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impact, gliding motion exercises are required daily. If the lumbar osteoarthritis does not improve over time and if the pain becomes disabling then in order to possibly improve the condition maybe only 50%, back fusion may be contemplated. This usually does not relieve the pain and can cause many other problems and pain. Other advances in the treatment of lumbar osteoarthritis may be the use of Syn-Visc injection into the joint. This has helped in larger joints in osteoarthritis but has not had the same success over the last 3 years in the spine. Medication such as chondroitin sulfate and glucosamine have been shown to be beneficial in some patients when taken for a minimum of one to two months. These agents should be used with some caution in bleeding disorders and diabetes.
DISK DISEASE TREATMENT
Disk disease is the most widely known lumbar spine problem and yet is misunderstood and often mistreated. Once the anatomical and physical findings match the complaints, unless there is an overwhelming neurological deficit, conservative therapy must be tried. Not all people with herniated discs have symptoms, nor do those people who have symptoms all require surgical intervention. Large herniated discs of the lumbar spine have been demonstrated to decrease, or resolve with conservative therapy (Maigne, et. al., 1992, Spine, 17:1071-1074, and Saal and Saal, 1989, Spine, 14:431-437).
Disk disease often responds to concurrently treating the chemical irritation, muscle spasms and compressive forces. Even if prior attempts of conservative treatment have failed, multi-modality, concurrent therapy is still effective 80% of the time. The therapy attempts to address all aspects of the problem at once. Anti-inflammatories are used for the nerve root and disk irritation. Non-sedating, short-term muscle relaxants help the muscle spasms. Narcotics do not relieve the problem but may allow the patient to participate in all forms of therapy if used for a very short term. Physical therapy with McKenzie exercises and traction may relieve the compressive nature of the disk. This should then be followed by spine stabilization exercises to prevent further injury. Physical therapy training in disk disease is outlined below. Published information on manipulation supports its use to improve recovery and reduce the need for alternative treatments. SNRB can help immediately, decreasing inflammation, allowing the other modalities to continue the improvement. The nerve root block performed on the suspected nerve root that is involved should yield either temporary paresthesia in the distribution of the pain due to the effect of the injected sensorcaine, or temporary to permanent resolution of the pain due to the injected steroid component. This takes affect after two to three days. If there is complete symptom resolution, no further therapy is needed. However, if there is temporary resolution surgical intervention can almost be assured of long lasting resolution of the radicular pain. If there is no paresthesia in the distribution of pain, or temporary relief of symptoms, then a malingering patient or area of compression at a different level should be suspected. It must be remembered that for severe pain or extreme compression, there may be no significant change with the injection. More than likely this would have been known after moderate conservative therapy before the intended injection. Once again, if medications, physical therapy and injections have not been tried during the same time period, improvement might not be seen. The concurrent therapy breaks the snowball cycle of irritation of the muscles, disk, nerves and joints. With this concentrated treatment there should be a (Continued on page 19)
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