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Lumbar Disc Herniation

    Lumbar Disc Herniation

    One type of weight-bearing joint in the human spine is the intervertebral disc. They are located between the vertebrae and consist of soft cartilage surrounded by a fibrous sheath called the annulus. In the center of all discs is a semi-gelatinous cartilage, oblong in shape, called the nucleus. The nucleus functions similarly to a ball bearing, acting as an axis for movement in all directions.
    What Is It?
     Although many patients are familiar with the concept of degenerative disc disease, meaning the loss of fluid and height of a disc as an age-related change, discs can also undergo a derangement of their internal architecture in the form of migration of the nucleus out of its normal position, usually backwards. If the nucleus migrates only to the point of mild pressure against the back of the disc annulus, the clinical result can manifest itself as back pain only. This is because the discs have pain nerve endings that allow us to feel them and experience pain, just as one can experience pain from any other joint in the body. If, however, the nucleus extends far enough backwards to come into contact with one of the lumbar nerve roots (that continue into the lower extremities), the additional symptom of nerve pain (e.g., “sciatica”) into the lower extremity occurs. The medical term for this is “radiculopathy”, and it can be associated with impairment of nerve function, such as numbness, tingling, and loss of strength. Disc herniations are further classified by location in the spinal canal (central, left or right), or foraminal (extending into the opening hole where a nerve exits), or far lateral (outside the opening hole). Herniations are further described by size, and whether the annulus remains intact (a disc protrusion), ruptured (extruded), or can consist of a free fragment of cartilage (sequestrated).
    Treatment Options
    The natural history (what happens even if untreated) of an acute lumbar disc herniation is generally favorable in that the majority will spontaneously shrink in size through healing. This process of healing, however, usually takes 2-3 months. A disc protrusion (intact annulus) is amenable to physical therapy involving extension exercises (arching the back) to apply a force that can in essence “push it back in”. If such exercises are effective, the disc protrusion is termed “reducible”, and the patient experiences relief of leg pain with extension movement. While waiting to see if a herniation will heal, the patient has to avoid or minimize aggravating activities that typically include bending, twisting and lifting, limit sitting, and sit with good lumbar support. Prescription medications may be necessary, and the symptoms can be lessened by spinal injections of a mixture of steroid and local anesthetic generally called “epidural steroid injections”, although injections will not make the herniation smaller.
    If leg pain persists to a significant degree, despite appropriate time and treatment, then the patient can choose to undergo surgery in the form of a “microdiscectomy”. The exception would be the patient with intolerable pain or with neurologic deficits, especially weakness, which might prove irreversible. In such instances, surgery may be indicated more urgently. This term refers to surgery through a small incision performed with a microscope and involves removing the portion of the disc that is herniated. A new suture technology is now available that often allows a repair of the wall or annulus of the disc to minimize the risk of another herniation at that level. The surgery typically takes 60-90 minutes, has a success rate of over 90%, and is often done as an outpatient procedure. Postoperatively, the patient is to observe the “BLT’s”, i.e. bending/lifting/twisting, restrictions along with a sitting restriction for four weeks to allow disc healing, but is otherwise up and about.

    Over the years, many attempts have been made to perform a discectomy in other, less invasive ways, but with lesser success than the gold standard of microdiscectomy. Patients may encounter information about percutaneous mechanized and laser discectomy, arthroscopic and endoscopic discectomy that sound attractive, but those procedures are indicated only for patients with contained protrusions (intact annulus), and published success rates are only about 80% or less. Please note that a laser is not FDA-approved for use within the spinal canal because of the risk of thermal injury to nerve structures. A laser can only be placed into the disc itself to vaporize disc material in hopes of reducing pressure within the disc and thereby the size of a contained herniation, similar to letting the air out of a tire.