Lumbar Disc Disease Treatment & Management
- Author: Kamran Sahrakar, MD, FACS; Chief Editor: Brian H Kopell, MD more...
Almost all patients with sciatica and disc herniations deserve a trial of medical therapy. The one obvious exception is a patient presenting with cauda equina syndrome or profound motor deficits.
Most practitioners are well versed in the initial management of cases of sciatica. Counseling and education about the disease helps the patient commit to a successful trial of nonoperative management. Encourage bedrest and prescribe anti-inflammatory agents (steroidal and/or nonsteroidal) with analgesics that are sufficiently strong enough to relieve pain. Muscle relaxants aid in relieving associated muscle spasm. After 7-14 days, slow mobilization is started.
Once the patient has recovered from the worst radicular pain, physical therapy can be instituted. Return to work (either limited or full) is important at this point. Stop steroidal medications. Reevaluate patients about a month after the onset of sciatica. At this time, studies can be ordered or a more intense back rehabilitation program can be designed so appropriate referrals can be made.
The success of conservative management of lumbar disc herniations may depend on the type of herniation. A review of over 600 patients concluded that noncontained herniations may respond more successfully to nonsurgical treatment.
What constitutes surgical therapy is open to discussion. The standard lumbar microdiscectomy has numerous variations, one of which is outlined below.
Percutaneous discectomies are still performed frequently. Lately, endoscopic techniques have gained in popularity. This method appears more applicable in small and contained disc herniations. Chemonucleolysis, although in principle an excellent alternative, is no longer performed. Other procedures, such as thermal ablation, are also performed.
A complete workup is essential. Based on the patient's age group and comorbidities, perform the appropriate laboratory examinations, radiographic examinations, and further tests, as needed, to ensure a safe anesthetic period.
The standard lumbar microdiscectomy is described. Variations in technique exist between institutions, regions, and surgeons.
The patient is anesthetized and placed in the prone position. The hips are flexed to open the interlaminar spaces. A protuberant belly should hang as freely as possible to reduce venous hypertension. The ulnar nerves at the elbow are padded to prevent neuropathy. The legs cannot be overflexed. The back is parallel to the ground. A preoperative radiograph with a spinal needle is obtained to confirm localization. The back is shaved and prepared.
After injection of a long-acting local anesthetic agent, a 3-cm incision is made over the disc space (as determined by radiograph). Unipolar cautery is used to dissect down through midline subcutaneous fat. The lumbodorsal fascia is opened paramedially. Muscles are stripped from the lamina. Obtain a repeat radiograph to confirm the appropriate location.
A small laminotomy is created with a drill or rongeurs. The ligament is excised with rongeurs or a knife. An operating microscope is now used. The medial facet is partially resected in most patients. Some evidence indicates that joint angles smaller than 35° result in resection of larger portions of the medial facet and result in more immediate postoperative pain. The root is then identified and retracted. The disc fragment is evident below the retracted root.
The annulus is incised and the disc removed with pituitary rongeurs. Loose fragments of the disc in the interspace are removed. The course of the nerve root is palpated with an angled instrument along its entirety to ensure adequate decompression. Significant controversy exists regarding the optimal extent of discectomy. Bleeding is stopped, the wound is irrigated, and then it is closed in interrupted absorbable sutures layer by layer. A light dressing is applied.
The patient is treated with oral narcotics and IV supplementation for pain. Antiemetics are administered as needed. The patient is mobilized 4-6 hours after surgery and should be able to void without help. Once the patient tolerates fluids, he or she may leave the hospital with an ample supply of narcotics, antispasmodic agents, and stool softeners. Rarely, the patient may remain in the hospital 24 hours after the operation.
The patient is seen in follow-up one month after surgery. For uncomplicated cases, the patient is then released from the surgeon's care. The patient is usually released to work 6-10 weeks postoperatively, depending on the occupation.
The overall complication rate is 2-4% for the surgery.
Despite endless reports of misadventures, surgeons still operate on the wrong level. Therefore, reliance on intraoperative radiographic confirmation of the intended level is strongly encouraged.
Bleeding intraoperatively can be copious and is almost invariably due to malpositioning. Engorged venous epidural channels can make the operation more difficult and far more dangerous. Very rarely, the anterior annulus is violated and a retroperitoneal vessel is injured. Awareness of this complication is essential. Should this occur, the back is closed while a vascular surgeon prepares to repair the vessel via laparotomy.
Infections, usually skin infections, can occur. The authors' protocol is to administer one dose of a preoperative antibiotic within one hour of surgery. Very rarely, postoperative discitis can cripple a patient who is recovering. Suspect discitis in the setting of an increasing sedimentation rate, fevers, severe localized pain, and recurrent symptoms.
Increased neurologic deficit is usually mild and is due to excessive retraction of the root. If a nerve root is mistaken for a disc herniation and is removed, the resultant injury can be severe. If possible, identify the root and disc in the same field. On occasion, a conjoined root can add significant technical complexity to the case.
Outcome and Prognosis
Almost every study measures the outcome from lumbar disc surgery differently. A good outcome may be defined as the decreased use of narcotics, prompt return to work, or reported reduction in pain. Understandably, outcome studies can be misinterpreted or misrepresented.
Patients who experienced symptoms 6 months or more prior to treatment (both operative and nonoperative) had worse outcomes following their treatment. Surgery’s relative benefit over nonoperative treatment was not dependent on the symptom duration.
Approximately 75% of patients who undergo a microdiscectomy have long-term reduction of sciatic pain and, thus, are considered cured. Reported results vary from 65-95%. Predominance of leg pain is the best determinant of good outcome from surgery for lumbar disc herniation.
Unfortunately, a rather large fraction of individuals who have had surgery for lumbar disc disease have recurrent or residual pain, which can be a significant challenge to treat. A methodical postoperative evaluation is necessary, focusing on symptom clarification, careful examination, and repeat radiographic examinations and MRI with contrast.
Interestingly, a large multicenter trial found that surgical and nonsurgical outcomes at 2 years were similar, but that the surgical group experienced faster pain relief.[8, 9] The limitations of this study are outlined in a more recent editorial.
Also, some patients who are surgically treated are more prone to further problems such as recurrent herniations, arachnoiditis, and vertebral instability.
A long-term follow-up study shows that frequent strenuous physical activity at work plays a prominent role in later hospitalization for herniated lumbar disc disease. Additionally, it has been found that while body height is also a significant predictor for herniated lumbar disc disease, body weight is only insignificantly associated with it.
A study of long-term results for lumbar disc herniation operations in 39,048 patients compared microdiscectomy, endoscopic microdiscectomy, and the 'classic operation,' laminectomy/laminotomy with discectomy. Laminectomy/laminotomy with discectomy was performed on 34,547 patients (88.5%), with a mean follow-up of 6.3 years, and 27,050 (78.3%) patients had good/excellent results. Microdiscectomy was performed on 3,400 patients (8.7%); the mean follow-up was 4.1 years, with 2,866 patients (84.3%) reporting good/excellent results. Endoscopic microdiscectomy was performed on 1,101 patients (2.8%), with mean follow-up of 2.9 years and 845 (76.8%) reporting good/excellent results.
Future and Controversies
Most areas of controversy are delineated within the above text. The major controversies are outlined in this section.
The duration of conservative management has been debated since the disease was identified. As surgical treatments become less invasive and medications change, the role and duration of conservative management will change as well.
Endoscopic operations are becoming safer and more prevalent. Although many microdiscectomies are now being performed in the outpatient setting, the impetus for even less invasive procedures continues. In fact, the endoscopic approach is even used in the traditionally more technically demanding recurrent cases. The theoretical advantage of reduced muscle injury in the endoscopic approach is somewhat in question as CPK and multifidus muscle atrophy are not significantly different when compared to conventional microdiscectomy.
The role of stabilization in lumbar disc surgery is very unclear. An increasing number of patients are having extensive fusions as the first-line management of lumbar radiculopathy secondary to disc herniations. However, the indications for stabilization need to be better established.
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