Herniated Lumbar Disc
Lumbar disc herniation is the result of degeneration and loss of the elastic properties of the intervertebral disc.
Discs are fibrous structures like cushions that exist between each two vertebrae to alleviate spinal movement. Various diseases or traumas, or simply age, cause these discs to lose their elasticity and may fragment. When all or some part of the affected disc moves away from its normal place it may compress nerve structures (nerve roots, spinal cord) and cause symptoms such as lower back pain radiating to the lower limbs (sciatica), feeling of wheezing, weakness in the legs or very rarely alteration in the control of urine or faeces. Osteoarthritis of the joints between the vertebrae sometimes produces the same or similar symptoms – sometimes a patient has a herniated disc and osteoarthritis at the same time.
Diagnosis is made by clinical neurological examination and confirmed by neurophysiologic and/or imaging tests (CT, MRI scans). The result of these tests is not always unreliable as different criteria may have to concur in their interpretation.
When is surgery indicated?
The surgical option is indicated as a therapeutic measure depending on the personal characteristics of the patient, their clinical evolution and the result of the diagnostic tests performed, and only when more conservative treatments have failed (rest, medicines, rehabilitation, change of activity if possible, etc). Two out of three patients with a herniated disc do not require intervention. In most cases the intent of surgery is curative; however, sometimes it is only intended to stabilize the symptoms and alleviate pain as much as possible. Patients intervened once may require new intervention(s) in the future directed to the same or other levels of the spine.
Surgical intervention of lumbar disc herniation is known generically as discectomy and requires a series of preoperative studies (chest X-ray, ECG, blood test). It is performed under general anaesthesia and consists in the extraction of the degenerated disc (or its fragments) and the release of the compressed nerve structures. It is approached posteriorly by means of a skin incision of a few centimetres in the lumbar area, as well as a resection of a ligament (flavectomy) and a greater or lesser portion of the bone (laminectomy).
What are the risks, complications and possible sequelae?
The risks of the intervention are those of any surgical intervention (reaction to anaesthetic drugs, infection, haemorrhage). The patient's previous illnesses will condition the postoperative period and the subsequent evolution. There may be intra- or postoperative complications that, although very infrequent, may be important: nerve roots involvement, disc inflammation (discitis), deep wound hematoma, cerebrospinal fluid leakage (CSF fistula) and, exceptionally, spinal cord injury and vascular injury with life risk.
Loss of foot mobility
The appearance of sequelae depends, mainly, on the patient’s condition prior to the intervention. Losses of strength or impairment in the control of long-standing sphincters do not usually recover, tending to resolve or improve in the rest of the cases. The ethics committee of the Spanish Society of Neurosurgery has prepared a list of complications with its frequency:
- New radicular injury, persistence or aggravation of the existing one (0.02%)
- Recurrence of herniated disc that needs reoperation (2,8-11) %)
- Cerebrospinal fluid fistula (0.1-0.9%)
- Surface infection (0.9-6.8%)
- Meningitis (0.2-0.3%)
- Discitis (0.4-3%)
- Mortality ( 0.02%)
- Casual Complications: Abdominal vessel injury, ureter injury
Postoperative Herniated Lumbar Disc
When the responsible doctor who takes your case decides the discharge, you will receive a clinical report detailing the characteristics of your illness, the type of intervention performed and the treatment to be followed at home. It will also be sent to Neurosurgery Outpatients within a specific period, in order to follow up on the evolution of your case. In general, avoiding important physical efforts and after a few weeks of the intervention, patients can return to their normal activities. Your doctor will recommend a series of physiotherapeutic or rehabilitative measures in detail. Sometimes the patient should continue with medical treatment.
Advice after discharge from hospital
The postoperative recovery period lasts at least six weeks after the intervention. During this time you should try to keep physical and mental rest, avoid trips and journeys, and take the series of measures listed below:
FIRST TWO WEEKS
Not so long ago, patients who underwent surgery for a lumbar disc herniation remained hospitalised for one and sometimes two weeks. Fortunately, surgical-anaesthetic advances currently allow early discharge (usually 24-48h). This should not make you believe that when you go home everything is over. You must accept that you will continue the hospitalisation period at home for a few more days. Take the medication exactly as prescribed by your surgeon.
If you are receiving any other treatment for any other disease, you should continue to do so unless you are instructed otherwise. The surgical wound should be kept clean and dry. You can shower, with assistance, and then dry well with a sterile pad or gauze, brush the wound with povidone-iodine (PVP-I, Betadine) and finally cover the wound with sterile dressing. Please be very careful when in the shower. Skin sutures should be removed after seven days of surgery.
Try not to sit in low chairs or seats for a period of two weeks. Avoid a sofa if your back is not going to be completely straight. You may sit on a high stool, or place one or two cushions on a chair, preferably with armrests. During the first week you should alternate resting periods in bed, walks around your house and sitting in a chair with a straight lumbar support. Do not leave home until sutures are removed.
Walk every day for brief periods of time (15 minutes) progressively increasing the distance. Do not travel by car or other means of transport during these two weeks (except to go to a health centre or visit the doctor). The first days you will find yourself more comfortable with a lumbar belt. You must place it when you get up – there’s no need to use it in bed. Try not to get too used to wearing the girdle.
When you reach the third week you will clearly feel recovery. It is possible that some residual symptoms – in the form of tingling or lack of sensitivity – persist in the leg(s), or that you notice pain in the lumbar region when moving. Keep in mind that complete healing requires between 4 and 6 weeks. Be patient. The wound must be completely healed and will not require any dressing but, if you wish, you may place a piece of gauze over the scar to avoid rubbing with your clothes. Start leaving home and walking increasingly long journeys, always on flat terrain and with sports shoes. Avoid stairs and slopes. Avoid unpaved roads. You may walk along the seashore barefoot if there is not much slope. You should not need the girdle anymore so it may be removed, but there won’t be a problem if you wear it for one or two more weeks if you wish. You may use normal chairs (i e, that are not too low): spring out your buttocks until they touch the backrest, and then proceed to sit down without bending your back.
Walk, on flat terrain and with sports shoes, if you can, for one hour every day. At the end of the fourth week you should go to the doctor’s practice for a review.