How to “Fix” Your Bulging Disk Without Surgery with Dr. Kimball

How to “Fix” Your Bulging Disk Without Surgery with Dr. Kimball

This seems to be a widely-researched topic by patients and while there is a lot of information out there about this topic from various non-physician sources, I wanted to give you a neurosurgeon's opinion as well as one that is based in scientific literature.

There is a well known multi-part study on disk herniation called the “sports study” and the take-away from this is about how 50% of disk herniations get better symptomatically on their own without surgery. This does not mean that the disk totally heals on its own or that your body stitches up that failed disk so that it looks normal again since we just don't have solutions to tell the body how to heal the disk. The disk is a very complicated structure and it doesn't have an internal blood supply, so unlike another part of your body where you cut the skin or you get a bruise and your body can actually send special proteins in healing cells, the disk just doesn't have that same capacity. The disk circulates nutrition by movement. If you're not moving your spine, you cannot heal it, but if moving your spine causes you pain, this is difficult to do.

The disk has two simple layers; an outer fabric called the annulus and the inner core that is soft, gelatinous and hydrated called the nucleus. Once there has been a tear, a defect or an asymmetric stretching in the annulus, you cannot get it to retrieve its elasticity. You can create a negative pressure in the disk by a distraction or extension maneuver, like through an inversion or traction table, but that will not cause the fabric of the disk to tighten back up or have the disk stay in its normal position.

Every disk herniation is different and every spine is different too. Telling a patient outright that a disk herniation can heal on its own is a frustrating concept for a surgeon. Without looking at it on an MRI or a CT scan or without physically understanding what the disk looks like or where the tear is or what kind of a disk failure has occurred, it's almost impossible to promise a patient that they will get better by doing a particular exercise, or eating a certain food, or taking a nutritional supplement.

Most of the therapies around you and your disks are not really about “healing” the disk but more about giving your nerve time and space to calm down and to stop being irritated and painful. On occasion, a disk herniation will dehydrate or shrink back but it is rare that it will disappear so unfortunately, there is no magic formula. We don't even have stem cell options that we've been able to create that allow us to regenerate the disk.

One way to create negative pressure on the disk is the Mackenzie Maneuver, where you lie on the ground on your stomach extending your spine and holding that position. Another way is with a pull-up bar, where you reach up and pull down on the bar, take your feet off the ground and then just allow your pelvis and everything else to completely relax. That's another way for a simple at-home traction which can take the pressure off your spine and disks but also create a negative pressure that can pull the disk back temporarily.

Although these are not permanent fixes, anything that takes the pressure off the nerve and makes you feel better is potentially going to give you some relief. Since we cannot heal the disk as such, these methods are buying you time and reducing inflammation so that your body can heal as much as possible on its own.

Avoiding surgery:

As mentioned, we cannot fix a herniated disk. We cannot go back in time and we don't have a process to actually inject a new cartilage in a cell to grow your disk back to normal. Very much like a tire on your car, it's going to continue to wear out. Even though I'm a surgeon and this is how I make a living I just want people to get better. This is important information for you in order to keep you out of my OR.

Your pain right now is due primarily to some sort of exacerbation or inflammation that’s occurring. It could be a chemical irritation from the disk that is torn and is leaking some inflammatory fluid, irritating your spine nerves and back or t could be that the disk is collapsing and now you're having some bone-on-bone phenomenon which is causing some pain.

Your only option outside of surgery and replacing that disk with a new disk is:

  1. To strengthen the supporting structures around your spine.

  2. To reduce the amount of stress that is on your spine. In other words, to lose weight through diet and exercise.

If you are in a lot of pain and you can't get onto exercise equipment or out jogging, you can try a bicycle or an elliptical. Most patients can do some form of aqua therapy water-based exercises for a low-gravity type of therapy which usually doesn't hurt your back so I recommended aqua aerobics, swimming or walking laps in the pool.

The next step is seeing a qualified physical therapist who is comfortable evaluating and treating you with regards to your spine. Physical therapy isn’t chiropractic therapy or massage therapy; these are different disciplines. A PT will provide you with tools, training and some professional advice to help you strengthen your core and your low back. If you don't do that, you are not going to be able to support the spine that has started to show signs of degeneration.

For symptomatic relief, I would recommend injections, steroids, anti-inflammatory medication chiropractic, acupuncture, acu-therapy and cognitive therapy; none of those things are off the table. The only bridge that you cannot uncross is surgery; you are able to back out of all these other options as they don’t cause a permanent modification to the anatomy of your spine.

Anti-inflammatory medication, steroids and injections:

Once there is a tear or a bulge, there is not much you can do to heal it or get rid of your pain. One of the things to try to reduce the inflammation that occurs when an injury happens, at least in the beginning, is a minimum of three months anti-inflammatory treatment for pain related to a disk, your back or a nerve impingement. Examples of anti-inflammatory, over the counter medications are Advil and Aleve and if you have high blood pressure or kidney problems, you might need to get that addressed with your physician first. These medications are different from acetaminophen or Tylenol, which are NOT anti-inflammatory medications. You do need to stay on the anti-inflammatories for a reasonable amount of time but when taking these for long periods of time, some people will develop gastritis or stomach ulcers so if these occur, patients should stop taking these medications.

If those simple over-the-counter medications are not working, there are some higher dosage, prescription grade anti-inflammatory medications that you could consider taking as well, but they don't always make a world of difference.

When you see a pain management doctor, a physiatrist or a spine surgeon, they may also consider recommending a short course of oral steroids. This is a steroidal anti-inflammatory as opposed to a non steroidal anti-inflammatory medication like Advil. These medications are similar to the hormone cortisol that your adrenal gland produces that reduces systemic inflammation in your body and we're giving you an extra dose of a similar type of hormone.

Steroidal anti-inflammatories can have other effects on your body. They can cause it to feel jittery, to feel hyperphagia (which is feeling really hungry), or it can make you feel like you are invincible. With elderly patients, it can cause serious side effects like psychosis or difficulty sleeping, or increased heart rate, sweating or even swelling of the extremities. If you are diabetic, it can bump your sugar so you have to be careful with it and talk to your doctor before you get prescribed. That being said, these oral doses are not prescribed to treat just one part of your body because you're taking them by mouth and they are going to your stomach and to your digestive system, so they basically go everywhere.

In contrast, sometimes we will prescribe a specific type of a steroid injection. The difference between steroidal anti-inflammatories and steroidal injections is you're going to get a much higher dose of the medication with the injections. Usually we inject that into a nerve or down the spinal sac or where we think there is an irritation happening. Based on the imaging, when injected on and around the nerves, those medications get a local response in a higher dose right where your provider thinks that the pain is coming from. In this way, they can last longer and have a higher dose. That dose will leak out and ultimately get reabsorbed by your bloodstream. You end up getting the systemic dose as well, but it's higher and lasts longer than the oral.

These medications are all built to reduce inflammation, reduce symptoms and make life more livable but they don't actually fix the problem. Although some people refuse these because they see them as just a band-aid, that isn’t going to fix the problem, sometimes you just need to give your body the time to do the healing that it can do and let the inflammation reduce so that you can hopefully withdraw from the pain that you're you're experiencing. That's one of the steps to fixing or allowing your body to do its natural healing to whatever injury that has happened in your spine.

Stem cell therapy:

Stem cell therapy is not surgery. A stem cell is a precursor cell in your body that has the ability to evolve into a specific cell type. It doesn't have an end determination built into it yet so can actually become a new cartilage cell, or a new disk cell, or a new bone cell or a muscle cell. It could become anything.

There are different types of stem cells. Some of them are stem cells that have partially differentiated and have chosen a pathway but still have some ability to select a different path. Stem cells can come from your body, or from the placenta of another human being, or they can come from your fat cells. In order to do a stem cell harvest from your fat cells, we would require removal of the fat, taking those stem cells out of them and then putting them back in. The most common type of stem cell that we use and remove from your body is a bone marrow stem cell and that's either taken from the spine or most commonly from the hip, which can be painful.

One of the challenges in the United States with stem cell transfer is the FDA has some strict regulations on what we can do to the stem cells after they've been taken out of your body and then put back in. Only minimal manipulation can occur so for example, if we took stem cells out of your hip and then isolated them, that would be more manipulation than is allowed by the FDA so the process of taking your cells and putting them back in is somewhat constrained in this country.

One way of getting around this, is taking stem cells that have been harvested from another human being, freezing them, thawing them and then injecting them. There is a lot of research around and uses for stem cells in orthopaedic literature for knees and hips but there's not a lot of reliable data available for the spine.

A lot of my patients ask these questions: “Where is stem cell therapy used in the spine?” “Is it helpful?”, “Can I fix my bulging disk by putting stem cells into the spine?”, “ If not, why and what is the problem with it?”

Stem cells are injected in the spine in two different primary locations:

  1. Into the disk space:

The process of a stem cell turning into an actual disk cell is complicated and involves that stem cell being exposed to lots of other signaling molecules that tell it to then turn into a new disk cell. That can happen outside of the human body in a petri dish but again, we have a challenge in taking those stem cells that have been manipulated and putting them back in. So just taking a stem cell without giving it the signaling molecules and putting them into your spine or in your disk that is bulging, will make those stem cells not know what to do when they get into the disk once they've been injected. The likelihood of them converting into a disk cell is not as good as you would think, so that's one of the challenges.

  1. PRP:

The other space where stem cells are used in the spine is in combination with something called PRP which is platelet rich plasma. Those are not stem cells so one has to be careful when talking about PRP vs. stem cells. These different combinations of injection can have different results. There are no stem cells in PRP, but it is used as an alternative to a steroid injection or like an anti-inflammatory and I've seen in my practice most of the benefits for PRP as an anti-inflammatory being injected in and around the facet joint complex. I've seen better results with patients in the neck versus the low back but that's not fixing your bulging disk. It could be related to some of the pain that you're experiencing and it has been used in some cases as an epidural injection as well.

As a reminder, the bulging disk is a result of the failure of the outside of a disk. The fabric or the annulus of the disk has somehow stretched or torn so even putting new disks, were we able to grow them, would not necessarily fix that outside of the disk. It's unlikely that a stem cell injection in your disk at this time is going to repair your disk unless we have new methods to tell those cells to turn into the right kind of cells, in the right location, at the right time.

Stem cell injections can be very costly and there's not a lot of scientific data around them. Patients often reach for anything but surgery and they'll turn to regenerative medicine or stem cell therapy but a stem cell injection harvest could cost anywhere from $4,000 to $10,000 on average and the going-rate is more like $5,000 or $6,000 in Denver, where my practice is located. Insurance is not likely to cover this so proceed with caution.

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