Disc disease

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  • If no Cauda equina syndrome or progressive neuro deficit → delay surgery for a month
  • Epidural steroids for temporary symptomatic relief
  • Discetomy gives better pain control over 4 yrs but not past 10
  • Microdiscectomy similar to standard discectomy but percutaneous or laser discetomy less effective than standard surgery

Spinal Stenosis

  • Low back pain that gets progressively worse over time
    • Check ankle-brachial index (ABI) to rule out vascular claudication
  • Avoid alcohol and strengthen legs to prevent falls
  • Exercise bike or walking recommended with rest when pain comes
    • Pain relieved with forward flexion (walking uphill)
    • Pain worse with extension (walking downhill)
  • Decompressive laminectomy for severe persistent pain
  • Adding spinal fusion to decompression improves outcome
  • Even with surgery, symptoms may reoccur in a few years

Chronic Back Pain

  • Neural remodeling and neuro-plasticity may explain chronic pain in absence of ongoing tissue injury - alters perception of pain
  • Intensive exercise helps
  • Antidepressants, especially tricyclics (better than SSRI), also helpful
  • No long term opioids
  • Goals may need to be refocused
  • Multiple surgical procedures are not helpful


  • Corsets and education not helpful
  • Weight loss, exercise, smoking cessation helpful