Herniated Disc in Tunisia
When to have surgery for a herniated disc?
The bones (vertebrae) that form the spine in the back are cushioned by discs. These discs are round, like small pillows, with a tough outer layer (annulus) that surrounds the nucleus. Located between each of the vertebrae in the spine, discs act as shock absorbers for the spinal bones.
A herniated disc (also called a bulge, slip, or rupture) is a fragment of the disc nucleus that is pushed out of the annulus, into the spinal canal through a tear or rupture in the annulus. Discs that become herniated are usually in an early stage of degeneration. The spinal canal has limited space, which is insufficient for the spinal nerve and the displaced herniated disc fragment. Due to this displacement, the disc presses on the spinal nerves, often causing pain, sometimes severe.
Herniated discs can occur in any part of the spine. Herniated discs are more common in the lower back (lumbar spine), but also occur in the neck (cervical spine). The area in which pain is felt depends on the part of the spine affected.
Causes of Herniated Disc
A single excessive strain or injury may cause a herniated disc. However, disc material degenerates naturally with age, and the ligaments that hold it in place begin to weaken. As this degeneration progresses, a relatively minor strain or twisting movement can cause a disc to rupture.
Some people may be more vulnerable to disc problems and, as a result, may suffer from herniated discs in several places along the spine. Research has shown that a predisposition for herniated discs may exist in families with several affected members.
Symptoms of Herniated Disc
Symptoms vary considerably, depending on the position of the herniated disc and the size of the herniation. If the herniated disc is not pressing on a nerve, the patient may experience low back pain or no pain. If it is pressing on a nerve, there may be pain, numbness, or weakness in the area of the body to which the nerve travels. Typically, a herniated disc is preceded by an episode of low back pain or a long history of intermittent episodes of low back pain.
Lumbar Spine (lower back): Sciatica/radiculopathy often results from a herniated disc in the lower back. Pressure on one or more nerves that contribute to the sciatic nerve can cause pain, burning, tingling, and numbness that radiate from the buttock into the leg and sometimes into the foot. Usually, one side (left or right) is affected. This pain is often described as sharp and electric-shock-like. It may be more severe when standing, walking, or sitting. Straightening the leg on the affected side can often make the pain worse. Along with leg pain, one may experience low back pain; however, for acute sciatica, the pain in the leg is often worse than the pain in the low back.
Cervical Spine (neck): Cervical radiculopathy is the symptoms of nerve compression in the neck, which may include dull or sharp pain in the neck or between the shoulder blades, pain that radiates down the arm to the hand or fingers, or numbness or tingling in the shoulder or arm. The pain may increase with certain positions or movements of the neck.
Tests and Diagnosis of Herniated Disc
Testing modalities are listed below. The most common imaging for this condition is MRI. Plain X-rays of the affected area are often added to complete the evaluation of the vertebra. Please note that a herniated disc is not visible on ordinary X-rays. CT scans and myelograms were more commonly used before MRI but are now rarely ordered as initial diagnostic imaging unless special circumstances warrant their use. An electromyogram is rarely used.
X-ray: Application of radiation to produce a film or picture of a part of the body can show the structure of the vertebrae and the outline of the joints. X-rays of the spine are obtained to search for other potential causes of pain, i.e., tumors, infections, fractures, etc.
Computed Tomography Scan (CT or CAT scan): A diagnostic image created after a computer reads X-rays; can show the shape and size of the spinal canal, its contents, and the structures surrounding it.
Magnetic Resonance Imaging (MRI): A diagnostic test that produces 3D images of body structures using powerful magnets and computer technology; can show the spinal cord, nerve roots, and surrounding areas as well as enlargement, degeneration, and tumors.
Myelogram: An X-ray of the spinal canal following injection of a contrast material into the surrounding cerebrospinal fluid spaces; can show pressure on the spinal cord or nerves from herniated discs, bone spurs, or tumors.
Electromyogram and Nerve Conduction Studies (EMG/NCS): These tests measure the electrical impulse along nerve roots, peripheral nerves, and muscle tissue. This will indicate if there is ongoing nerve damage, if the nerves are in a state of healing from a past injury, or if there is another site of nerve compression. This test is rarely ordered.
Non-Surgical Treatments for Herniated Disc
The initial treatment for a herniated disc is usually conservative and non-surgical. A doctor may advise the patient to maintain a low, pain-free activity level for a few days to several weeks. This helps decrease inflammation of the spinal nerve. Bed rest is not recommended.
A herniated disc is frequently treated with non-steroidal anti-inflammatory medications if the pain is only mild to moderate. An epidural steroid injection may be performed using a spinal needle under X-ray guidance to direct the medication to the exact level of the herniated disc.
The doctor may recommend physical therapy. The therapist will perform an in-depth evaluation, which, combined with the doctor's diagnosis, dictates a treatment plan specifically designed for patients with herniated discs. Therapy may include pelvic traction, gentle massage, ice and heat therapy, ultrasound, electrical muscle stimulation, and stretching exercises. Pain relievers and muscle relaxants may also be beneficial in conjunction with physical therapy.
Surgical Treatments for Herniated Disc
A doctor may recommend surgery if conservative treatment options, such as physical therapy and medications, do not reduce or end the pain. Doctors discuss surgical options with patients to determine the proper procedure. As with any surgery, a patient's age, overall health, and other issues are taken into consideration.
The benefits of surgery should be carefully weighed against its risks. Although a large percentage of patients with herniated disc report significant pain relief after surgery, there is no guarantee that surgery will help.
A patient may be considered a candidate for spine surgery if:
Radicular pain limits normal activity or impairs quality of life
Progressive neurological deficits develop, such as leg weakness and/or numbness
Loss of normal bowel and bladder functions
Difficulty standing or walking
Medication and physical therapy are ineffective
The patient is in reasonably good health
Lumbar Spine Surgery
Lumbar laminotomy is a procedure often used to relieve leg pain and sciatica caused by a herniated disc. It is performed through a small incision down the center of the back over the area of the herniated disc. During this procedure, a portion of the lamina may be removed. Once the incision is made through the skin, the muscles are moved aside so the surgeon can see the back of the vertebrae. A small opening is made between the two vertebrae to gain access to the herniated disc. Once the disc is removed by discectomy, it may be necessary to stabilize the spine. Spinal fusion is often performed in conjunction with a laminotomy. In more involved cases, a laminectomy may be performed.
In artificial disc surgery, an incision is made in the abdomen, and the affected disc is removed and replaced. Only a small percentage of patients are candidates for artificial disc surgery. The patient must have disc degeneration in only one disc, between L4 and L5, or L5 and S1 (the first sacral vertebra). The patient must have undergone at least six months of treatment, such as physical therapy, pain medication, or wearing a back brace, without showing improvement. The patient must be in good general health with no signs of infection, osteoporosis, or arthritis. If degeneration affects more than one disc or significant leg pain is present, the patient is not a candidate for this surgery.
Cervical Spine Surgery
The medical decision to perform the operation from the front of the neck (anterior) or the back of the neck (posterior) is influenced by the exact location of the herniated disc, as well as the surgeon's experience and preference. A portion of the lamina may be removed via laminotomy, followed by removal of the herniated disc for the posterior approach. Patients who are candidates for posterior surgery often do not require surgical fusion. For anterior surgery, once the disc is removed, the spine must be stabilized. This is accomplished using a cervical plate, interbody device, and screws (instrumentation). In a selected group of candidates, the artificial cervical disc is an option versus fusion.
Post-Operative Follow-up
The doctor will give specific instructions post-surgery and will usually prescribe pain medication. He or she will help determine when the patient can resume normal activities such as returning to work, driving, and exercise. Some patients may benefit from supervised rehabilitation or physical therapy after surgery. Some discomfort is expected during a gradual return to normal activity, but pain is a warning signal that the patient might need to slow down.