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Lumbar Disc Herniation

Lumbar Disc Herniation

Lumbar disc herniations (herniated nucleus pulposus) are seen commonly in patients from age 18 to 60. It is estimated that 1-2% of the population throughout the course of their lifetime will have a herniated disc requiring medical/surgical treatment. It can cause back and lower extremity (buttock/leg) pain together, back pain alone, or lower extremity pain alone. It can often be misdiagnosed when the symptoms are limited to the back, as most lower back pain is not due to a disc herniation.

The lumbar spine is composed of intervertebral discs and vertebra. The discs are soft cushions that function as 'shock absorbers' between the vertebra (bones). The discs have an outer ringed structure (known as the annulus fibrosis) as well as an inner, jelly like material (known as the nucleus pulposus). Imagine that the disc is like a jelly doughnut, with a soft, gelatinous inner portion, and then a more study, tougher outer portion. Just like the jelly doughnut has a hole in it where the jelly can come out of, so does the disc. In fact, the disc has two holes where the jelly can leave the doughnut, one on the right and one on the left. That is why most people develop symptoms in one lower extremity or the other when they have a disc herniation.

The jelly inside the intervertebral disc is unlike the warm, colorful, and friendly jelly that is seen in a jelly doughnut. It is actually a very irritating substance, similar to bleach. Thus, as a result of the jelly leaking out of one of the holes of the disc, the jelly (nucleus pulposus) can touch the nerve and cause the nerve to become very irritated or swollen. This cause the nerve to work abnormally, causing unusual sensations (paresthesias), pain, and even weakness. Each person is different; sometimes a large piece of jelly causes minor problems in one person while a small piece of jelly can cause tremendous problems in another person. No one can tell from the size of the disc herniation how much pain or discomfort a person should experience. The size of a disc herniation (seen on MRI) is no reason to rush to surgery.

Fortunately, 75-85% of people who have a disc herniation improve without surgical treatment. Normally, the jelly that leaked out of the disc melts away slowly over time. As it melts away, or resorbs, the symptoms become less severe. The main goal of non-operative treatment of a lumbar disc herniation is to keep the patient comfortable and functional while nature runs its course. This typically takes 6 to 12 weeks; it can take up to twice as long in diabetics and smokers. These non-operative treatments include medications, physical therapy, and epidural injections.

Surgery is reserved as a last resort for those people who have debilitating pain, have had pain for more than 2-3 months, who have weakness in the lower extremity that is worsening, and/or people who have problems with the nerves going to the bowel/bladder region. 

The details of the surgery needed to treat the condition varies in the younger and the older patient, but both are generally minimally invasive and done as an outpatient. In the older patients, the bone spurs are removed and more room is created for the nerve to move away from the herniated disc. This procedure is called a microscopic foraminotomy. In the younger patient, the herniated disc fragment/jelly is also removed to create more room for the nerve, and this procedure is called a microscopic discectomy. These procedures usually result in immediate relief of the pain and any weakness - if present - should return to normal in a few weeks/months.

Please discuss any further questions about your specific situation with a fellowship-trained orthopedic spine surgeon.