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Disc Prolapse & Diskectomy

Disc Prolapse

Natural History of sciatica

The commonest age this occurs at is between 30 and 50. There is a strong genetic influence on the occurrence of this condition but also a variety of other factors such as activity, cigarette smoking, occupation etc. Most people do get better with time but it is a very painful condition and a lot of patients want reassurance and to be able to feel more comfortable while the condition improves on its own.

Risk Factors/Prevention

In children and young adults, discs have high water content. As people age, the water content in the disc decreases. They become less flexible. The discs begin to shrink. The spaces between the vertebrae get narrower. The disk itself becomes less flexible. Conditions that can weaken the disk include: Genetic factors, improper lifting, smoking, excessive body weight that places added stress on the discs(in the lower back), sudden pressure (which may be slight) and repetitive strenuous activities

The gel-like inside (nucleus) of a disc may protrude into or through the disc's outer lining (annulus). This herniated disk may press directly on nerve roots that become the sciatic nerve. The nerve may also get inflamed and irritated by chemicals from the disc's nucleus. About one in every 50 people experience a herniated disc often called a slipped disc. Of these, 10-25 percent have symptoms lasting more than six weeks. About 80-90 percent of people with sciatica get better, over time, without surgery. The problem is that often the pain is unbearable and makes it difficult to carry on with normal activity including work.

Management

The condition usually heals itself if you give it enough time. It can be a debilitating condition that causes a lot of misery due to severe pain.
Tell your doctor how your pain started, where it travels and exactly what it feels like. A physical examination may help pinpoint the irritated nerve root. Your doctor may ask you to squat and rise, walk on your heels and toes or perform a straight leg raising test or other tests. Most cases of sciatica affect the L5 or S1 nerve roots. Later, X-rays and other specialized imaging tools such as MRI (magnetic resonance imaging) may confirm your doctor's diagnosis of which nerve roots are affected.

MRI scanning (magnetic resonance imaging)

This is a modern diagnostic imaging technique that produces cross-sectional images of your body. Unlike CT scans, MRI works without radiation. The MRI tool uses magnetic fields and a sophisticated computer to take high-resolution pictures of your bones and soft tissues. Tell us if you have implants, metal clips, pacemakers or other metal objects in your body before you undergo an MRI scan. It is also best avoided in the first trimester of pregnancy.

You lie as motionless as possible on a table that slides into the tube-shaped MRI scanner. The MRI creates a magnetic field around you, then pulses radio waves to the area of your body to be pictured. The radio waves cause your tissues to resonate. A computer records the rate at which your body's various parts (tendons, ligaments, nerves, etc.) give off these vibrations, and translates the data into a detailed, two-dimensional picture. You won't feel any pain while undergoing an MRI, but the machine may be noisy and it may feel quite claustrophobic within the chamber.

An MRI may take 15-30 minutes, and is not available at all hospitals.

Patients sometimes find that this is a claustrophobic experience. Most patients can manage to have their investigation. It is helpful to shut your eyes before sliding into the scanner.

MRI appearance of a disc prolapse

Medication

Treatment is aimed at helping you manage your pain without long-term use of medications. First, you'll probably need at least a few days of bed rest (usually no more than 2 days are recommended while the inflammation settles. Non steroidal anti-inflammatory medications (NSAIDs) such as ibuprofen, diclofenac, aspirin or muscle relaxants may also help. Often stronger pain killers such as codeine, dihydrocodeine or combinations of codeine with paracetamol such as codydramol are useful. You may find it soothing to put cold on your painful muscles.

Your general practitioner is best placed to advice regarding your medication.

Posture and rest

Find positions that are comfortable, but be as active as possible. Motion helps to reduce inflammation.

These positions help in reducing the intradiscal pressure and therefore symptoms of sciatica.

Injection treatment

Most of the time, your condition will get better within a few weeks. If pain is not well controlled with medication, your surgeon may elect to do a nerve root block or a caudal epidural injection which can often provide dramatic relief very quickly. Often injections settle the pain within 2-3 days allowing a return to work. Relief may be long lasting, not because the injection acts ‘forever’ but because the natural history may improve the condition by itself.

Injections are thought to improve pain by reducing the inflammation at the interface between the herniated disc and the nerve root. A lot of chemical mediators are present at this site and they can be counteracted by the washing out effect of the injection and possibly the steroid.
This is not a numbing injection and does not increase the possibility of causing further damage by reducing awareness.

Typical lumbar disc herniation with an inflamed interface

Risks of injection

The commonest problem is that the injection may not succeed in improving pain. That could happen in 20-30% of patients. This is sometimes the case if the injection is not technically perfect as it can be difficult to get it into the right spot. Either due to this- or the pain returning within 6 weeks, the injection may need to be repeated.
Sometimes the pain becomes worse for a few days before improving- the steroid flare.
Rarely the injection could disrupt women’s menstrual cycles for a few weeks.
Very rarely there is a risk of more serious complications such as infection or damage to the nerve root.
As soon as possible, start physical therapy with stretching exercises to help you resume your physical activities without sciatica pain. At the beginning, your surgeon may want you to take short walks.

Physiotherapy

Mackenzie exercises

Hyperextension of the back centralises the pain to the back rather than cause sciatica.

Chiropractic/ Osteopathic adjustments/manipulations

This could settle the pain, although hard evidence that it makes a difference is not available

Acupuncture

This could possibly help pain.

Surgery for disc herniation

The only absolute indication for surgery is for the cauda equina syndrome.. This is a surgical emergency which often presents dramatically The disc will press on the cauda equina, which consist of the nerve roots to the lower limbs, the bladder and the rectum, causing the following motor and sensory problems:

  • Loss of perianal sensation "saddle anaesthesia"
  • Bilateral weakness in the legs
  • Sphincteric disturbance
  • Inability to sense bladder filling, painless retention and overflow: urinary incontinence
  • Loss of anal tone: faecal incontinence

This is a surgical emergency requiring an emergency MRI scan and subsequent decompression within 24 hours of onset of symptoms; not presentation.

Relative indications for surgery are

  • Unrelenting leg pain despite adequate conservative measures
  • Progressive neurological deficit
  • Recurrent acute attacks of pain

SURGERY

Diskectomy – removal of a portion of the disc to relieve pressure on the nerve root

  • 90% relief of leg pain
  • Recurrence rate 5-10% over 7 years
  • Low rate of complications 1-2% (nerve injury and CSF leak)
  • Failure rate – 5-10%
  • Very rarely cauda equina syndrome
  • Results for back pain not as good

The operation

A part of the herniated disk may be removed to stop it from pressing on your nerve. The surgery is done under a general anaeshetic.

It is done through a 3-7 cm incision over the lower back. A small portion of the lamina and the ligamentum flavum are removed to gain access to the involved nerve root and disc.

Surgery is done with loop magnification or a microscope.

The disc fragment compressing the nerve root together with any other loose fragments are removed. The whole disc is not removed. The wound is closed with dissolving sutures that do not need to be removed.

Stay in hospital is usually for a day.

Local anaesthetic around the wound is normally adequate for pain but occasionally intravenous pain killers are used together with tablets. Some basic exercises are taught by the physiotherapist and also the patient mobilises and walks up and down stairs.

You have a 90 percent chance of successful surgery if most of your pain is in your leg.
Avoid driving, excessive sitting, lifting or bending forward for about a month after surgery. Your doctor may give you exercises to strengthen your back.

Following surgical treatment for sciatica, you will probably be able to resume your normal lifestyle and keep your pain under control. However, it's always possible for your disk to rupture again. This happens to about 5 percent of people with sciatica.

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