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Do I Need Surgery Doc?



As a Chiropractor in Charlotte, I see patients with many complaints.  It is my job to evaluate patient’s both subjective and objective complaints by taking a careful history and administering orthopedic, neuromuscular exams.  Sometimes an Xray or MRI is used to further ascertain the correct prognosis of the issue at hand when red flags are present.  Some red flags may include the symptoms progressively getting worse, the patient is not responding to treatment after 3-4 visits, the patient wakes up due to the symptoms, there is a history of cancer in the family, or a traumatic event has occurred.

It is very important for the treating physician to not take the findings of the  MRI or the Xray as the ultimate answer to what is going on with the patient.  There have been many times when the patient presents with a pain that radiates from his/her back to the right leg, but the MRI shows herniation is to the left.  MRI or any other imaging is a tool and not a magic test that gives you all the answers.  Studies have shown that if you take 10 nonsymptomatic patients and you take an MRI  of their low back, 4 of the patients will show a herniated disc.

So the lesson of the story is that as a doctor you have to use all of the information at hand to come to the right diagnosis and not isolate one finding.  Obviously, if the finding is a tumor or some sort of growth that is provoking the symptoms, an immediate referral is made and the flow chart in the doctor’s head is over.  Statistically, in a chiropractor’s clinic, there is about a 1% chance that cancer is the culprit of the pathology.

So let’s take a look at lumbar disc derangements.  When a patient comes in with a herniated disc, what is the probability that this patient is going to go under the knife?  The human body is an immaculate instrument that is self-regulating and heals itself when all of its mechanisms are working properly.  The natural history of herniated disc favors regression.  Even if no treatment is administered, there should be signs of improvement between 3 to 6 weeks.  If a patient exhibits pain in both leg and back, as the pain in the leg decreases, back pain may start to increase.  Back pain itself should improve in about 1-3 months.

One of the last things to improve is the sensory deficit.  In 35% of cases when there is a long term compression of the nerve, the feeling may not come back at all along that dermatome due to the irreversible damage sustained.  Although this is a general natural history of a herniated disc, variations may occur that are based on different favoring and unfavorable factors.  Some of the favoring factors include a large extrusion or sequestration of the disc material.

The bigger the better, as your body will see this material as a foreign substance and will use macrophages to eat away at the disc material.    When a small herniation is causing the pain, a long history of chronic pain may persist and may take longer to resolve, but not necessarily leading to surgery.  Also when leg symptoms are resolved at least 50% within the first six weeks, the prognosis is favorable.  Many times when a patient comes in and is unmotivated with poor fitness level the outcomes are poor at best, as this patient is already in a constant state of inflammation due to their poor diet.