This is one of the most common reasons of low back pain in patients. Hernia occurs when the discs between the lumbar vertebrae are torn and compress the nerves. Having a sedentary lifestyle or severe working conditions are among important factors causing hernia. Nowadays, along with the development of technology, diagnosis can easily be made thanks to imaging devices such as MR and tomography.
Lumbar Spine Anatomy
It can generally be examined in 3 sections. These sections consist of 7 cervical, 12 thoracic, and 5 lumbar vertebrae. Between these vertebrae are fibrocartilaginous structures called intervertebral discs. They serve as some kind of shock absorbers between the vertebrae.
Intervertebral Disc Structure
They are structures of a soft and elastic consistency located in between two vertebrae. They consist of three parts called nucleus pulposus, annulus fibrosus, and end plate. Nucleus pulposus is at the center of the disc. It has a tenacious, although soft, fibrocartilage structure. As for annulus fibrosus, it is a structure that surrounds the nucleus pulposus in a radial manner. The structure of the disc has a semi-liquid content. When there is load on the spine, nucleus pulposus expands radially towards the edges. After a certain amount of expansion, this radial movement is restricted by the annulus fibrosis. The cartilage plates are composed of hyaline cartilage and they are placed on the cancellous structure of the vertebral bones.The nutrition of the disc is provided from the adjacent vascular cancellous bone by diffusion. After 8 years of age, the blood flow to the discs begin to clear out. Therefore, there is no blood flow within the disc in adults. The transfer of fluid is observed under pressure. Weight changes throughout the day are also proof of this fact. Our height is also actually longer when we wake up in the morning, than it is compared to the evening. Continuing pressure on the disc all day long, shrinks the thickness of the disc. So, the height of the spine reduces at the end of the day.
Why Does Lumbar Disc Herniation Occur?
The term ''lumbar disc herniation'' in medicine, is used for what is known as ''slipped disc'' among people. It is the protrusion of these discs, located between the vertebrae, out of their normal range. ''Lumbar disc degeneration'' has a big part in this situation. This protruding fragment compresses the nerve roots emerging from the spine and the spinal cord. What happens when there is a tear in the outer layer of the disc? A gel-like structure (nucleus pulposus) pops outwards from the torn area. This structure compresses the nerves or spinal cord. In addition, this protruding structure, leads to the inflammation of the nerve. And this takes part in the formation of pain. There is never a complete recovery in this torn part of the disc. Instead, scar tissue fills its place; there is expansion in the blood vessels and new pain fibers form in this area. The torn area grows as a result to strains. The compression of the protruding material on the nerve increases, and the pain becomes stronger.
Stages of Lumbar Disc Herniation
It is evaluated in 4 stages:
Disc degeneration: Structural deterioration begins, but there isn’t an over flow.
Prolapse: There is a slight over flow towards the spinal canal or nerve. It is referred to as bulging or protrusion at this level.
Extrusion: Nucleus pulposus, which is the gel consistency of the disc, tears the outer layer and protrudes outwards; but its connection with the disc continues.
Sequestration: It pops outwards due to the rupture of the outer layer, annulus fibrosus.
Causing Factors of a Herniated Disc
Using a vehicle for a long time
A sedentary or inactive lifestyle
Using a motorcycle
What Are the Symptoms of Disc Herniation?
The symptoms may differ depending on the position of the compression, its relation to the nerve root, and the size.
The main symptoms are:
Low back pain
Leg pain (Sciatica): It is one of the most common symptoms. 85-90% of lumbar herniated discs compress the bottom two nerves, which are L5 and S1. Siyatalji also spreads in the same pattern as these nerves. It starts from the top of the leg, and extends down in a few days or weeks. The pain starts from the hips and the back of the thighs; and continues toward the back and side of the leg.
The pain increases by coughing or straining.
Numbness and / or tingling in the leg and foot
In severe cases; urinary incontinence, stool incontinence, numbness in the anal region. Impotence (sexual impotence) may occur.
How is Diagnosis Made Lumbar Disc Herniation?
In a patient with such symptoms, diagnosis can easily be made by using imaging techniques in accordance with the patient's medical history and a physical examination performed by a neurosurgeon or a physical therapist.
Conventional radiography: It is one of the first imaging techniques used for displaying bone structures. It is both cheap and easy to use. But it isn't possible to see discs, neural structures, and soft tissues such as ligaments. Osteophytes, spurs, narrowing of the disc spaces, and calcification of ligaments may be seen in anteroposterior and lateral radiographs, due to lumbar disc degeneration. Also, scoliosis and loss in lordosis in the lumbar region may be observed.
Discography: It is an imaging technique done by injecting a contrast agent in the disc. It can be used in rare cases. The localization of the hernia and the torn part is evaluated by taking a conventional radiography or tomography.
Computerized tomography (CT): It was preferred in diagnosing hernia before MR was discovered. It shows the bone structures in detail. But the fact that MR shows soft tissues has majorly caused it to take CT's place in diagnosis. But in cases that MR is contraindicated, such as cardiac pacemakers, hearing aids, and implants in the spine; CT can easily be used.
Magnetic resonance imaging (MRI): It is the most commonly used noninvasive test when diagnosing a herniated disc. The localization of the hernia and the nerve it has affected can easily be seen. In patients who have had low back surgery; specific anatomical structures, the changes that have occurred after surgery, recurrent hernia, and the epidural scar tissue can easily be differentiated, by giving the patient an intravenous contrast agent.
EMG: This is a test that measures nerve conduction. It is done by neurologists. It is used to show the localization of the compression on the nerve or in differential diagnosis with neurological diseases.
It is easily diagnosed with the evaluation the doctor makes using these imaging techniques, especially MRI.
Treatment of Lumbar Disc Herniation
Surgical treatment isn't required in 90% of the herniated disc patients.
Firstly, the following treatment protocols may be applied.
Limited bed rest
Acetaminophen or NSAID drugs
Short-term steroid therapy
Physical therapy and rehabilitation program
Epidural steroid injections
Intradiscal laser or RF applications
Epidural Steroid Injections
Along with the effect varying from one patient to another; in interventions made with the first six months of the beginning of the complaints, 80-90% of the patients recover and further treatment isn't required. In later cases, 50-70% of the patients have a symptomless period over 2 months to 1.5 years.
The aim of an ‘’epidural steroid injection’’ is; to relieve the patient of pain, help them return to their daily life, and ensure that they can participate in physical therapy and exercise programs without any pain.
In these types of injections, steroids and local anesthetic drugs are injected to the epidural region. C-arm fluoroscopy is an easy technique performed by using an X ray device in the operating room. After the procedure, the patient is discharged from the hospital after a 2 hour rest. This method may be applied in mild cases. It can be repeated up to 4 times a year. The complication rate is very low.
Laser Treatment for Herniated Disc
This method may be applied to cases with mild nerve compression. C-arm fluoroscopy is an easy technique performed by using an X ray device in the operating room. The intervertebral disc is entered between both vertebrae, through a hole called a foramen; which the nerve emerges from. The procedure is performed under local anesthesia, using a needle. A fiber optic cable, which allows laser transmission, is slipped through the needle. The laser creates a specific energy inside the intervertebral disc, and reduces the size of the disc by burning the tissues inside it. This reduces the patient's symptoms by decompressing the nerve. It is a short procedure that takes 30-45 minutes. The patient is discharged from the hospital after a 2-4 hour rest.
Transsacral Epiduroscopic Lumbar Laser Discectomy
Despite a 6-8 week period of conservative treatment, 10% of the patients suffering from low back pain aren’t able to make progress. In some cases, the doctor wishes to try other treatment options. However, this is not an easy decision. Especially for elderly patients and patients who have had back surgery before. ''Epiduroscopic laser discectomy'' method has become one of the minimally invasive surgical procedures for low back pain and herniated discs. This technique was introduced in 1966 for diagnosis and treatment. It is possible to reach the lesion and treat it, without causing morbidity. This method can easily be applied on patients with lumbar disc herniation or patients, which have had back surgery and developed a scar tissue around the nerve.
Application method of the procedure:
The patient is laid in a prone position. Imaging of the spine is done using local anesthesia, under sterile conditions, with a C-arm X-ray device.
After local anesthesia, the sacral hiatus is entered using a 90mm long 18G needle. A guide wire is slipped through. The guide wire is sent in after checking the anatomical disc space using the fluoroscopy device. A 3 mm skin incision is made. A 3,8 mm.+17,8 cm dilator is sent in over the wire. A flexible catheter is sent in after removing the dilator. A fiber optic camera and laser is slipped inside. Saline serum is injected into the epidural space. After the distance is verified, the protruded disc and adhesions are burned with the laser's heat effect, via the optic camera. After the nerve root is adequately decompressed, depot steroid is injected and the catheter is pulled out. One suture on the wound is enough. It is a comfortable method. After a 4-hour follow-up, the patient is discharged home.
When Is Back Surgery Necessary?
Back Surgery is necessary for patients suiting the following criteria.
Pain lasting more than 6 weeks
Cauda equina syndrome: This condition requires EMERGENCY SURGERY. It may be associated with bilateral or unilateral low back and leg pain, of which severe low back pain is in the forefront; a saddle-like pattern of numbness and insensibility at the anal region; progressive loss of strength in the legs, which may even go to paralysis; loss of sensation in the legs; and urinary incontinence.
Rapid and progressive loss of strength (in less than 24 hours) aka a paralysis state
Mild, persistent weakness
Chronic pain resistant to narcotic drugs
Continuous complaints despite physical therapy and rehabilitation
Social Factors (busy working life or being a famous athlete, etc.)
Williams, Yaşargil, and Caspar have made using microsurgery, in back surgery, popular. The introduction of the microscope, has increased the success rate of surgery. The surgical microscope has allowed us to easily see the nerve structures, by enlarging them, and retract and decompress the tissues in a more gentle and safe way. It is the most commonly used surgical method of herniated disc surgeries among neurosurgeons. In surgeries performed with ''microsurgery'', the procedure is carried out by making a small incision under a microscope.
Microsurgical technique: It is performed under general anesthesia. The standard position is; the patient is laid down in prone position on the chest pads releasing the abdomen. The lumbar region is slightly bent. This helps position helps open the intervals between the vertebrae. Distance determination is made with the C-arm X-ray device. A 1,5-2 cm skin incision is made at the midline. The muscles are peeled off. The bone region called interlaminar is reached. Some bone structures are taken from what is called the lamina and facet joint structures. The ligament called flavum, which is revealed, is taken out. The nerve root is pulled aside under the microscope. The protruded disc (hernia) is taken out using surgical instruments. The main purpose is to relieve the nerve. Reducing the pressure on the nerve is accurate. The wound is terminated with subcutaneous stitches. the success rate of pain reduction is 90-95%. However, the recovery of weakness may take time. Therefore, surgery should be administered to patients that have developed weakness due to of hernia, as soon as possible.
The patient is discharged the next day.
Endoscopic Lumbar Discectomy Method
This technique is one of the minimally invasive spine surgery. This surgical technique has been discovered with the idea to preserve the natural structure and function of tissues, and to minimize the damage given to patients by surgery. It is a new technique, which has been slowly developing for the last 30 years. In our country, these surgeries are performed in very few centers due to both the expensive costs of the endoscopy equipment and the fact that surgeons aren’t trained in this regard. However, trainings continue to be delivered in courses provided for surgeons, throughout the world. Special equipment such as an endoscopic video unit, monitor, cold light source, and video player are needed in order to carry out the process. Also, smaller hand tools than the ones used in microdiscectomy are required. Dilators with the diameter ranges of 5.9 to 6.9 mm and lengths of 145 to 185 mm are used to separate the muscles. Also 5.2 mm disc forceps are used. Lasers may also be used optionally in these operations. The most commonly used endoscopic systems are Storz and Richard Wolf brand.
There are 2 different approaches called transforaminal and interlaminar. In the transforaminal approach, the spine is entered with an angle of 45-60 degrees, 14-15 cm outside the midline. First, the needle is sent in. The disc is inserted from the foraminal hole. Discography is done after giving a contrast agent inside. A 0.5 mm incision is made and the guidewire and dilators are used to peel off the muscles. The irrigation system is started and the endoscopic system is inserted into the cannula. The hernia is observed and removed; the nerve is relieved. These operations, which are performed with small incisions; may be carried out with the conscious patients, according to the doctor's preference. The difference of ''endoscopic herniated disc surgery'' from other surgeries is; that it is performed using small tools, a small incision is made, it leaves less tissue damage in the operation site, and it allows the patient to return to his/her daily life more quickly.
The patient may be discharged the same day.