Slipped disc, effective treatment vs liver strain
May 17, 2024 12:19 AM   Subscribe

My partner has a back injury diagnosed (via MRI) as L5/S1. He's been prescribed pain meds, but he only takes them sporadically because he's worried about his liver.

I think it really hurts, because he's not usually someone who complains about pain. But he's too anxious to take the prescribed 600mg of Ibuprofen 3x a day.

I'm worried because those meds are anti-inflammatory. If he's not taking them, how will the inflammation go down?

I'm also concerned because I believe he'll end up taking lower or irregular doses of potent pain meds for months (it's been four weeks already), rather than a higher dose for just a short time. That seems inefficient and probably worse for his liver and kidneys?

And lastly, I'm worried about pain memory. I don't know much about neurology, but I've heard that nerves will "remember" injuries that caused them to fire, sometimes leading to chronic pain. I believe this can be avoided by actually taking enough pain meds.

I'm happy to be told I'm wrong. Maybe he's doing this right, and it will just take a long time. But if my concerns are warranted, I'd like him to know so he can make an informed decision. He will happily read clear explanations from reputable sources, but I've had trouble finding any.

PS: He was also prescribed physical therapy, but doesn't really want to go. He thinks it won't help with the amount of pain he's experiencing.
posted by toucan to Health & Fitness (22 answers total) 5 users marked this as a favorite
I slipped a disc when I was 28 and very fit - I slept on the floor for two weeks , took the pills and couldn't climb stairs for ten days. And I was was fine. Sometimes you need the hard[er] drugs and ibuprofen is low on the scale imo. Ditto for things like voltaren. It's only a week and he'll be done.
'Doing his own research' won't solve anything.
posted by unearthed at 12:45 AM on May 17

Highly recommend PT. Doc & sis told me I could take 800mg of ibuprofen without worry, IANTD.
posted by HearHere at 1:09 AM on May 17 [2 favorites]

daily, not more than a month
posted by HearHere at 1:10 AM on May 17 [1 favorite]

I agree with you that controlling pain helps prevent a lot of bad things - can minimize compensation (which brings strain elsewhere in the back), and allow *some* movement which obviously helps, plus lets you sleep (which promotes healing)… however I think there are better options than Advil (which some research suggests slows healing time, plus it increases risk of gastric bleeding and even various heart problems. Which I was sad to learn because I ate it like candy for years because it so often seems to work for minor aches)

I can share with you what I was suggested at a pain clinic (was sent there for a small fracture in a part of a vertebrae, idk if your spouse’s doc would make a referral to a pain clinic or not): gabapentin, Voltaren, and Robaxacet (Tylenol + methocarbamol, though I’m remembering something about it perhaps not being available OTC everywhere) for pain, plus physio. There are risks to all those, too, and I encourage you to read about them. The pain clinic didn’t prefer me to take Advil/NSAIDS orally, that’s for sure. That combo has helped me get through nerve pain and periodic muscle spasms in the worst of it, now I only occasionally take a gabapentin.

Please also read Back Mechanic by Stuart McGill. The main idea is to 2) avoid painful postures while using pain-free ones, while 2) strengthening the back/core. Mainly by bracing as if you’re going to take a punch (good cue for me, “stiffening” the core muscles) as often as you can remember to. There are in-depth self-assessments plus a few easy exercises that are modifiable. He talks about “the big three” (Google that + his name), but some people might benefit from slightly different ones which he also talks about.

That said, “600mg of Ibuprofen 3x a day”, man I lived off that for years. It probably won’t touch his pain though.

Wait - which pain meds was he prescribed? Opiates or gabapentin?
posted by cotton dress sock at 1:10 AM on May 17 [2 favorites]

Max dose for ibuprofen is 3200 mg a day for adults. He's only getting 1800 mg. He's well under the max dose.

Also, how NSAIDS work is by blocking the COX (cyclooxygenase) enzyme body uses to make prostaglandins (so NSAIDS are also known as COX-inhibitors). Prostaglandins are manufactured near "wounds" of the body to create inflammation and surgery may cause an excessive amount of them released, which will cause increased pain sensitivity. None of this really involves the liver. What can potentially hurt the liver if overdosed was Acetaminophen (i.e. Tylenol).

He's literally suffering for NOTHING, IMHO, of course, and I am not a doctor nor do I play one on TV.
posted by kschang at 1:12 AM on May 17 [5 favorites]

I had my first of five back operations when I was 15 (Almost a half a century ago). I have had a fusion at L4/L5 and multiple levels of my cervical spine. I am in pain more than I am not. If taking 600mg of Ibuprofen 3x day was a problem even in the short term, my liver would be mush. I have taken that much ibuprofen a day for maybe 250 days a year for DECADES. I get blood work done often bc of multiple medical reasons. My liver function is one of my better organ functions.

I get that I am one anecdotal case, but my back doctors have all been ok with it. Heck, more than ok, I guess, they prescribe it. I have also been (not currently) prescribed regular doses of acetaminophen as part of Hydrocodone 5/325 or 10/325s. I avoid those because of the addiction issues, but back in the day, I took a lot of them without peril to my liver. I also have a prescription for Gabapentin, they work, but I do not like how I feel when I take them, so I generally don't.

The way I look at it is that I did not spend $500,000 and take 12+ years to become a doctor. When my accountant tells me what to do, I listen. Same as my lawyer or even my dry cleaner. They are the experts. If you don't trust them to give you good advice, go to another one who you do trust. Then follow their advice.

If the MRI indicates a herniated disc at L5/S1, if it persists long-term, perhaps surgery should be considered as a pain reliever. My laminectomy lasted a good 20 years. During that time, I played hockey, basketball, ran cross-country, lifted weights, and worked manual labor in the summers.

As for how to get rid of the inflammation without the meds, rest and immobilization and/or lack of any strenuous exercise will give the inflammation time to reduce.

(NSAIDS sound like cox-blockers. Sorry.)
posted by JohnnyGunn at 1:42 AM on May 17 [2 favorites]

To your partner: Take the anti-inflammatories and go to the physical therapy. They're prescribed because they work. Whatever you've read on the internet is not more correct that what the doctor has told you. You're not being a hero, you're being ignorant and suffering pointlessly. And you're worrying the hell out of your poor partner who has to look after you. Be a better human and do what you need to do, for yourself and your partner.

To you: He can do what he wants to himself, but he's expecting you to live with the consequences of his actions and that's not cool. I'm sorry you're going through this, hopefully he'll see sense soon. For what it's worth you're absolutely correct to think that following the medical advice is the right thing to do.
posted by underclocked at 3:27 AM on May 17 [6 favorites]

A lot of the latest research into chronic pain says that one of the most common ways people develop chronic pain is

1. injury causes acute pain

2. that injury is then not treated with adequate pain relief

3. the brain "gets used to" being in pain, and continues to send pain signals even when the physical damage that first caused the pain has healed.

So trying to tough it out could lead to him developing long term chronic pain.

(If you're interested in research into chronic pain, Noigroup is one of the world leaders in this field.)
posted by chariot pulled by cassowaries at 5:32 AM on May 17 [2 favorites]

JFC. I'm like, "the doctor told you to take these meds and go see the PT. Why aren't you taking the meds? Why aren't you going to PT? If you take meds, PT won't hurt! Are you spine doctor? What the hell. You go to doctor for treatment, you don't do what doctor says, you expect cure anyway? What the hell."
posted by seanmpuckett at 5:44 AM on May 17 [1 favorite]

I feel like your chances of getting him to take the appropriate meds and do the physical therapy are slim. He has pre-rejected two of the most effective things that would help relieve his suffering due to his "beliefs." You can't argue someone out of their beliefs. He'd rather suffer than risk vague improbabilities.

In case reason can prevail though...

Just because ibuprofen can damage the liver it doesn't mean that it will damage the liver.

As someone else noted, 1800mg of ibuprofen daily is well below the max dose. If he needs reassurance, he should talk to his doctor or the doctor/nurse help line if your coverage provides one.

If he won't accept the authority of his doctor, then honestly he's brainwashed himself and it might not be possible to convince him to do the right thing for himself.

I injured the same disc when I was 20, injured it more when I was 32 and ended up having a partial laminectomy later that year (I just turned 60*). When I reinjured it the only position I could be in with any relief was standing on one foot holding my other foot so my leg was completely bent. Sleeping was impossible.

Not managing his pain is hostile to himself and is unfair to you.

Every doctor who has told me to take ibuprofen for various injuries I've had had told me that it works best when it is maintained in the patient through regular dosing. Taking it ad-hoc (they told me) reduces its effectiveness. My experiences with it support that view.

Pain causes stress, and it's possible (likely even?) that stress can cause or worsen liver inflammation.

Re: physical therapy, if he doesn't believe it would be effective, well, there's one way to find out for sure, right? I didn't think it could do anything for the nerve pain from the flattened discs in my neck (different injury than my lower back), but it made a substantial improvement after just the first session.

After worrying about this for four weeks you have this Internet commenter's permission to do the tough love thing. You might be able to penetrate his delusions if you tell that dumbass that seeing him in pain is hurting you, and seeing him refuse to take the minimal safe and medically prescribed steps to deal with his pain is confusing you and making you angry.

Give him any info about it you feel is appropriate, then be done with talking about it. He deserves empathy for his suffering of course, but empathy should not shield him from a pretty stern wakeup call.

*Before the surgery my back would be 30% fucked up most of the time and 150% fucked up 4 times a year, three weeks per episode. My range of motion was terrible. After the surgery my back is 10% bad half the time, I have a couple 80% bad episodes of one week each per year and the rest of the time I don't even think about it. My range of motion is almost 100% and I can lift heavy objects without back pain. Recovery was fast - I was out of the hospital the second day after the surgery and I went on a 60 mile bike ride a week after being discharged.
posted by under_petticoat_rule at 6:14 AM on May 17

Echoing what everyone above said about listening to the doctor. And if he’s that worried about liver/kidney function, there are blood tests to monitor that.
posted by corey flood at 6:35 AM on May 17 [1 favorite]

I'm going to give another answer from my position of authority as someone who's had to manage this same injury for 40 years.
  • This is a permanent injury. No amount of time will heal the disc. He will have to manage this for the rest of his life.
  • The disc has bulged or ruptured such that it is causing pressure on his nerves. It is possible for the inflammation to subside to the point where he is pain-free, but he will always be literally a millimeter away from an episode.
  • Alleviating the pain can be accomplished by a combination of pharmaceutically reducing the inflammation and physically strengthening the muscles that support the injured area. Short of surgery, there is no other way to relieve this.
  • Pain management is not a convenience. The muscles supporting the area are locked in tension and will be until the pain is relieved. Physical therapy will have a much more substantial obstacle to surmount if the pain is not managed.
  • He cannot "tough it out." He will not "tough it out." If he chooses to try to "tough it out" he will NEVER be free from pain. Never. However, if he manages his pain and inflammation NOW through meds and pt, he can have a lot of pain-free days between now and his next episode.
  • There will be future episodes, and they will be bad. He will need to know how to relieve them, and that protocol is what he has been prescribed, and he needs to start practicing it NOW.
  • Him doing anything less is him making a decision to live in pain for the rest of his life.

posted by under_petticoat_rule at 6:53 AM on May 17 [5 favorites]

I'd also like to clarify that there is no such thing as a slipped disc. Vertebral discs to not slip out of place, and they cannot slip back into place.

Discs can bulge, they can rupture, they can become flattened. None of these can be repaired (currently). They can only be managed. Surgery can mitigate them in some cases.

There is no condition where a disc will "slip" back into place. There is only the removal of pressure on the nerves which is achieved by reducing inflammation and improving muscular support of the area. Or by surgery, removal of the offending disc material.

Slipped disc is an obsolete concept and using it euphemistically implies remedies that don't exist.
posted by under_petticoat_rule at 7:08 AM on May 17 [2 favorites]

Here is something that brought the value of rehab exercises home to me. Buy him one of those Everlasting Comfort back cushions off Amazon ($30-$40, depending on the day). Have him use it while sitting at a chair, which with that injury probably quickly leads to discomfort without it. Have him note how much longer/with less pain he can sit using the cushion. Ask him to consider how much nicer his life would be if his core muscles could provide that support internally (which they more or less can, if they're strong enough!).

It's a very discouraging and demoralizing permanent injury. Sometimes it feels easier to give up. At the same time, you don't want to live in an atmosphere of perpetual complaint without taking action.
posted by praemunire at 7:45 AM on May 17

I had the same injury at L5/S1.

It was, by a good measure, the worst physical pain I have ever experienced. It was probably the second-worst emotional/mental pain I have ever experienced, as well.

I didn't sleep for more than two weeks after my final ruptures. I couldn't stand for more than five seconds at a time. Opiate drugs did nothing. I mean NOTHING. I couldn't lie still enough to have an MRI done on me. Gabapentin helped a tiny bit, but not enough.

(One of the doctors treating me gave me a quality-of-life questionnaire, and I put my QoL score at 1.5/10, where before the injury, it was closer to 8/10. Seriously, this is an injury that drives some people to end their lives.)

All of that said, ibuprofen and naproxen actually reduced the pain a bit. I could not imagine going through that again and refusing those anti-inflammatories.

ALSO, under_petticoat_rule is right that this is a permanent condition. It's in his best interest to find a template for treating it now. That includes figuring out what he can do to make himself feel OK about taking drugs that might actually help him manage.

HOWEVER, I'll also add that I don't think it has to be permanent if your partner is eligible for surgery, and you have quality surgery options available. My microdiscectomy removed two gigantic ruptures and made me mobile again. I was playing tennis within a few months, and apart from a very occasional, dull ache that disappears quickly, I have had zero pain in more than five years.
posted by yellowcandy at 8:04 AM on May 17 [1 favorite]

Wait the **prescription** was the Advil? I was reading late, misunderstood, thought that was your idea - is this doctor joking? Second opinion needed

If in Canada, see a sports medicine doctor for adequate pain control. In the US I guess you can go to a specialist with no referral but might be wary of pain clinics in that context. Probably see a physiatrist or sports medicine physician. Don’t let anyone put a needle (cortisol) in there or cut in there without giving physiotherapy a serious shot. Long term outcomes are equivalent for surgery, cortisol destroys soft tissue

Other pain control option: cymbalta (low dose = pain modulator vs antidepressant. Relative had a neck broken in 3 places and it does help them.) Lyrica.
posted by cotton dress sock at 9:12 AM on May 17

Ibuprofen is often prescribed for inflammation from all sorts of injuries in the U.S. They'll offer a script for high dose pills, but if you don't want the prescription version they'll tell you how much OTC ibuprofen to take. Ibuprofen is not a joke.
posted by under_petticoat_rule at 11:58 AM on May 17 [1 favorite]

So, your partner has the same herniated disc (L5/S1) I had in 2016. PT plus that dose of ibuprofen is the first and most conservative treatment for that condition. I did that for about 6 months before deciding to have surgery (microdiscectomy). My liver is fine. Actually, I don't even think ibuprofen harms the liver (that's Tylenol), though it can cause ulcers or something. I didn't get anything like that either. I asked my doctor about the side effects of long-term ibuprofen use, and he told me to take it with food and I'd be fine.

I'll bet that the pain will eventually cause him to give in and take the meds, because it's pretty bad pain. He also has to do the PT to see if it helps. The pain is almost certainly not going to go away by itself anytime soon, even with the ibuprofen use. The PT has worked for some people I know, and it helped my symptoms improve. I decided to have the surgery because the pain was still limiting my life more than I wanted it to.

The surgery was a complete cure by the way. I run and do heavy squats almost every day with no issues. I have zero pain, and have had zero pain since about a few weeks after I healed from the surgery (almost 8 years pain free). A miscrodiscectomy is also a really simple outpatient procedure (although you need general anesthesia) with a high success rate, so definitely don't rule it out as an option if the pain persists. There seems to be some stigma surrounding back surgery more than other forms of surgery that keeps people from getting this really effective treatment.

I'd add that if his doctor is not actually a spine specialist, he should consider seeing one soon, who will likely tell him most of what I said above (because that's what my surgeon told me).
posted by crLLC at 12:06 PM on May 17 [1 favorite]

Another L5/S1 herniated disc patient here. I had a microdiscectomy in 2003. Every once in a while something will go a little wonky and I'll have some pain for a few days. In 2017 or so I had more severe pain and ended up getting a nerve block (epidural) that brought it under control again. I had more pain within the last week, and taking ibuprofen (about 400-600mg daily) has been enough to get back to normal, and remind me it would be a good idea to lose some weight and work on my core strength.

Taking ibuprofen to treat the inflammation to be able to begin PT is the starting point, and absolutely worth trying and I didn’t experience any long-term downside with that even though I progressed to surgery pretty quickly. If that isn’t enough to resolve the problems, there are next steps.
posted by jimw at 3:09 PM on May 17

If it helps convince him to go to PT, you can explain to him that PT isn't just about doing exercises (though that part is important). When I saw a PT for spine/hip issues (genetic condition, destroys all my joints, not fun), the PT helped me assess ergonomics of my work set up, and my sleeping position, etc. The ergonomic desk/chair/monitor that I found with my PT's help was literally LIFE CHANGING. It was the thing that made the single biggest difference in my quality of life. So much so that I sit at this desk a lot of the time even when I'm not working (set up is at home).

As already mentioned, pain that isn't treated adequately is one of the biggest things that will cause chronic pain. My back problems took a year to get diagnosed, and I was in an insane amount of pain. When I finally got in to see a pain management doctor, his focus was on breaking the "pain cycle." It took a long time for my nerves to stop firing like crazy with all those pain signals. You do not want to deal with that. He needs to treat the pain.

Ibuprofen can be hard on GI, but shouldn't impact liver. I can't take oral NSAIDs b/c of pre-existing GI issues, but Toradol injections were the most helpful thing. (Toradol is a more powerful NSAID.) May not help if he's that terrified of NSAIDs, but something to consider. Longer term, Gabapentin did help the nerves settle down. But the anti inflammatories really are an important component of treating the acute pain.
posted by litera scripta manet at 5:30 PM on May 18

IANAD but consider applying diclofenac gel, an over-the-counter topical NSAID. Use for anything other than arthritis is off-label, but it is really effective for acute pain.

It still has the NSAID stomach ulcer warning on the box, so I have no idea if it is actually better for organ health.

Also: do the PT. A strengthened core and changes to posture are the only ways to live with this condition long-term. Even if you opt for surgery, you’re likely to injure nearby vertebrae without the core strength. There’s no getting out of PT.
posted by Headfullofair at 9:53 PM on May 18

Response by poster: Thanks to everyone who took the time to answer. I'm not sure how this will end yet, but I wanted to let you know that reading about options, happy outcomes, and misconceptions helped us both a lot (he also looked at the thread).

Now, ten days later, he decided to check in at the hospital. He did start taking higher doses of pain meds, but the pain (and now, more concerning to him, numbness/weakness) persisted. At the hospital, he's already had a neurological exam by a doctor who seemed very thorough and competent. He's in the leading center for spine surgery of our region (in Germany). I think he's pretty set on getting surgery, now, unless he hears convincing arguments against it from the doctors. I still sort of think that physical therapy would have been a good idea, additionally or instead, but I also feel like the surgery is safe and simple enough that he'll be fine either way. I really hope he goes to PT after the surgery, though, because several other discs are showing signs of wear, and PT could help him avoid another episode like this. But I've pulled back a little bit, as some of you advised, because all this is ultimately his responsibility.

Thanks, again, because this is really quite stressful and I felt less lost with all your thoughts.
posted by toucan at 5:26 PM on May 26

« Older GoFundMe-like service for a beneficiary in Jakarta...   |   How to look impressive at my job Newer »

You are not logged in, either login or create an account to post comments