Treatment
Medical Therapy
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.1
Epidural steroid injections can be used at almost any time.
Surgical Therapy
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.2 Chemonucleolysis, although in principle an excellent alternative, is no longer performed. Other procedures, such as thermal ablation, are also performed.
Preoperative Details
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.
Intraoperative Details
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.3 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.4 Bleeding is stopped, the wound is irrigated, and then it is closed in interrupted absorbable sutures layer by layer. A light dressing is applied.
Postoperative Details
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.
Follow-up
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.
Complications
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.
More on Lumbar Disc Disease |
| Overview: Lumbar Disc Disease |
| Workup: Lumbar Disc Disease |
 Treatment: Lumbar Disc Disease |
| Follow-up: Lumbar Disc Disease |
| Multimedia: Lumbar Disc Disease |
| References |
| Further Reading |
| « Previous Page | Next Page » |
References
Nakagawa H, Kamimura M, Takahara K, et al. Optimal duration of conservative treatment for lumbar disc herniation depending on the type of herniation. J Clin Neurosci. Feb 2007;14(2):104-9. [Medline].
Mirzai H, Tekin I, Yaman O, et al. The results of nucleoplasty in patients with lumbar herniated disc: a prospective clinical study of 52 consecutive patients. Spine J. Jan-Feb 2007;7(1):88-92; discussion 92-3. [Medline].
Celik SE, Celik S, Kara A, et al. Lumbar facet joint angle and its importance on joint violation in lumbar microdiscectomy. Neurosurgery. Jan 2008;62(1):168-72; discussion 172-3. [Medline].
Eugene J. Carragee, MD, Anthony O. et al. A Prospective Controlled Study of Limited VersusSubtotal Posterior Discectomy: Short-Term Outcomesin Patients With Herniated Lumbar Intervertebral Discsand Large Posterior Anular Defect. Spine. 2006;31:653-657.
[Best Evidence] Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT): a randomized trial. JAMA. Nov 22 2006;296(20):2441-50. [Medline].
Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT) observational cohort. JAMA. Nov 22 2006;296(20):2451-9. [Medline].
Mazanec D, Okereke L. Interpreting the Spine Patient Outcomes Research Trial. Medical vs surgical treatment of lumbar disk herniation: implications for future trials. Cleve Clin J Med. Aug 2007;74(8):577-83. [Medline].
Hoogland T, van den Brekel-Dijkstra K, Schubert M, et al. Endoscopic transforaminal discectomy for recurrent lumbar disc herniation: a prospective, cohort evaluation of 262 consecutive cases. Spine. Apr 20 2008;33(9):973-8. [Medline].
Bussieres AE, Taylor JA, Peterson C. Diagnostic imaging practice guidelines for musculoskeletal complaints in adults-an evidence-based approach-part 3: spinal disorders. J Manipulative Physiol Ther. Jan 2008;31(1):33-88. [Medline].
Resnick DK, Choudhri TF, Dailey AT, Groff MW, Khoo L, Matz PG, et al. Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 2: assessment of functional outcome. J Neurosurg Spine. Jun 2005;2(6):639-46. [Medline].
Ehni BL, Benzel EC. Lumbar Discectomy. Spine Surgery. 1999;1:389-400.
Hardy RW. Extradural Cauda Equina and Nerve Root Compression from Benign Lesions of the Lumbar Spine. Neurological Surgery. 1996;3:2357-2374.
Loupasis GA, Stamos K, Katonis PG, et al. Seven- to 20-year outcome of lumbar discectomy. Spine. Nov 15 1999;24(22):2313-7. [Medline].
Williams RW. Lumbar disc disease. Microdiscectomy. Neurosurg Clin N Am. Jan 1993;4(1):101-8. [Medline].
Woertgen C, Rothoerl RD, Breme K, et al. Variability of outcome after lumbar disc surgery. Spine. Apr 15 1999;24(8):807-11. [Medline].
Further Reading
Clinical guidelines
Bussieres AE, Taylor JA, Peterson C. Diagnostic imaging practice guidelines for musculoskeletal complaints in adults-an evidence-based approach-part 3: spinal disorders. J Manipulative Physiol Ther 2008 Jan;31(1):33-88. 9
Resnick DK, Choudhri TF, Dailey AT, Groff MW, Khoo L, Matz PG, Mummaneni P, Watters WC 3rd, Wang J, Walters BC, Hadley MN, American Association of Neurological Surgeons/Congress of Neurological Surgeons. Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 2: assessment of functional outcome. J Neurosurg Spine 2005 Jun;2(6):639-46. 10
Keywords
lumbar disc disease, disc herniation, herniated disc, degenerative disc disease, lumbar disc, lumbar degenerative disc disease, lumbar disk disease, degenerative disc, lumbar spine disc disease
