LUMBAR DISC HERNIA
Lumbar part of our spine is composed of five vertebrae. There is a special disc-shaped connective tissue which facilitates movement between the vertebrae, enables spine to be strong, and functions as a protector against impacts. This disc is composed of two sections, inner and outer layer. The soft layer inside protrudes when the outer layer is deformed. This herniated section compresses the nerves in the spinal canal and entraps these nerves. Sometimes, this herniated section excretes chemical substances, resulting in pain. These are all called lumbar disc hernia. Herniated lumbar disc in young people is rather associated with lifting heavy objects or forced lumbar movements. In elderly, minor but repeated forced lumbar movements over years can lead to herniated lumbar discs over time.
The most common complaint of patients with herniated disc is the pain from the lower back radiating down the legs and feet. In progressed cases, problems such as numbness and weakness can occur in addition to pain in low back and legs. In untreated patients, loss of upward movement of the ankle, which we call foot drop, and urinary incontinence can occur.
Clinical examination is very important in diagnosis. The source of the pain can be identified by a detailed clinical examination. The diagnosis is made definitive by MRI study. Nerve assessment called EMG should also be performed in suspected cases to support the diagnosis.
The primary purpose of treatment of disc hernia is to eliminate the pain to ensure that the patient can go back to his/her normal daily life. The first thing to do is bed rest and medication and then to educate the patients. The physician should tell the patients about the cause of the pain and what to do to prevent recurrence of the disease.
The structures around the spine are strengthened and the body mass is distributed more equally through physical therapy exercises so that the load on the disc can be partially reduced and complaints can be minimized. Epidural injections or blocks are other methods used to eliminate the pain of patients. This is provided by corticosteroid injections administrated in the space around spinal nerves.
In case of loss of strength and sensation in the legs and feet, or conservative treatment methods fail to eliminate the complaints of patients, herniated disc material is surgically removed to relieve the nerves. In addition to open surgery, microscopic or endoscopic surgical methods can be applied in lumbar disc surgery depending on the clinical and radiological findings. Another treatment method used at our clinic is application of disc prosthesis. The use of disc prosthesis in appropriate patients will conserve the spinal movements and enable elimination of the pain. Conservation of movement avoids degenerative problems that might occur in the future.
LUMBAR DEGENERATIVE DISC DISEASES
There are structures called “disc” between the vertebrae in lower back area of our spine which allow movements and carrying weight. Between the vertebrae, discs and vertebral bones joining at the back, there is a spinal canal in which there are the spinal cord and nerves extending to legs. Ligaments attaching the vertebrae to each other and the joints between the vertebrae are thickened as a result of calcification with age. The discs between the vertebrae lose their spongiform nature and start to contain less water with age. This causes decrease in disc height and calcified disc which camber towards spinal canal. And bony spurs called osteophyte which is formed by the body to limit the spinal movement compress the nerves. All these changes result in stenosis of spinal cord which is either called “spinal stenosis” or “narrowed canal”.
The most common complaint in patients with spinal stenosis is back pain. The pain characteristically increases with sitting, walking, coughing and straining and decreases with rest. The neurogenic claudication which is a typical sign of spinal stenosis is characterized by pain, numbness, tingling in legs especially in calf produced by walking that decreasing by rest. Although it typically starts from the low back and radiates down the legs, it is not always the same and location and character of the pain can be changed even during the day. Most patients complain about cramp and common numbness and even sudden occurrence of sensation of weakness (legs giving way) during walking. Patients have a typical posture when standing and walking. The pain (sciaticalgia) radiating various parts of leg depending on the level of stenosis and nerve compression can occur. The curvatures can develop on the spine to reduce the pain and tension of compressed nerve roots, and lumbar lordosis (curve of low back) can be decreased. This is colloquially called flatten back. The patients may experience decrease in strengt in various areas of muscles, and sensation and reflex defects in time depending on the level of compressed nerve root. Untreated patients are likely to visit a doctor with complaints such as bowel and bladder control (urinary and fecal incontinence).
Anamnesis (medical history) and physical examination are the first steps in diagnosis. Sensorial and reflex examination should be performed by specialists for all patients. Direct radiographies can be used to identify bony pathologies and curvatures in the spine. It is possible to view all vertebrae and the legs from the skull to the feet on the same image, and to explore balance disorders in the body through EOS graphies available at our hospital.
Computerized tomography can clearly display the spinal canal, facet joints and bony pathologies related to back bone structures. Another method used in diagnosis is myelography. Myelography is a diagnostic method performed by radiologists which involves injection of contrast material into subarachnoid space to display the margins of spinal canal. It can display compression on the spinal cord or nerve roots.
EMG (electromyography) can also display the nerves. It is a useful method in choosing a treatment method for identifying the location and severity of compression on nerves. Magnetic Resonance Imagining (MRI) is the most valuable standard noninvasive diagnostic method in identifying spinal diseases. It is also useful for differential diagnosis of the diseases with similar complaints.
The treatment is started with bed rest accompanied with analgesics and relaxants and continued with physical therapy. Since the underlying cause will not be changed with conservative treatment, it is not possible to gain long-term perfect outcomes. Epidural steroid injection as caudal or transforaminal selective nerve root block is administrated through interlaminar space. Such applications can provide benefit in selected patients.
In case of severe pain that is nonresponsive to conservative methods and significantly restricts the daily life activities of the patient, surgical treatment will be required in patients with neurological findings. If clinical findings, physical examination and imaging outcomes of patients with such complaints (especially neurogenic claudication) match spinal stenosis, a surgical treatment must be planned. The consequences of surgical treatment only for back pain are not favourable.
The primary objective in surgical treatment is to remove compression on spinal cord. This is called decompression and done by removal of bony structures (laminectomy) forming posterior wall of spinal canal by the intervention from lower back. Another stage of decompression is to remove the discs causing compression. Resulting space between the vertebrae after removing the discs is supported by placing titanium cages filled with bone grafts. This intervention can be performed from anterior (ALIF), lateral (XLIF) or incisions on the low back (TLIF). Enabling balance and stability of spine through screw fixation again performed from the back (posterior instrumentation) is essential to provide postoperative patient comfort and prevent recurrence of the disease. Regaining of normal physiological curvatures of the spine (spinal balance) must be enabled after surgical treatment.