In the first three months of onset, we operate on disc prolapses causing severe incontrollable pain (Sciatica) and/or associated with neurological deficit, and of course in cases of huge prolapses with impending features of ‘Cauda Equina’ syndrome.
After the first three months; we operate, in addition to the above, on cases with pain interfering significantly with life style and not settling on conservative treatment.
Conservative management is indicated in absence of neurological deficit and in certain cases associated with co-morbidity. The old fashion treatment of bed rest, wood board, floor bed etc. is non-effective and out of question.
Pain control: usually by using balanced analgesia techniques which means using different pain killers with different mechanism of action including simple pain killers, non-steroidal anti-inflammatory, morphine, etc.
Muscle relaxants: used to alleviate the vicious circle of pain and spasm, and facilitate active physical therapy and rehabilitation, I am a great fan of Valium as muscle relaxant as it make wonders with patient with acute pain.
Physiotherapy and Lumbar disc prolapse: physiotherapy role is to facilitate return to usual activities and mobilize the spine in safe way. It may include manual techniques, dry needling, and traction depending on the case. In the market there is advocate of special traction devices and magnetic devices, we do not support these methods as it is not supported by any objective research and we consider it ineffective without any randomised controlled trial. Osteopath and chiropractor involvement is reasonable but they do not have magic hands when compared to physiotherapist.
Epidural injection: epidural injection is a great, simple and safe method to treat lumbar disc prolapses with 50% chance of success, its mechanism of action is to reduce pain to a tolerable limit and reduce the inflammation around the nerves in the spinal canal. It can be repeated up to three times and can simply cure you.
The cases estimated to require surgery are only 7% of the total cases, in which conservative treatment failed and in presence of neurological deficit. There are many techniques for lumbar discectomy surgery. All techniques share the same philosophy of removing the pressure on the nerves without damaging the spine and the surrounding soft tissue. Patient selection, surgeon preference, and advanced instruments availability are the key of successful outcome.
In this respect, I will explain some of the available techniques and its advantages and disadvantages for public understanding.
This what some surgeons and interventional radiologist refer to as, non-surgical treatment. This procedure is considered a minimally invasive surgery in which special instruments are inserted under x-ray or CT guidance in the disc space, which allow mechanical excision of the disc material (decompression) from the intervertebral space. I prefer to describe it as indirect discectomy, and I feel it is suitable in cases of far lateral mild lumbar disc bulges rather than prolapse, but the results for large posterio-lateral, or central disc prolapses are not encouraging at all.
Intradiscal electrothermal annuloplasty (IDET), is a similar method but using radiofrequency generator to produce thermal energy within the disc to help shrinking and decompression of the disc bulge, rather than extracting the disc material mechanically.
The alternative is to use a Laser generator (Laser Nucleoplasty) rather than radiofrequency to produce the same effects. The success rate of these methods are approximately 50%, hence a careful patient selection has to be carried out trying to increase the success rate. These methods are not without risk of complication and in fact the rate of complication is higher than formal surgical discectomy in some reports.
Nucleoplasty should never be considered a replacement of open micro discectomy surgery or attempted before micro discectomy as a prior option. It is indicated on its merits whenever it is suitable. I believe it is valuable option in selected patient only.
This is the gold standard procedure techniques for lumbar discectomy, it is performed by small 5 cm incision directly over the involved disc area and creating an access to the intervertebral disc via the ligamentum flavum and may require removing part of the lamina (Laminotomy) to access the disc space and excise it. The procedure has been modified over the last 20 years and some surgeon use extra equipment to improve visibility like microscope (Microscopic Micro discectomy), or an endoscope (endoscopic Micro discectomy), or simply use eye loops. Whatever is used; the technique is virtually the same. The advantage of using the microscope or the endoscope is that the assistant surgeon will have the same surgical field view so it has an educational advantage. The important thing to realize is that endoscopy screens only show 2 dimensions of the field, but the human eye would be able to see the depth as a third dimension of the surgical field, which would be a technical advantage.
The endoscopic technique has been reported to have a higher complication rate, with no significant advantage for the patient over the other techniques.
Minimally invasive micro discectomy:
This is generally the same as micro discectomy but the instruments are special dilating cylinders to allow access to the surgical area without significant damage on the paravertebral muscles. It is certainly advantageous for postoperative pain and also provides excellent visibility during the procedure.
Discectomy is considered alone without fusion in case of disc prolapse with symptoms concentrated in the leg with no significant lower back pain. It may be carried out as well as part of inter vertebral spinal fusion procedure such as PLIF (posterio-lateral interbody fusion), or TLIF (Trans foraminal interbody fusion) to address the lower back symptoms if significant.
There is nothing called Laser Discectomy in spinal surgery, some surgeons use laser probe and coagulate the disc space after finishing the micro discectomy procedure but this has no scientific proven advantage and it is possibly used or designed for marketing and propaganda purposes.
Complication of Lumbar Micro Discectomy:
The complication risk is 2-3 %, complication are usually minor and reversible including minor weakness, sensory disturbance, haemorrhage, infection, Dural tear and CSF leak. The major complication of paralysis and inability to function including Cauda Equina syndrome are theoretical in our current era and in experienced hands.