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Lumbar disc herniation
Introduction
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Anatomy
The lumbar spine is the lower part of our back and comprises five lumbar vertebrae. These vertebrae consist of a vertebral body at the front and a vertebral arch at the back, which surrounds the spinal canal and nerve structures. Lateral openings (intervertebral foramina) allow nerves to exit the spinal canal and innervate our legs.
The discs are located between the vertebral bodies and act as shock absorbers between the vertebrae. They are formed of a fibrous, elastic, and very strong ring, at the center of which is a ball of gelatinous material (nucleus pulposus). It is thanks to the elasticity of the ring that the nucleus can deform according to the stresses to which it is subjected (body movements, axial or vertical load, resistance against force). The disc and the two vertebrae above and below it form a functional unit called the vertebral segment.
The vertebrae move against each other at the level of the disc anteriorly and at the level of two joints (facet joints) posteriorly. Small movements, on the order of 3 to 5° per segment, are possible in all directions (flexion-extension, lateral flexion to both sides, rotation to the right and left). Considering the entire lumbar spine, the movements are therefore on the order of 15 to 20° in each direction, depending on the patient's age and flexibility. Most of the mobility we believe occurs in our back actually takes place in our hips.
Signs & symptoms
Typically, the patient will complain of sharp pain in one leg (sciatica) and sometimes in the lower back. In cases of significant nerve compression, sciatica may be associated with tingling, decreased sensation, or even weakness in the same leg (neurological deficits).
The pain is usually more intense when sitting or standing, and lessened when lying down with legs slightly bent.
In very rare cases, the patient may experience incontinence (especially urinary incontinence). This constitutes a surgical emergency, and the patient must seek immediate medical attention.
What is this?
A lesion of the disc ring (tear) can generate a bulge of the disc (disc protrusion), or even, in severe cases, the exit of a fragment of disc into the tunnel of the nerves (herniated disc).
Depending on the size of the hernia, there may be compression of the nerve elements passing through the spinal canal, thus causing pain in the leg (sciatica).
Risk factors
Lifting heavy weights without properly positioning the back and lumbar spine.
Some violent rotational movements, flexion-extension of the back.
Certain excessive sporting activities performed without adequate preparation can endanger the disc structure and cause a disc injury or even a herniated disc, or worsen or decompensate an already present lumbar osteoarthritis.
Screening & Diagnosis
The medical examination will focus on the history of the pain, an examination of the back, and especially the legs. An examination of nerve function (neurological examination) is essential.
Patient evaluation may require standard X-rays, a CT scan, or an MRI scan (nowadays, the best examination for properly identifying a herniated disc and its relationship to the nerve elements).
Treatments
Self-treatment
In the absence of neurological deficits (loss of sensation, muscle weakness, urinary incontinence), the patient can begin treatment:
- Reduced physical activity, rest
- Lying down, with a cushion under your knees
- Over-the-counter pain relievers and anti-inflammatory medications
Medical treatments
In the majority of cases (90%), sciatica will lessen or even disappear spontaneously within 6 to 12 weeks, and initial treatment will focus on reducing symptoms to maintain or restore the patient's physical activity. Only 10 to 20% of patients with sciatica due to a herniated disc will require surgical treatment.
- Conservative treatment (modification of physical activity, drug treatment, painkillers and anti-inflammatories, physiotherapy)?
- Epidural injections?
- Surgical treatment (lumbar microdiscectomy)
The only absolute indication for surgical treatment is the development of significant nerve damage such as sudden paralysis or the progression of neurological deterioration (worsening muscle weakness, loss of sensation or control of bladder or bowel function). All other indications are relative and depend on the duration and severity of symptoms.
In the absence of significant neurological deficits (loss of sensation, muscle weakness), treatment will usually begin with non-surgical approaches. The patient's physical activity should be modified according to their symptoms, and pain should be managed with rest and pain relievers, anti-inflammatories, and possibly low doses of cortisone. Physiotherapy should be initiated. A series of epidural injections may be indicated to maximize the benefits of this treatment. In the vast majority of cases, this treatment will lead to a gradual reduction, or even complete disappearance, of symptoms within the following weeks.
In cases of severe sciatica due to a herniated disc, resistant to non-surgical treatment, microdiscectomy has demonstrated some efficacy, but does not guarantee complete resolution of symptoms. Surgical treatment is described as more effective for sciatica, but less effective for back pain.
Whether after non-surgical treatment or after a microdiscectomy, a recurrence of herniated disc is always possible.
Our favorite methods
Conservative treatment
In the absence of neurological deficit (loss of sensation, muscle weakness, urinary incontinence), we will always start with non-surgical management (rest, medication, physiotherapy).
Epidural or epidural infiltration
To enhance the anti-inflammatory effect on compressed nerve structures, an epidural injection can be considered. This procedure is performed under local anesthesia. Under radiological guidance, a needle is inserted until it reaches the nerves (into the epidural space), where small amounts of cortisone are deposited, thus maximizing the anti-inflammatory effect. These injections are performed on an outpatient basis, and the patient can return home after a monitoring period of approximately one hour.
If the complaints improve, the infiltration may be repeated at an interval that the doctor will have to define (3 to 6 weeks).
Lumbar microdiscectomy
Partial disc resection under microscopic guidance (microdiscectomy) is the usual procedure for lumbar disc herniation. This surgery is performed under general anesthesia through a small incision of about 2-3 cm in the lower back. The location of the skin incision is determined by an X-ray taken before the procedure. The muscles covering the spine are then separated to allow the spinal canal, which carries the nerves, to open. By carefully moving the nerve structures, the surgeon gains access to the diseased disc. The disc fragments within the herniated disc are removed to relieve the previously compressed nerves. This operation does not require a blood transfusion.
After the operation
After leaving the operating room (you will be awake), you will spend a few hours in the recovery room. You will be under the care of your anesthesiologist, who will manage your pain. Everything will be done to ensure your comfort and keep your pain under control. You will be lying on your back, and if you wish, the nursing staff can turn you onto your side.
As soon as you are sufficiently awake, the anesthesiologist will authorize your transfer from the recovery room to your room.
Surgery
Preparation for surgery
We will be in constant communication with your family doctor to discuss and proceed with the best treatment option for you.
Once the surgical indication has been established and scheduled, you will receive a summons letter from the Bois-Cerf Clinic containing information regarding:
Pre-hospitalization consultation
Before your hospital stay, you will be seen in consultation by one of our anesthesiologist doctors to assess your health, carry out the necessary examinations (blood test, chest x-ray, electrocardiogram) and discuss the course of the anesthesia which will be a general anesthetic.
What day and what time should I arrive at the reception of the Bois-Cerf Clinic (it can be the day before or the day of the procedure).
Hospital stay
What you need to bring with you:
- Your personal belongings
- Music player
- Your personal medications (if you are receiving treatment at home)
- Your optimism and energy... we'll take care of the rest.
Upon your arrival at the clinic, after completing the administrative formalities, you will be greeted by the receptionists and shown to your room. The nursing staff will take care of you to ensure you are comfortable. Some tests may still be necessary as requested by your doctors. Skin care (disinfection) will be performed on the area of the future surgical wound.
You will receive visits from your surgeon and the anesthesiologist (pre-operative visits). A physiotherapist will visit to instruct you on breathing exercises and how to move in bed and get up after the procedure.
In principle, the surgical procedure will be performed at the time previously communicated to you by your surgeon. As before, the operation is carried out under general anesthesia.
Your anesthesiologist will prescribe medication one hour before the operation and, if necessary, the evening before, to help you relax and reduce stress related to the procedure.
Visits are generally permitted in the recovery room (approximately one hour after your departure from the operating room, only one person) and freely in your hospital room.
Recovery
The patient will be mobilized and allowed to get up and move around starting on the day of the operation or the following day, under the supervision of their physiotherapist or nursing staff. A shower is permitted on the second postoperative day, as soon as the patient is without drains or IV fluids. The suction drain is removed 24-48 hours after the operation. During hospitalization, physiotherapists will teach the patient rehabilitation exercises and how to perform daily living activities correctly. Wearing an elastic lumbar support brace is recommended for 3 to 6 weeks, depending on the procedure performed. Hospitalization is usually 2 to 5 days and depends on the patient's progress and situation at home. For patients requiring spinal fixation, hospitalization may last 6 to 7 days.
Pain in the buttock and leg (sciatica) is usually well relieved after the operation. Some discomfort and back pain are always present after the operation and will gradually decrease as the muscles heal.
A check of the surgical wound may be necessary approximately 10 days after the operation (possibly removal of the stitches).
Upon your return home, you will need to lead a quiet life (you are recovering). You will need to pay attention to the surgical wound (according to the instructions received during your hospitalization).
For the first 2 to 3 weeks, you should avoid sitting in low positions (sofa, armchair), avoid physical exertion (household chores) and lifting/carrying heavy objects.
A clinical check-up is scheduled approximately 3 weeks after the procedure to plan the follow-up (medication, physiotherapy, resumption of activity, sick leave, etc.).
A physiotherapy rehabilitation program will begin 2 to 3 weeks after surgery, usually following the initial medical visit. Physiotherapy focuses on restoring muscle function and strengthening the abdominal muscles, flexibility exercises (neuromeningeal stretching), and progressive mobilization of the lumbopelvic junction. This program may be conducted on land, sometimes with the assistance of a pool attendant.
The recovery rate varies from patient to patient, and you will usually need to take 2 to 6 weeks off work. You can drive as soon as you can sit comfortably and without pain, generally 2 to 3 weeks after the procedure.
901% of patients obtain good relief from their sciatic pain with this type of surgery. However, approximately 51% of cases will experience a recurrence of the herniated disc in the same location, as well as approximately 51% of patients who will develop chronic back pain due to progressive disc degeneration (see lumbago).
Possible risks
Since the procedure is performed under general anesthesia, the patient may be exposed to all the risks associated with this technique, especially if their overall health is not optimal (drug allergies, cardiopulmonary, renal, or metabolic problems, etc.). The rate of these complications is low and will be discussed with the anesthesiologist.
Infection
In any operation, there is a risk of developing an infection, a complication which is fortunately rare (less than 0.5%).
Nerve damage
Because the surgeon comes into contact with nerve structures passing through the spinal canal, nerve damage is always possible, even with the use of an operating microscope. According to specialized medical literature, this risk is approximately 11/3T.
Dural tear/fistula
Inside the spinal canal, the nerves are surrounded by a membrane (dura mater). A small tear in this membrane can occur during the procedure and nerve manipulation that the surgeon must perform (1-2%). The tear will be repaired during the operation. In very rare cases, the tear may recur and be accompanied by a leak of spinal fluid (fistula), which may require further surgery.
Frequently Asked Questions
How long does the operation take?
Where is the scar?
What is the length of the incision?
Is the operation possible by numbing only the legs (epidural anesthesia)?
When I leave the operating room, will I be lying on my stomach?
How many days will I stay in the clinic?
Will I be in a lot of pain after the operation?
When can I start driving my car again?
After an epidural injection, when can one resume physical activity?
Should we be concerned about the use of cortisone during epidural infiltration?
Are there risks of recurrence (sciatica recurring)?
Will all my pain disappear after the operation?
If I continue to experience pain after the operation, is there anything that can still be done?
In case of a recurrence of sciatica, is there anything that can still be done?
Summary
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