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,