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LUMBAR DISC HERNIATION REVIEW 1

athleteathlete Posts: 60
edited 06/11/2012 - 7:34 AM in Back Surgery and Neck Surgery
DISCLAIMER: THIS IS SOME LIMITED INFORMATION THAT I HAVE FOUND HELPFUL ABOUT LUMBAR DISC HERNIATIONS THRU READING (my synopsis, not copied) AND MY AND ONLY MY PERSONAL EXPERIENCE BUT IT IS NOT INTENDED TO SUBSTITUTE FOR YOUR DOCTOR'S ADVICE. AS ALWAYS, CONSULT YOUR OWN PHYSICIAN FOR DIAGNOSIS AND TREATMENT.

Back pain and sciatica are common. Most people will experience back pain at some point in their life (most commonly muscle strain injuries).

We are all different. The tough 65 yo male farmer or 85 yo woman may have a terrible looking MRI with severe DDD, disc protrusions, severe stenosis yet they hardly complain
while another patient may complain of incapacitating back bain and a completely normal MRI.

Lumbar disc herniations are common. I sometimes hear people say they have a couple of disc herniations or bulges causing them problems-maybe, but many disc herniations are asymptomatic (herniation aka protrusion or extrusion NOT bulges, which I don't even acknowledge because bulges are so common I almost consider them normal). (Study by Boos et al., 1995- On MRI, 76% of ASYMPTOMATIC people with higher risk jobs for back injury had at least one disc herniation (protrusion or extrusion), however, only 13% were severe/large extrusions. 85% of this asymptomatic group had DDD at least one level). So, your pain may not be at all related to a disc hernation seen on MRI. This is why your Doctor needs to correlate your symptoms to the MRI. Radicular pain such as leg pain allows your doctor to better identify the cause of problems than back pain, which is nonspecific with many causes (DDD,facet,disc,strain,etc.).

Lumbar microdiscectomy. A trial of conservative therapy (cautious waiting, meds-anti-inflammatories +- steroid dose pack, epidural steroid injections, PT, etc.) for 3-6 months for a symptomatic lumbar disc herniation is common. Why? Because more than 90% of people will improve over this time. Disc herniations will shrink slightly and nerves will adapt with time as inflammation resolves (rarely, extrusions will completely resolve on their own). More immediate surgery is needed if you develop bowel or bladder problems. Earlier surgery is considered for significant progressive weakness or intolerable uncontrolled pain.

Do surgery patients do better than those treated with conservative therapy? At 1-2 years, there is probably no real difference in patient outcome although there is evidence that the surgery group does slightly better at 3-6 months. However, surgery is not without risk or cost. Remember, once you have surgery you will never be quite the same- back mechanics are altered (although less so with micro than open techniques). This is why core exercises (transversus abdominus and multifidus work in particular) are so important for the remainder of your life (surgeons, neurosurgeon or experienced spine dedicated orthopedic surgeon, often neglect the post-op longterm care after their surgery is done. Dropping any excess weight, exercising/walking, quiting smoking, and controlling diabetes are also important. A positive outlook, good support network, and avoiding self pity help.

What disc herniations are most likely to benefit from surgery? Radicular/leg symptoms are MUCH MORE likely to be improved from discectomy than just back pain (much lower likelihood of success). Symptoms lasting less than 6 months are more likely to improve (symptoms lasting more than a year are MUCH LESS likely to improve with discectomy).
These types of herniations are listed from better to worse outcome: extrusion with a small anular defect> contained fragment> extruded fragment and massive posterior anular loss> No Fragment-Contained (group did poorly)

What about fusion? As I said, I am talking about lumbar disc herniations in general, NOT lumbar instability/slippage/spondylolisthesis or spinal stenosis. For me fusion, is a LAST resort because I'm young (40) and active. My fear with fusion is that I would do ok for a few years until the next level degenerated and then needed a fusion and so on and so on. I'm skeptical of fusion but it is a real possibility for me in the future-hopefully not for at least 20 years.

Hope this helps someone,
W
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Comments

  • Thanks for posting this synopsis of an article that I think is the so-called Swedish study of surgical versus non-surgical treatment of low back pain. It's important to point out that for low back pain without either radiculopathy or acute neurological deficits, fusion surgery may not be appropriate.
    I speak from experience. I had a 360-degree two-level lumbar fusion several months ago and am in worse pain than before the surgery (at best I'm at the same level of pain as before). I also had a laminectomy at L5-S1. There was plenty of correlation between the MRI and my symptoms, but the basic problem seems to be weak back muscles from sitting at a desk for 20+ years and not getting enough exercise, plus a bad car accident 10 years ago.
    The old adage -- move more, eat less -- applies to the back just as it does to the heart and other parts of the body (I'm normal weight but I'm tall, so sitting for long periods at a stressful job turned my back into mush). There needs to be more education starting at an early age about back care basics.
    In any case, it's good to note that within the medical community there is a strenuous debate over the need for fusion surgery for low back pain from degenerated discs alone (see various articles by Richard Deyo, James Weinstein et al.). I should emphasize that this is a debate, i.e. there are strong views and good evidence on either end of the spectrum, so please talk to your doctor about what's best for you.
    Cheers,
    -P
  • Thanks for the feedback P,
    This info from MY REVIEW of many resources and review of the medical literature (texts and papers, not abstracts or web info) sums up what I have found most useful. Yet, many people including docs don't know this or forget about it. MRI is great when it correlates (especially with radicular symptoms or an acute onset of symptoms) but frankly your pain of several years is unlikely to be caused solely by a smaller disc hernIation or bulges alone seen on MRI without clear correlation. ASK ANY RADIOLOGIST-HOW MANY NORMAL (NO FINDINGS, NO BULGES, NO DDD, NO FACET DDD, NO STENOSIS, NO NOTHING WORTH COMMENTING ON) THEY SEE IN PEOPLE IN THEIR 30'S AND OLDER-THEY WILL LIKELY TELL YOU THAT A TRUE NORMAL SCAN IS A RARE OCCURRENCE-ESPECIALLY IN THE OVER 40 CROWD.

    YES, EXERCISE! (CORE ESPECIALLY, AND REAL CARDIO WORK, WITH SOME WEIGHTS) AND KEEPING THAT WEIGHT DOWN HELP. IF YOU ARE OVERWEIGHT? IT IS LIKELY CONTRIBUTING TO YOUR CURRENT AND FUTURE PROBLEMS SO DO SOMETHING SOONER SINCE IT ONLY GETS HARDER THE LONGER YOU WAIT. THE MORE OBESE THE MORE PROBLEMS AND BACK PAIN YOU CAN EXPECT. We far too often focus on the drugs and surgery but exercise and fitness with core strengthening have given me HUGE physical and psychological benefits.

    OBVIOUSLY, ANYTHING YOU DO, SHOULD BE UNDER YOUR OWN DOCTOR'S GUIDANCE. THIS IS MY PERSONAL OPINION NOT FORMAL ADVICE. SEE YOUR DOCTOR FOR DIAGNOSIS AND TREATMENT. DON'T LISTEN TO ME.

    W
  • I am behind you with your advice and information on the synopsis above. You have encouraged me many times to keep up with my exercise during this ordeal and for my daughter too, and you are absolutely right, it is important to watch our weight and keep healthy along with the core strenghtning because the surgeons part has mechanically fixed the problem the rest really is up to us to condition our bodies. When I feel lazy about doing my walk etc, I do think of your advice, and I push on because I know it will help me recover and give me better results.

    I, like you worry that a fusion is in my future, I am only 39, and the surgeon told me my disc at L5-S1 is so degenerated that if this doesn't work then indeed it would require a fusion as there is nothing left to work with, so I am hopeful to get as many years out of this surgery before that happens, the road to recovery looks alot harder after the fusion.

    Thanks for all your support
    Sandra
  • Seems to me the best advice might be what a physiatrist told me before I ever spoke to a surgeon: walk, exercise, and wait. Time heals all wounds (not literally, of course, but in some back pain cases, yes).
    I recently came across a piece of research saying that there is no correlation between imaging (MRI etc.) and symptoms. And it is well-known that if you took MRI's of a cross-section of the population, a majority would show some disc degeneration and other problems but would report no pain.
    I find that too many people here have become their pain. They identify themselves by their MRI findings, surgeries and meds. Forgive me if anyone takes offense at what I am saying. I know that pain is all too real. I'm still suffering eight months after posterior lumbar fusion. But has all this expensive hardware, all the drilling, hammering, cutting and sewing, really made us better?
    I have yet to be convinced that fusion surgery for low back pain is the right approach. Clearly it is indicated for certain specific conditions. But are we not over-fusing, over-drugging, leaving otherwise healthy people permanently scarred, pain-ridden and sent off to pain management doctors when the surgery hasn't helped?
    We need to re-think this whole business.
    -P
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