David Salkin, 50, is the former mayor of Freehold County, New Jersey, and a top-selling author of military fiction. He has led an active life — football in high school, ski team in college, and various outdoor activities. Unfortunately, like many energetic people, he has had injuries. More than 30 years ago, Salkin suffered his first herniated disc during a high-school football game. It is an injury that he has aggravated several times over the years, most recently when, inspired by his nephew’s track scholarship, he took up running after a long time away.
“I decided if he could run two miles in nine minutes, I could run one in nine minutes,” he says. “It was a bad idea.” After several weeks of pushing himself, he moved the wrong way, and he was in pain.
“This cost me another three months of agony,” says Salkin, who five years earlier had been scheduled for spinal fusion surgery: not a welcome scenario. “Luckily, I found a neurosurgeon who wanted to try epidurals and physical therapy.” He decided to go with the non-invasive option instead. He would do so again this time.
Several months of spinal injections, physical therapy, and chiropractic care helped him heal without surgery, but others are not so lucky. A herniated disc, especially with sciatica, puts some sufferers flat on their backs indefinitely, and surgery is sometimes their best option.
This type of injury is more common than many people realize. According to the late Gerald M. Silverman, MD, 57 percent of people over age 60 and 20 percent under age 60 have at least one bulging disc. For some, herniation is painless or merely an annoyance. For others, meaningful movement — walking, sitting, or turning — is excruciating and sometimes impossible.
Pain and prevention
A herniated disc is a rupture of the structure between two vertebras. “The structure,” according to Alfred O. Bonati, MD, founder of the Bonati Spine Institute, “has a central area that is soft, then the nucleus pulposus, and a hard outer area called the annulus.” Injury to the disc can cause the annular area to bulge, and this introduces pain.
Sciatica brings even greater discomfort. “When the damaged area of the disc becomes more than five millimeters in size of deformity and presses the nerve,” explains Bonati, “the pressure causes radiculopathy [also known as sciatica].” Sciatica is radiating pain that extends down the back and to the legs.
If the disc ruptures and the nucleus pulposus material opens, the pain intensifies even further and requires immediate intervention. “This is when we see people in the emergency room,” says Bonati.
Like Salkin, many herniated disc sufferers describe turning the wrong way or lifting an object while standing at an awkward angle. One minute they are mobile and free of pain, the next they are in agony — they have ruptured a disc.
According to David Hanscom, MD, author of Back in Control: A Spine Surgeon’s Roadmap Out of Chronic Pain, bending at the waist with the legs straight is a common culprit. “Unsupported bending creates a large amount of stress across the disc,” he says. Hanscom likens the injury to spitting a watermelon seed between the fingers and admits to hurting his own back years ago while setting up his son’s crib.
He went from being the doctor to the patient in one swift move. “It was a terrible and enlightening experience,” he says. “The pain created by a pinched nerve is intense, and I developed a new respect for the suffering of my patients.”
Proper posture — sitting and standing straight — is another preventative measure, which helps keep the spine even and less likely to be damaged. When sitting at a computer, for example, be mindful of slouching in the chair or constantly bending forward. Strength training the midsection through exercise helps keep the back and abdominal muscles strong, and this also protects the lumbar spine. Losing weight is another preventative measure, especially girth carried in the midsection. As with any exercise or weight-loss program, always check with a doctor first.
Unlike David Salkin, who opted for epidurals and other therapies, Mike Weems, a 47-year-old director of finance, found himself on the operating table. It all started in 2011 when Weems, an avid runner, weightlifter, and cyclist, began experiencing back pain. By 2014, the situation grew worse, and he started to lose feeling from the neck down.
Adam Lipson, MD, of IGEA Brain and Spine, gave Weems an MRI. The results showed a severely herniated C5-6 disc that was compressing his spine. This new injury was in addition to two lumbar or back herniations. Lipson was surprised that Weems could still walk.
“It was an extremely scary experience when Dr. Lipson showed me the MRI…” Weems says. “If it would have snapped, I would have been paralyzed from the neck down.”
Lipson performed an immediate anterior cervical disc replacement, and Weems came through the surgery like a champion.
“Literally, when I woke up from surgery, I had full feeling and range of motion. Everything was back. It was amazing.” Within five days of surgery, Weems was able to drive his daughter out of state to tour colleges. Such an outcome is not uncommon.
According to Lipson, IGEA Brain and Spine enjoys a 90 percent success rate with the type of surgery Weems had. In fact, spine surgery has evolved so much in recent decades that it should no longer be considered as scary as it once was. Despite this, the stigma of paralysis, or surgery exacerbating back problems, remains. “There is a perception,” says Lipson, “of poor outcomes, but the data show that is not the case. Outcomes are on par with joint replacements.”
Bonati agrees and has patented Bonati Spine Procedures, a series of operations geared toward the individual. “Procedures are performed using conscious IV sedation,” he says, “so the patient is awake, aware, and alert and can remain in communication with the surgeon throughout the surgery.” Many of Bonati’s patients are up and walking within minutes of their procedures.
Other types of herniated disc surgery, when non-surgical interventions fail to relieve pain, include discectomy or microdiscectomy. Usually, during the minimally invasive microdiscectomy, the herniated section of disc is taken out with the use of a special microscope, giving the nerve more space to heal. This procedure is often done on an outpatient basis.
Laminotomy and laminectomy are procedures that require opening the vertebrae to alleviate pressure on the nerves. Sometimes the spine’s vertical arch is removed completely, but the procedure can still be performed on an outpatient basis.
Artificial disc surgery is another common procedure. In this case, the damaged disc is taken out and a plastic or metal replacement is inserted. This surgery sometimes requires a day or two in the hospital.
Spinal fusion is also an option. This procedure means that two or more vertebrae are fused together. Bone grafts can come from other parts of the body or from a donor, and the surgery may require screws and rods to stabilize the corrected portion of spine, which is permanently immobilized following surgery. This procedure can mean a weeklong hospital stay.
These days, however, even complex surgeries are less invasive, which allows for faster recovery. Many patients find themselves driving or walking a day or two post-op. And spinal surgery for the herniated disc is always evolving. Even now, Bonati is looking toward the future, imagining ways to make spinal surgery even less invasive and more patient friendly. “I have some ideas,” he says, “but nothing I’m going to discuss, yet.”
Salkin, who opted to take the non-surgical route, found a neurosurgeon who set him on a different road to recovery.
Because herniated disc can self-repair over time, non-surgical interventions are becoming more common. “Compromise of bowel and bladder function is a true emergency where we operate as quickly as possible,” says Hanscom. But this is not the norm.
“Pain and sleep medications can buy time while the disc is healing,” he explains. “Cortisone injections will decrease inflammation.” He calls the injections the mainstay for easing the agony caused by a ruptured disc with sciatica.
Other non-surgical options include non-steroidal anti-inflammatory drugs like ibuprofen or naproxen. Steroid injections are often prescribed via lumbar epidurals, delivering pain relief directly into the spine. Muscle relaxants are another possibility. These approaches can be used in various combinations and are usually followed by or used in conjunction with prescribed exercise and/or an individualized physical therapy regimen. Again, it is important not to attempt any exercises or therapies without checking with a doctor.
Many of these non-surgical approaches have helped Salkin over the years, but he is especially fond of a particular treatment. “I’d be remiss if I didn’t point to the one thing that I think saved me from surgery. I found a chiropractor that does ART,” he says. “Active Release Technique took the pressure off the sciatic nerve and literally saved me from the knife.”
ART is a chiropractic treatment that relies on a pressure massage to influence soft tissue, often working on one area to relieve stress on another.
One thing people who have back pain can do on their own during or following treatment: fix their posture.
Because Salkin has had several bouts of back trouble over the years, he has adopted good posture. “I need great posture while standing or sitting,” he says, “or my back starts to hurt.” He advises his fellow back-pain sufferers to do the same. Sit strong. No slouching.
The finish line
Several months post-surgery, Weems returned to his active lifestyle, including weightlifting. Unfortunately, his lower back pain worsened, and in April 2015, he and Lipson decided on a microdiscectomy. This would address the herniated disc that was not addressed during his previous surgery.
Again, Weems felt immediate relief following the procedure. “I had really been struggling with leg pain,” he says, “and it was gone.”
A few months after his final surgery, he went back to weightlifting, running, and biking. In 2016, he ran a half-marathon with his 18-year-old daughter. They crossed the finish line together at 2:15:07. Now he is training for a triathlon.
Salkin is also pain-free as of late but knows what he has to do to stay that way. “Having lived with back issues for so long, I know what I can and can’t do,” he explains.
He tries to start his days with a floor routine of stretching, core exercises, and pushups. “Having a strong core and avoiding weight gain are the keys to spine health,” he says. “If I get lazy and don’t do my routine, my back lets me know, and I get back on track.”
Salkin is active in a few organizations and says, “I work with wounded warriors with real problems.” He sees his back as “nothing but a thing” in comparison. He recently traveled to Washington, D.C., to research a book he’s writing. And because he works for county government and the job of mayor rotates, he’ll be holding that office again soon. Already, he is anxious to get out and meet with his constituents.
Advances in herniated disc treatments — therapy regimens and less-invasive surgeries — mean that people with back pain can live pain-free, resuming activities and moving forward with their lives. Spine surgery is constantly evolving, and new therapies are always on the horizon. Currently, more than 20 clinical trials are in the recruiting stages.
“Being trapped by pain is possibly the worst part of the human experience,” says Hanscom. People like Salkin, Weems, and thousands of others have learned that they don’t have to be.
Developing Strong Posture
Stand strong: Stand straight and share the weight. When standing for a long period of time, alternate weight from foot to foot, or periodically rest one foot on a low stool or curb to shift the load off your back.
Sit strong: Remember to move. If a job requires hours of sitting, choose a chair with good lower back support and change positions often.
Lift strong: Lift with the legs. When lifting a heavy object, keep the back straight, bend only at the knees, and hold the object near the body. In other words, bend into a squatting position, keep the back straight, and lift until standing.