If the hernia is expelled, the material emerges from its interior and comes into contact with the blood vessels.
The result is inflammation and swelling that presses on the nerve root and causes sciatica.
If the leg pain caused by the hernia immediately improves with non-surgical treatments, the patient can be cured in 6-12 weeks.
The operation for herniated disc (disc hernia) is becoming increasingly rare, because it usually does not help to eliminate sciatica or cervicobrachialgia.
Most disc hernias occur in the lumbar part of the spine (L4-L5) or lumbosacral (L5-S1).
Rarely, they occur at the level of the cervical spine. In this case, the intervertebral discs C5-C6 and C6-C7 are more often affected.
If conservative therapy of disc hernia (medication, physiotherapy according to McKenzie, ozone treatment, etc.) does not show success, then the doctor may advise surgery.
You have to weigh the pros and cons of the intervention. The indications are:
- Severe and sudden onset of sciatica with other symptoms such as paralysis and incontinence.
- Sciatica or lumbocruralgia, which does not pass despite 3-6 months of therapy and medication.
- Inability to walk (walking without touching the ground with the tips of your feet) due to sciatic nerve inflammation.
Discectomy is a surgical procedure used to remove part of the intervertebral disc and leaked tissue.
The surgery is performed when a healthy discus fragment shifts and presses on the spinal canal or a nerve.
The attending physician is the neurosurgeon who explains the surgical procedure and follow-up treatment.
Anesthesia depends on the type of operation and on the decision of the anesthesiologist. It can be spinal or general.
Symptoms of disc hernia in L4-L5 and L5-S1
In addition to the symptoms of sciatica, pressure on the nerve can cause:
- Compression of the L5 nerve (at the level of L4-L5) can lead to a reduction in strength when stretching the big toe and flexion of the ankle joint towards the back of the foot (drooping of the toe).
- On the back of the foot, symptoms such as numbness and pain may develop.
- The complaints can also radiate to the buttocks.
- The symptoms can spread to the outside of the foot.
Nerve compression in S1 (at L5-S1) can lead to reflex loss and cause weakness in the ankle.
Options for surgery for herniated
Surgical treatment of the hernia includes the following options:
The conventional treatment of disc hernia is open surgery. With this technique, the surgeon gets to the damaged disc through an incision through the skin, muscles and surrounding structures.
Endoscopic or laparoscopic surgery
Endoscopic surgery of the spine is the second option and uses endoscopes and special surgical instruments. This method causes only a small incision.
This shortens the time of surgery and recovery.
Endoscopic discectomy is a modern technique used to remove damaged disc material.
The following consequences are not to be expected:
- removal of bone fragments,
- skin incisions,
- Muscle lesions.
Endoscopic discectomy is performed with the help of a camera connected to the screen (with zoom) and X-ray images to guide the endoscope probe into the disc space.
Another type of minimally invasive surgery is foraminotomy.
This procedure treats the pressure on the intervertebral disc caused by the following diseases:
- compression of the intervertebral disc (disc hernia),
- bone spurs (osteophytes),
- Scar tissue
- excessive development of the ligament.
Recovery times for endoscopic foraminotomy are short due to the minimally invasive procedure. The patient can resume his usual activities in a short time.
Microdiscectomy of a lumbar herniated disc
A microdiscectomy is performed to remove parts of the intervertebral disc and relieve the nerve root. This promotes the recovery of the nerve.
The doctor removes only a small part of the disc: most of the disc remains intact.
Indications for microdiscectomy
The person carries out his normal daily activities as long as the discomfort is bearable.
It is recommended to postpone the operation to see if the discomfort passes.
If leg pain does not improve with conservative therapies, microdiscectomy surgery is a reasonable choice to reduce pressure on the nerve root and speed up healing.
Immediate surgery is necessary only in the following cases:
- Incontinence of stool and urine (cauda-equina syndrome).
- The operation is also recommended if the pain in the leg is very strong.
Microdiscectomy may be indicated in patients who have the following signs:
- Leg pain for at least six weeks.
- Increasing loss of strength, sensitivity and reflexes.
- Persistent symptoms after conservative treatment (such as oral corticosteroids, nonsteroidal anti-inflammatory drugs and physiotherapy),
- If there is no improvement after three months of conservative treatment, microdiscectomy surgery may be considered in the following three to six months.
In a microdiscectomy or microdecompression of the spine, the surgeon removes the part of the bone above the nerve root and part of the intervertebral disc to relieve pressure on the nerve.
If the nerve has more space available, it regenerates more easily.
Microdiscectomy is performed in a disc hernia and is effective for pain in the leg (radiculopathy) of lumbar origin.
Pressure on a nerve root can cause pain in the legs.
Normally, it takes weeks or months to completely cure the symptoms at the root of the nerve.
Microsurgical surgery provides immediate relief to the patient.
How is microdiscectomy performed?
A microdiscectomy is performed by means of a small incision (from 2.5 cm to 3.5 cm) in the middle of the lower back.
First, the back muscles (back extensors) are lifted from the spine (lamina).
Because these muscles run vertically, the surgeon may confuse the location of the incision.
The surgeon works inside the spine and removes the tissue that is located above the nerve roots (yellow band). To see the latter, microscopes or special glasses (lenses) are used.
Often, the doctor removes a small part of the inside of the facet joints to facilitate access to the nerve root and take the pressure off the nerve.
The doctor pushes the nerve root to the side and removes part of the intervertebral disc.
Since almost all joints, ligaments and muscles are never injured, microdiscectomy does not change the mechanical structure of the lower spine (lumbar spine).
The procedure takes about 40-45 minutes.
This procedure is indicated in the case of a disc protrusion (protrusion) without a complete prolapse.
The surgeon directs a laser beam of high potency at the hernia area. The energy is almost completely absorbed by the intervertebral disc within 3-4 mm from the emission range, without causing damage to the surrounding tissue.
The laser causes evaporation and withdrawal of the leaked disc tissue, reducing the pressure on the nerve root.
The procedure takes about 30 minutes.
Is disc surgery dangerous?
Complications and risks of microdiscectomy
As with any spinal surgery, there are many dangers and complications, including:
lesion of the dura mater (loss of cerebrospinal fluid).
This complication occurs in 1-2% of cases.
This does not affect the surgical results, but after the operation, the patient is asked to stay in bed for a day or two to allow the following symptoms to be cured:
- Injury to the nerve root
- Stool and urinary incontinence
However, the complications mentioned above are very rare.
Microdiscectomy success rate
The success rate of spinal surgery is 90-95%. In 5-10%, patients develop another herniated disc.
Recurrence of the disc hernia can occur immediately after the procedure or many years later.
Therefore, after the operation, further hernias may develop in the upper or lower levels.
If there is another herniated disc, a repeat of the operation is recommended.
After a recurrence, the patient has a higher risk of a hernia (15-20% probability).
For patients with multiple disc hernias, vertebral fusion is recommended to prevent further recurrence.
Removing the entire intervertebral space and merging the two vertebrae is the most common way to prevent further disc problems.
If the posterior facet joints are not affected, an artificial disc replacement can be considered.
Disc hernias are not directly related to the patient’s activities, but are caused by degeneration of the intervertebral disc.
How long does recovery take? Length of hospital stay and postoperative convalescence
After the operation, the patient should follow the doctor’s instructions (medications, clothing, etc.) for faster recovery.
The success of the operation is very good and the patients are able to pursue their normal activities after only 2-3 days.
Nevertheless, you should observe some precautions postoperatively to minimize the risk of recurrence.
In the first 3 months you should not lift weights over 15 kg.
For a month you should not drive or do sports. After that, you can start gradually.
Postoperative exercises for rehabilitation
Normally, the exercises for postural gymnastics in sciatica should be tackled in the first few days after surgery.
Many exercises can help strengthen the spine, muscles, ligaments and tendons. Most of these movements focus on the lower back, abdominal muscles, buttocks, and pelvic muscles.
When trained correctly, these muscle groups provide relief because they support the spine, keep it stable and facilitate extensor and flexion movements.
Support the upper body on the elbows while the pelvis remains on the floor.
Remain in this position for a few seconds until the back relaxes.
Slowly lift the upper body, supporting it with your hands.
Perform 10 repetitions.
Isometric abdominal exercises
This exercise can be performed while sitting, standing or lying down.
Inhale and tense the abdominal muscles.
Hold this position for as long as possible.
When lying on the floor, press your back to the surface without the help of the abdominal muscles and legs.
Perform 10-12 repetitions per day.
Stretch your back and buttocks
You start lying down with your stomach up (supine position) with bent knees, your arms stretched out relaxed on the side.
Slowly you let the knees fall to one side. Hold this position for a few seconds and return to the starting position.
Repeat the exercise to the other side.
Perform 10 repetitions for each page.
Extension in prone position The starting position is the prone position
, the legs are slightly spread and the palms at shoulder height on the floor.
Lift the shoulders by pressing the arms, keeping the pelvis in contact with the floor.
Perform 10 repetitions in at least 3 series.
After the stitches are removed, the doctor may recommend swimming while walking is not indicated, as this would mean excessive strain on the spine.
Revised by Dr. Veroni Andrea