Lumbar Disc Herniations Surgical versus Nonsurgical Treatment

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Lumbar Disc Herniations Surgical Versus
Non-Surgical Treatment
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ByDR. IBRAHIM A. NASSAR   Prof.
Orthop.Surg. Al Azhar University Al Ogaly
poly clinic Madinah Munawara
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• Lumbar disc herniation is among the most common
  causes of lower back pain and sciatica.

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• Anatomy

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• The intervertebral disc is one component of the
  spinal motion segment. The disc consists of three
  zones

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• (1) Outer annulus (2) Inner annulus
• (3) Nucleus pulposus,

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• The normal discs blood supply is restricted to
  the peripheral outer annulus.

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• Annulus is innervated, but no nerves have been
  identified in the substance of the disc itself .

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Spinal Nerve root compression
Posterior Longitudinal ligament
Effect of 1o Disc Affliction
Nerve Root
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Dural Sleeve
Dorsal Root
Ventral Root
DRG
Disc
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Change in disc innervations

• .

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• Nerve terminals usually exists in outer annulus,
  end plate and periannular connective tissue.
• Nerves goes deeper together with vascularization
  in disc degeneration

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• Simple degeneration is not painful.
• Painful discs is associated with change in nerve
  supply

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Disc Associated Neuralgia

• Nerve roots are "sensitized" with exposure to
  autologous nucleus pulposus by chemical
  irritants
• Serotonin.
• Histamine.
• Prostaglandins.
• (Chronic DRG compression produces neuropathic
  pain.)

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• Mechanism Of Back Pain

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• The mechanism of back pain is most
• Likely multifactorial but involves
• -Mechanical stimulation of the nerve endings in
  the outer annulus,

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• -Direct compression on the nerve root,
• -And/or the chemical inflammatory cascade
  induced by the exposed nucleus pulposus

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• Clinical Presentation

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• LBP associated with sciatica, which is radiating
  pain in a dermatomal distribution and classically
  described
• as a burning, stabbing, or electric sensation,
  sometimes accompanied with paresthesias.

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• Provocative maneuvers are

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• (1)Straight leg raising
• (2)Crossed S.L.R.

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• (3) Bowstring test.
• (4) Femoral stretch test

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• Patients with a herniated disc may have a loss of
  lumbar lordosis,

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• A functional scoliosis secondary to leaning away
  from the painful side, and the affected hip and
  knee may be slightly flexed and externally
  rotated to relieve tension on the nerve root

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• MOTOR
• SENSORY
• REFLEXES

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• Imaging

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• PLAIN X-RAY
• C.T.SCAN

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• M.R.I. has become the examination of choice for
  diagnosing L.D.H.s. It has the advantage of
  having no known side effects or morbidity, no
  radiation exposure, and is noninvasive.

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• Treatment

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• In a classic study by (WEBER)1995,nearly 70 of
  patient symptoms resolved within 4 to 6 weeks.

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• It is also known that the degree of neurologic
  deficit does not correlate with outcome, and
  patients with weakness can improve with
  non-operative treatment.

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• NON- OPERATIVE TREATMENT

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• Lumbar supports,
• Bed rest,
• Oral analgesics ,
• Muscle relaxants,
• Spinal manipulation,
• Physical therapy,
• Epidural steroid injections.

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• Operative treatment

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• The maturation of spinal surgery as a specialty
  has also led to the develop-ment of new surgical
  techniques ranging from minimally invasive
  operati-ons to disc repair and disc replacement.

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• (WEBER) Concluded that
• in the short term the surgical group fared better
  than the non-operative group, but the
• difference diminished over time with no
  significant difference after 4 yrs.(2000)

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• Various non-operative and operative treatment
  strategies have been tried with varying degrees
  of success.

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• Treatment often involves
• patient education,
• physical
• therapy,
• alternative medicine options,
• and
• pharmacotherapy.

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• If these fail, surgical intervention is usually
  recommended

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• Most patients can be treated
• successfully by non-operative
• means if the patient can comply
• with physical therapy,
• medications, and epidural steroids
• and most importantly, allow
• adequate time

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• Ten years after lumbar discectomy, the average
  recovery rate calculated by using Japanese
  Orthopedic As-sociation scores was 73.5 in one
  group.
• These results equal Webers findings for
  non-operative treatment.
  

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• The purpose of surgical intervention is to
  address the leg symptoms not the back pain.
  
  

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• (McCULLOCH)2001 stated that
• there are eight basic principles that the
  surgeon and the patient should understand when
  operative treatment is recommended

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• (1) LDHs are common
• (2) More than 90 have some improvement with
  non-operative treatment

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• (3) Only2 to 4 of patients with LDHs are
  surgical candidates
• (4) MRI will reveal a LDH in approximately 20
  to 30
• Of asymptomatic patients

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• (5)Surgical intervention will improve short term
  outcomes,
• but long term studies show little difference with
  those treated non-operatively .

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• (6) Surgical intervention rarely
• indicated before 6 weeks from the onset of
  symptoms but should not be delayed to beyond 3 to
  4 months
• (7) The disc will continue to degenerate with
  either form of treatment

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• (8) Scar tissue will form, creating a poorer
  prognosis in the future if repeated discectomy is
  required.
  

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• The one absolute indication is cauda equina
  syndrome.
• Most practitioners would also consider a
  progressive motor deficit as a strong indication
  for surgery

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• Most texts would agree that the relative
  indications for surgery are

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• (1) failure of an adequate trial of non-operative
  treatment

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• (2) Recurrent sciatica after a successful trial
  of non-operative treatment,
• (3)Significant motor deficit with positive nerve
  root tension signs,

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• (4) A herniation into an already stenotic spinal
  canal,
• (5) Large extruded fragments,
• (6) Intractable pain.
  

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• Minimally invasive techniques have been developed
  with a focus on minimizing the soft tissue
  dissection, creating a laminotomy without
  creating instability, safely retracting the cauda
  equina and the individual nerve root, and
  finally, excising the disc herniation
  

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• The standard of care remains an open partial
  discectomy in which the herniation is removed
  through a small annulotomy.
• The remainder of the stable disc is preserved.
  

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• Surgery provides nearly 85 to 95 of patients
  with good to excellent short term results. These
  results can, however, deteriorate with time.

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• Lower back pain is
• usually the cause for the drop in satisfaction.

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• Arthroscopic techniques
• have recently emerged as an alternative to
  microdiscectomy

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• Since (WEBERs) landmark findings ,there has been
  a trend towards non-operative treatment.

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• (POSTACHINNI)2005 summarized
• In the last two decades, we have shifted from an
  aggressive surgical approach for the treatment of
  patients with a herniated disc to an excess of
  non-operative management,

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• passing through chemonucleolysis
• and the various methods of percutaneous
  discectomy,

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• Complications

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• Any surgical procedure,
• no matter how carefully it is done,
• has risks.

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• Most can be avoided with proper patient
  selection, education, thorough preoperative
  planning, and meticulous attention to anatomy and
  surgical technique

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• More common complications include

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• wrong level
• Missed pathology
• Retained disc,

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• Durotomy, Epidural venous bleeding, lesions from
  positioning, Residual back and/or leg symptoms,

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• Iatrogenic
• instability,
• Thromboembolism,
• Epidural fibrosis,
• Arachnoiditis

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• Recurrent disc herniation,
• Cauda equina, Epidural hematoma, Infection,
• Discitis,

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• DISCUSSION

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• Operative treatment clearly is indicated in cauda
  equina and possibly for patients with progressive
  motor deficit,.

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• Otherwise, no one method of non-operative or
  operative treatment seems definitively to be
  superior on reviewing the literature.

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• Severe neurologic deficits without pain also may
  be a good reason to consider operative treatment

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• Most practitioners would agree that as long as
  the patient does not have a (progressive or
  significant neurologic deficit, cauda equina, or
  severe intractable pain), a minimum of 6 to 8
  weeks should be reserved for non-operative
  treatment.

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• Nonoperative treatment methods should not extend
  beyond 4 to 6 months if the patient shows only
  minimal improvement

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Thank You