Author: Dr. George Frey

A common cause of low back and leg pain is a herniated disc. Discs, which act as shock absorbers for the spine, are located in between each of the vertebrae in the spine. Each disc contains a tire-like outer band (called the annulus fibrosus) that surrounds a gel-like substance (called the nucleus pulposus).

A herniation occurs when the outer band of the disc breaks or cracks and the gel-like substance from the inside of the disc leaks out, placing pressure on the spinal canal or nerve roots. In addition, the nucleus releases a chemical that can irritate the surrounding nerves causing inflammation and pain.

Symptoms of a lumbar disc herniation may include the following:

• Dull or sharp pain in the lower back, intensified by movements or activities such as bending, coughing, or sneezing.
• Muscle spasms or cramping.
• Sciatica (pain, burning, tingling, and numbness that extends from the buttock into the leg or foot).
• Leg weakness or loss of leg function.

MRI showing herniated lumbar discs

How Do Discs Herniate?

Most lumbar disc herniations occur as a result of sudden stress, such as likefrom an accident. Sometimes they do occur gradually, over weeks or even months.

 

Stages of Disc Herniation 1. Disc Degeneration: chemical changes associated with aging causes discs to weaken, but without a herniation. 2. Prolapse: the form or position of the disc changes with some slight impingement into the spinal canal. Also called a bulge or protrusion. 3. Extrusion: the gel-like nucleus pulposus breaks through the tire-like wall (annulus fibrosus) but remains within the disc. 4. Sequestration or Sequestered Disc: the nucleus pulposus breaks through the annulus fibrosus and lies outside the disc in the spinal canal (HNP).

The risk factors that can contribute to the chances of a disc herniation, include:

• Aging. As we get older, discs gradually dry out, losing their strength and resiliency.
• Lifestyle choices. Lack of regular exercise, not eating a well-balanced diet, being over-weight, and tobacco use substantially contribute to poor disc health.
• Poor posture, incorrect and/or repetitive lifting or twisting can place additional stress on the lumbar spine.

Treatment for Lumbar Disc Herniation

The good news is that most cases of lumbar disc herniation do not require surgery! Long-standing evidence suggests that pain associated with a herniated disc often resolves without any treatment within 4-6 months. Unfortunately, it is not possible to predict which cases will have natural resolution, and which will not. Thus, patients are usually prescribed non-surgical treatments initially to help relieve symptoms. These include the following:

• Pain medications such as anti-inflammatories to reduce swelling and pain, muscle relaxants to calm spasms, and narcotic painkillers to alleviate acute pain.
• Heat/cold therapy, especially during the first 24-48 hours.
• Physical therapy exercises such as gentle massage, stretching, and pelvic traction to decrease pain and increase flexibility.
• An epidural injection of anti-inflammatory medication. This is for patients who have severe pain and significant leg weakness.

If after non-surgical treatment the patient still has intolerable pain, or if there is evidence of neurological deficit (e.g. weakness in the calf muscles) then we may recommend surgery to treat the disc herniation.

Surgical Options

To relieve nerve pressure and leg pain, surgery usually involves removing all or part of the damaged disc. This is called a discectomy. At CCSI, this procedure can often be done utilizing minimally invasive techniques. Minimally invasive surgery uses smaller incisions and tiny specialized technology such as endoscopes ("mini-video cameras"). Minimally invasive techniques often result in quicker patient recovery times compared to traditional techniques, as they reduce trauma to soft tissues and minimize blood-loss during surgery.

If necessary, the space left by the removed disc may be filled with a bone graft – a small piece of bone usually taken from the patient's hip. The bone graft is used to join or fuse the vertebrae together. Recently, the availability to surgeons of bone morphogenetic proteins (BMPs), i.e. a "substance" that causes bone growth, has given doctors at CCSI a new "tool" to more reliably create fusion of vertebrae. In some cases, some instrumentation (such as rods or screws) may be used to help promote fusion and to add stability to the spine.

Minimally invasive discectomy

In addition to a discectomy, a portion of the bone covering the nerve may also need to be removed. This procedure is called a laminotomy.

Recovery

At CCSI, most patients can begin getting out of bed on the same day surgery is performed! Activity is gradually increased and patients are typically able to go home within 24 hours after their procedure, depending on the extent of the surgery. There will probably be some pain after the procedure. However, we have pain medications available that will keep you comfortable.

At home, you will need to continue to rest. You will be instructed on how to gradually increase your activity. You may still need to take the pain medications for a while. However, pain and discomfort should begin to reduce within a week or two after surgery. We will discuss with you other techniques for reducing pain and increasing flexibility before you leave CCSI. We will also discuss with you a timeframe for when you can resume basic activities such as walking, driving and light lifting, and when you can return to more advanced activities such as work, sports and yard work.

At CCSI, your health is our primary concern. Like you, we are eager to see you return to a healthy, pain-free and active life. If you have any questions about your condition, your treatment or your recovery, do not hesitate to call us.