Ask the Doctor: ‘I suffer from back pain and a bulging disc, and have seen no results from physio – what are my other options?’

“I have suffered with back pain for many years and have a bulging disc. I recently took early retirement and would like to spend more time on the golf course. I have been attending physiotherapy for a long time with not enough results. Do I have any other options that might provide a more satisfactory and permanent solution?”

Answer from Prof. Seamus Morris, consultant orthopaedic surgeon specialising in spine at the National Spine Institute, Beacon Hospital.

Back pain is very common. Overall, 60% of people experience some degree of ongoing back pain, with up to 15% of people experiencing a new episode of severe back pain each year.

Most new onset back pain settles quickly, within eight to 10 weeks. Gentle exercises, the application of heat and over-the-counter medications such as Paracetamol and Ibuprofen are often sufficient to help things begin to settle. Physiotherapy is also very helpful with gentle exercises to mobilise the spine, deep massage and dry needling all proving useful to help alleviate early spasms.

If symptoms are failing to settle, you may need to see your GP. Other factors that would warrant an urgent review by your doctor would be severe pain that wakes you from sleep, altered sensation in your perineum (private parts) or loss of urinary continence. In these scenarios, an urgent MRI is the next step.

MRI scans are incredibly sensitive investigations, giving a clear picture of the nerves, bones and discs in the spinal column. Most people over the age of 30 have signs of wear and tear (degeneration) of the intervertebral discs and in the vast majority of cases, these are painless incidental findings.

In patients who have persistent ongoing back pain, rehabilitation plays an important role in building up the muscles that surround the spine (core muscles). Useful strategies to strengthen the muscles include a home exercise program prescribed by physiotherapy and pilates. Swimming is also very useful, with front and back crawl recommended.

Some activities can exacerbate back pain due to the repetitive stresses they can place on the joints and discs in the low back. Unfortunately, this can include lifting weights in the gym and golf, due to the rotation of the low back that occurs during the drive. Modification of these activities (e.g. shortening the golf swing) can allow people to continue their sporting activities.

If symptoms fail to settle following a number of months of rehabilitation, or continue to occur intermittently, steroid injections into the spine may prove useful. These are typically undertaken in the operating room under x-ray guidance and will target specific joints or nerves that are giving rise to ongoing pain.

If patients only derive temporary relief from these injections, a rhizotomy may be considered. This involves ablating the nerve supply to the spinal facet joints using small electrodes which can be passed through needles under x-ray guidance. This procedure can give up to three year’s pain relief.

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