Lumbar disc herniation is one of the most common causes of low back pain and sciatica.
Disc herniation is a medical condition in which a tear in the outer ring of an intervertebral disc allows the soft central portion to bulge out between vertebra and vertebra as a result of important, sudden or repetitive efforts. These discal protrusions or hernias can compress the nerve roots that exit the spine and extend to the legs.
Patients that have had conservative treatments and have not noticed an improvement with leg pain and the disability after 4-6 weeks, should consider undergoing surgery. The persistence of sciatic pain is the main reason for undergoing surgical treatment.
Performing a discectomy is suggested in order to reach a more effective relief of symptoms in patients suffering from lumbar disc herniation with radiculopathy whose symptoms justify a surgical intervention.
Lumbar disc herniation is one of the most common causes of lower back pain or lumbosciatica.
Performing the surgical intervention before six months is suggested in patients that suffer from symptomatic lumbar disc herniation and whose symptoms are severe enough to justify the surgery. Early surgery (between 6 months and one year) is related to a faster recovery along with more successful long-term results. The prolonged duration of preoperative symptoms has a negative impact on a patient’s outcome.
In some occasions, subacute surgical treatment may be necessary when the patient is suffering from a great loss of motor function or unbearable sciatic pain. However, acute surgical treatment is only indicated for patients with horsetail (sphincter dysfunction) syndrome.
In some cases, a Microsurgical nerve decompression is needed.
The aim of lumbar disc herniation surgery is to decompress the affected root of the nerve by removing the hernia. The patient can be placed in various positions, depending on the surgeon’s preference (prone, lateral decubitus). The level of lumbar disc herniation is generally marked using an image intensifier (fluoroscopy) before the skin incision. An incision on the midline allows the surgeon to dissect unilaterally the paravertebral muscles until he/she reaches the laminae, and after that, an incision on the yellow ligament is made to be able to visualize the nerve and the intervertebral disc. In general a partial hemilaminectomy is performed. The herniated disc material and loose fragments in the disk are removed to decompress the neural structures involved. The surgery is performed under microscope or magnifying glasses, depending on each surgeon’s preference.
Currently highly effective techniques called “Minimally Invasive” (MIS for its English acronym) can address the herniated disc through small incisions in the skin, with less tissue damage, allowing the stay in hospital to be shortened and the recovery (going back to daily routines) to be much faster. This type of surgery offers less pain and a much faster recovery. It can be done with epidural anaesthesia. Patients may even be discharged 1 day after the surgical procedure. For patients that undergo microsurgery, the hospital stay is around 2-3 days.
Generally, the pain in the buttocks and leg (sciatica) is relieved after surgery has taken place. A small percentage of people may notice some pain even after surgery, although this will improve gradually. During the first 2-3 weeks the patient should avoid sitting on very low seats and lifting or carrying heavy objects.
Recovery depends on each patient. However, it usually takes between 2 and 6 weeks.
Results: 90% of patients have no pain or sciatica and may return to their normal work after about 6 weeks. Approximately 5% of patients may experience recurrent disc herniation as well as 5% may develop chronic back pain.
1. Intraoperative bleeding
2. Dural tear
3. Damage to the nerve root during surgery, which can lead to motor or sensory symptoms.
Preoperatively it is important to inform the patient of the suitability of not taking some medications before surgery such as: aspirin, NSAIDs, anticoagulants, warfarin or bisulfate clopigogrel.
The length of the hospital stay depends on a patient’s mobility after surgery. The aim is that patients can wander and be mobilized the same day the surgery took place.
The results from undergoing a surgical discectomy have shown success rates of 80-90%. Likewise, the satisfaction rate for ten years after the surgery has taken place is 72 %. Short- and long-term studies in patients that have undergone surgery have shown significant rates of recovery and improvement of leg pain, general satisfaction with the treatment and with the recovery compared to patients that have not been operated on.
The factors that have been identified to predict a positive outcome (pain relief in the legs and / or satisfaction with the surgical option and / or return to work) are:
– Short duration of preoperative leg pain.
– No preoperative morbidity.
– Limited time for surgery (<6 months).
– Patient expectations: high or positive expectations in the surgical treatment of lumbar disc herniation have shown a better result, based on pain relief and recovery time.
In the early stages when being affected by lumbar disc herniation, a conservative medical treatment should be considered before deciding to undergo a surgical treatment. Follow the methods of non-surgical treatment:
-Self-care: In most cases, the pain of a herniated disc will get better within a few days and disappear completely within 4-6 weeks. Restricting the patient’s activity, ice therapy / heat and taking pain medications will help recovery.
It is recommended to be aware and take into consideration weight control and the correct physical activity. It is not recommended to prolong staying in bed. If necessary, resting in bed should be limited to no more than 2 days.
-Medicines: Your doctor may prescribe pain medications, nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxants and steroids.
• Nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin, naproxen, and ibuprofen are used to reduce inflammation and relieve pain.
• Pain relievers, such as paracetamol, can relieve pain, but have no anti-inflammatory effects like NSAIDs. Prolonged use of analgesics and NSAIDs can cause stomach ulcers, kidney and liver problems.
• Muscle relaxants, such as methocarbamol may be prescribed to control muscle contraction.
• Steroids may be prescribed in order to reduce nerve inflammation. They are taken for a few days, orally and in a small doses. They have the advantage of providing pain relief almost immediately within a about of 24 hours.
• Injecting steroids into the area where the lumbar disc herniation took place may be prescribed if the pain is severe. This procedure, performed under fluoroscopy, involves a steroid injection and an analgesic-anaesthetic agent into the epidural space of the spine to reduce swelling and inflammation of the nerves. About 50% of patients will find relief after an epidural, but the results tend to be temporary. The injections can be repeated every 2 weeks if it should be necessary to obtain better results in the shortest period of time possible. If the injection is useful, it can be done up to three times a year.
-Physiotherapy: The aim of physical therapy is to help the patient return to normal activity as soon as possible and to avoid further injury. Physical therapists can instruct the patient on how to carry out the correct posture, walking techniques, and how to work on strengthening the muscles of the back, legs and lower abdomen. In addition, they can help stretch and increase flexibility of the spine and legs.
Strengthening exercises and exercise in general are the key elements for a patient’s treatment and should be part of their routine for the rest of their life.
Dr. Vicenç Gilete, MD, Neurosurgeon & Spine Surgeon.
Neurosurgery volumes I–III. Edited by Robert H. Wilkins and Setti S. Rengachary. McGraw-Hill.
Handbook of Neurosurgery. Mark S.Greenberg, Seventh Edition. Thieme.
Last Update 2018-02-16 11:31:35