Prolapsed intervertebral disc and homoeopathy

Dr Ila Yadav

INTRODUCTION:
The prolapsed intervertebral disc (PIVD), also known as herniated disc, a common condition affecting the spine frequently causing neck pain or back pain is a displacement of disc material (nucleus pulposus or annulus fibrosis) beyond the intervertebral disc space.

INCIDENCE:
Neck or back pain is experienced in 60%–80% of adults at some point in their lifetime. Some studies have demonstrated that it is one of the most common cause of visits to a physician. The highest prevalence is among people aged 30-50 years, with a male to female ratio of 2:1. It is an emerging problem with an incidence that is the highest in worldwide. In people aged 25-55 years, about 95% of herniated discs occur at the lower lumbar spine (L4/5 and L5/S1 level); disc herniation above this level is more common in people aged over 55 years.

AETIOLOGY/RISK FACTOR:
Radiographical evidence of disc herniation does not reliably predict low back pain in the future, or correlate with symptoms; 19-27% of people without symptoms have disc herniation on imaging. Risk factors for disc herniation include weight-bearing sports (e.g., weight lifting, hammer throw), and certain work activities, such as repeated lifting. Driving a motor vehicle has been suggested to be a risk factor for disc herniation, although evidence is inconclusive.

Some of the causes of prolapse:

• Traumatic: 80% of the cases are traumatic in origin. There may be a sudden severe strain to the affected part of the spine.
• Increased tension: The nucleus pulposus may absorb excess fluid and swell, so that this bulges the annulus or even burst through it. Such absorption may occur in some physical illness and emotional stress.
• Degeneration: In about 15% cases, it is degenerative in origin. The disc loses its elasticity, weakened disc cannot resist body weight and is liable to herniate. Simple unequal stress or minor trauma will cause increase in intradiscal pressure which will lead to protrusion or prolapse of the disc.

CLINICAL FEATURES:
The patient is usually an adult between 20-40 years of age, with a sedentary lifestyle. The commonest presenting symptom is low back pain with or without the pain radiating down the back of either or both leg (sciatica). In case of cervical disc prolapse, patient presents with a vague history of injury to the neck – often a jerk or a twisting strain. The neck become stiff and the pain radiates down the shoulder to the outer aspect of the hand, to the thumb. Paraesthesia will be felt in the hand. A preceding history of trauma is present in some cases. In a few cases, there is a history of exertion such as having lifted something heavy or pushed something immediately preceding a sudden-onset back pain/ neck pain.

The following symptoms are common:

• Neck pain/Low backache:  Onset of pain may be acute or chronic. An acute pain is severe with the spine held rigid by muscle spasm, and any movement at the spine is extremely painful. In chronic cases, the pain is dull and diffuse, usually made worse by exertion, forward bending, sitting or standing in one position for a long time. It is generally relieved by rest.
• Sciatic pain: This is usually associated with low back pain, but may be the sole presenting symptoms. The pain radiates to the gluteal region, the back of the thigh and leg. The pattern of radiation depends upon the nerve root compressed.
• Neurological symptoms: Sometimes, the patient complains of paraesthesia, most often described as ‘pins and needles’ corresponding to the dermatome of the affected nerve root. There may be numbness in the neck, hands, leg or foot and weakness of the muscles.

DIAGNOSIS:
The diagnosis is mainly clinical. Plain X-ray does not show any positive findings in a case of acute disc prolapse. In cases of chronic disc prolapse, the affected disc space may be narrowed. Investigations like CT scan, MRI scan may be done to confirm the diagnosis, especially if surgery is being considered.

GENERAL MANAGEMENT:
Absolute rest and traction with the help of cervical collar or back supportive belt is advised for 2-4 weeks. Conventional mode of treatment suggests NSAIDs and cytokine inhibitors, muscle relaxant and at times epidural injections of corticosteroids.

HOMOEOPATHIC MANAGEMENT:
Homoeopathy is frequently used to treat prolapsed intervertebral disc. The selection of appropriate remedy is based upon the theory of individualization and according to the precise symptoms of each individual patient (symptoms similarity) by using holistic approach. The aim of homoeopathy is not only to treat prolapsed intervertebral disc prolapse but to address its immediate or proximate underlying cause and individual susceptibility.

These are indications of few rubrics which are helpful in the selection of medicines for treatment of PIVD:

• Back, concussion, of spine = Hyper.
• Back, injuries, lifting from = Calc, Rhus-t
• Back, pain, lumbar region, lying, on something hard, amel = Nat-m, Rhus-t
• Back, pain, lumbar region, extending to, gluteal muscles and thighs = Kali-c
• Back, pain, sacral region, motion, gentle, amel = Puls
• Back, pain, aching, lumbar region, turning, must sit up to turn over in bed = Nux-v
• Back, pain, constricting, lumbar, takes away the breath = Puls

• Back, pain, lancinating, lumbar, lying, on back = Coloc
• Back, pain, pressing, weight, after walking = Rhus-t

• Back, stiffness, draft, from a = Rhus-t

These are indications of few homoeopathic medicines which are helpful in the treatment of PIVD:

1. Aesculus hippocastanum: Weakness, weariness and lameness in the small of the back sore and tired mornings when awaking; constant dull backache, walking almost impossible, scarcely able to stoop or to rise after sitting, especially across HIPS AND SACRUM; darting and shooting pains in upper and lower extremities, most on left side; paralytic feeling in arms, legs and spine; (<) by exercise, (>) by rest.
2. Arnica montana: Lumbago from overexertion and straining; weakness of cervical muscles with great sensitiveness to pressure; crawling in vertebral column; pressive pain between scapulae seeming to extend from the posterior wall of the stomach, and cutting thrusts extending into chest while walking; every part of body feels sore; (<) from excitement, (>) by rest.
3. Bryonia alba: Drawing and stiffness of cervical muscles, especially right side; shooting stitches in back through to chest; viol
4. ent pain in first dorsal vertebra, extending through thorax to lower portion of sternum and impeding respiration; small of back pains as if bruised when lying upon it, (<) by even a light touch on spine and from slightest motion; every spot on body painful to pressure, (<) mornings.
5. Calcarea carbonica: Drawing pains between scapulae and pressure which impedes respiration, and painfulness in bones of spine to touch; pain in small of back so that he can hardly rise from sitting; muscular debility and soreness; stiffness when beginning to move; PARTS FEEL SUBJECTIVELY COLD AND ICY COLDNESS IN AND ON HEAD; trembling of inner and outer parts; weak feeling in back, (<) from mental annoyance, can hardly rise; softening of spine, with contraction of limbs; (<) from cold, damp air, from washing; lumbago from over lifting; SPINAL IRRITATION FROM SEXUAL EXCESSES OR MASTURBATION.
6. Hepar sulphuris: OVERSENSITIVENESS TO PAIN OR TO COLD; rheumatic pain in back, with sensation as if bruised, while walking, standing or lying with sharp pressure in lumbar vertebrae extending to lower limbs and compelling to limp.
7. Hypericum: After a fall, slightest motion of arms or neck extorts cries; cervical vertebrae very sensitive to touch; violent pains and inability to walk or stoop after a fall on coccyx.
8. Lachesis: HYPERSENSITIVENESS WITHOUT SORENESS, yet often relieved by rubbing; back-pain, with great restlessness, gaping and stretching of extremities; stiff neck, with tearing pains form nape up either side to top of head; pain in coccyx when sitting down, as if sitting on something sharp.
9. Lycopodium: Stiffness and tensive pain in neck and occiput; pain as from sprain in nape, with sensitiveness to touch; burning, pressing and drawing in back, (<) by fanning back; sensation as if flesh were loose on lower part of back; pains and aches across the small of back, (<) by passing urine; sticking stitches in back on breathing; BURNING AS FROM GLOWING COALS BETWEEN SCAPULAE; limbs and extremities cold, with feeble circulation; NEURASTHENIA AND BRAIN-FAG, hence (<) in the afternoon from 4 to 8; spinal anaemia; impotence.
10. Nux vomica: BACKACHE ACCOMPANYING ABDOMINAL PLETHORA, with piles, constipation and urging to urinate, must sit up in order to turn from one side to the other; pain as if flesh were beaten loose from last cervical vertebra; burning, tearing and constrictive pains in back and small of back pain in pelvic region as if dislocated; tearing and pulling in lower portion of back while walking and sitting but not while lying; numbness of limbs; increased sensibility to external impressions; heart feels tired, with tendency to faint, (>) while lying down.
11. Rhus toxicodendron: Rheumatic stiffness of nape, with pain as if a heavy weight were upon it; pain in cervical muscles as if asleep; constrictive pain in dorsal muscles while sitting, (>) by bending backward, (<) forward; violent rheumatic pain between scapulae, only relieved by heat, (<) from cold; stiffness and aching in lumbar region, (>) from motion and from lying on something hard (Natr. m.) burning feeling in loins; spinal irritation from ovarian and uterine troubles, especially if caused by straining, lifting or becoming wet; often resulting from sexual excesses, when there are tearing, contusive pains in back, (<) during rest, with increased sexual desire and nightly pollutions.
12. Sepia: Depressed, anxious and fearful state of mind, with a sense of helplessness; pain in back and small of back with stiffness, (>) by pressing back against something hard or by walking and by belching; pulsations in back; backache causes nausea and faint feeling while standing; icy coldness of feet; excessive to pain; twitching of limbs during sleep; frequent micturition at night; hysterical spasms.
13. Theridion: GREAT SENSITIVENESS BETWEEN VERTEBRAE; patient sits sideways on a chair to avoid pressure of back against the spine; pains in bones as if every part would fall asunder, followed by violent coldness, not relieved by heat; weakness, trembling, anxiety.
14. Zincum metallicum: Constant pain in back and loins so severe as to render life miserable; pain in back when walking relieved by continuing to walk; stiffness and tension of neck; tearing pains, burning in shoulder-blades; burning along whole spine, (<) sitting; tearing, trembling and lameness in limbs; twisting in affected limbs and frequent jerking of whole body during sleep; great weakness of limbs; weakness of lumbar region and bend of knees; TENDENCY TO CONVULSIONS FROM INJURY TO SPINE; transfer of pains from one side to another; wine increases the pain and nervous weakness.

REFERENCES:

1. Essential Orthopaedics by J. Maheshwari.
2. Hutchison’s clinical methods by Michael swash.
3. Practical medicine by P. J. Mehta.
4. A concise textbook of surgery by S. Das.
5. Pocket manual of homoeopathic materia medica and repertory by William Boericke.
6. A synoptic key of the materia medica by C. M. Boger.
7. Concordant materia medica by Frans Vermeulen.
8. Repertory of the homoeopathic materia medica by J. T. Kent.
9. Herniated lumbar disc by Jo Jordon, Research Information Manager, Kika Konstantinou and John O’Dowd,  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2907819/
10. Prevalence and Risk Factors for Low Back Pain in 1,355 Young Adults: A Cross-Sectional Study by Sudhir Ganesan, Anita Shankar, Ravi Chauhan and Shankar Acharya. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5573856/
11. Andersson GB. Epidemiological features of chronic low-back pain. 1999; 354:581–585. https://pubmed.ncbi.nlm.nih.gov/10470716/

Dr. Ila Yadav
PG Scholar, Department of Organon of Medicine
U/G/O Dr. Parvinder Kaur (MD Hom.) Professor in Department of Organon of Medicine
Sri Guru Nanak Dev Homoeopathic Medical College and Hospital, Ludhiana, Punjab.