in about a third of patients (J Neuroradiol, 2004; 31: 183-9). Alcohol chemonucleolysis has a better record, claiming a success rate of nearly 100 per cent (J Neuroradiol, 2001; 28: 219-29). But neither technique has yet undergone any clinical trials.

The lack of objective trial data is also the problem with electrothermal therapy and artificial hydrogel discs, both of which can only be described as ‘promising’ (Orthopedics, 2002; 25: 767-71).

Trials have been done on cortisone injection – and subsequently led to its being largely abandoned. In a controlled, blinded study of more than 150 patients, cortisone initially showed a slight benefit but, after three months, there was no difference between it and the saltwater placebo. In fact, regardless of treatment, the patients were 17 per cent worse (N Engl J Med, 1997; 336: 1634-40).

Clinical trials of Vax-D traction have been generally positive, with a claimed “success rate” of nearly 70 per cent. It is also alleged to be safe (Neurol Res, 2001; 23: 780-4). However, there have been – albeit rare – reports of a “sudden, severe exacerbation” of pain due to “marked enlargement of the disc protrusion”, requiring emergency surgery, with the device (Mayo Clin Proc, 2003; 78: 1554-6).

More conventional traction, despite being a long-standing technique, has not withstood the scrutiny of clinical trials, which have shown it to be of equivocal effectiveness (J Spinal Disord, 2000; 13: 463-9). In fact, many osteopaths believe traction to be positively harmful, as it may exacerbate any tears in the annulus.

Tony Edwards