WHAT IS HERNIATED DISC?

Our spine is formed with bones called vertebrae connecting to each other. These bones are linked with a “disc” and two “facet joints”. Discs have important roles such as spine movements, spine flexibility, distribution of the load regularly on the vertebrae and spine and shock absorption and distribution as well as connecting the vertebrae. The main aim of all these structures is to protect biomechanics of the spine and the spine passing through spine channel. Discs consist of two layers. Exterior parts have a rigid and thick structure. This part is called “annulus fibrosus”. The inner part has soft and water-based cartilage (similar to jelly) structure and is called “nucleus pulposus”. The exterior layer surrounds this part as a capsule. Structure of exterior rigid layer deforms due to various reasons. As a result, exterior layer ruptures and the soft part (nucleus pulposus) protrudes and may compress the spine and/or nerve roots spreading to the body from the spine. Sometimes, the exterior rigid layer does not rupture by loses its rigid structure. In this case, the inner soft layer pushes the exterior layer and compresses the spine and/or nerve roots. These two conditions are called “herniated disc”. “Protruded herniated disc” known by the public is the type that occurs with the rupture of exterior part. However, in that case, the important part is the compression exposed by the spine and both types can be called “herniated disc”.

WHAT ARE THE RISK FACTORS OF HERNIATED DISC?

80% of the adults complain of pain in the back at least once throughout their lives. Even though the herniated disc is seen mostly between the ages of 30-60, it may occur at any age. Rather than the group in which herniated disc is seen, risk factors that may lead herniated disc should be discussed. Most known risk factors are as follows; Obesity; Excessive weight is the most observed reason for the herniated disc. Our weight is carried out by our spine. When the discs that provide the flexibility of the spine and act as support pillow are exposed to excess compression, their structures and shapes deform. With the weight gain, as the load on the spine, accordingly discs, increases, the risk of herniated disc increases. During pregnancy, as the center of gravity of the body moves towards the front, it may lead additional load on the spine. Inactivity: Our weight is not carried out just by our spine. Functions of all neck, back, waist and abdominal muscles throughout the spine are also very important. In the case of inactive life and lack of regular exercise, as the muscles are not strong enough, the load which should be carried out by the muscles is carried out by the spine. This condition increases the risk of herniated disc. Smoking: Smoking is reported to cause deformation in the discs as in all body tissues and slows down the healing in many publications. Not moving according to spine physiology during daily life: During our daily life, we should move according to spine physiology in many movements such as lifting the load, pushing, pulling objects. While lifting the load, first one should bend the knees and then lift the load. While lifting a load above the shoulders (hanging out the laundries, placing the wardrobe), one should be careful and should use a ladder or chair while doing these jobs. During daily work, especially in office works, one should sit straight and the chair should support the waist cavity. In case that the chair is not suitable, an additional pillow can be used to support the waist cavity. While getting up, one should avoid loading on the waist. First of all, the person should turn aside, droops the feet and receive support from the elbows. Factors related to the profession: Professions requiring heavy physical activity and carrying heavy load, professions requiring bending forward, turning while bending forward, professions which expose the body to vibration such as driving car, bus, truck, professions requiring standing and sitting for a long time, football, weight lifting, rowing and rassling increase the low back pain and herniated disc. Genetics: Even though the genetic reason for cervical disc herniation and herniated disc is not proven, those who have this disease in their families are at more risk. In addition, a herniated disc may be seen in those who do not have the above-mentioned factors.

IS EVERY LOW BACK PAIN IS A HERNIATED DISC? WHAT ARE THE SYMPTOMS OF HERNIATED DISC?

Most of the people having low back pain firstly suspect of the herniated disc. However, only 2-3% of low back pain cases have symptoms of herniated disc requiring operation. There are many reasons for low back pain rather than herniated disc. The most common type is called “mechanic low back pain” which may cause damage to muscle, ligaments, and joints of the waist or caused by wrong work of these structures. Also, there are many diseases that may cause low back pain. A herniated disc is just one of them. The herniated disc has specific symptoms. As the nerves to the legs are compressed, its symptoms include pain radiating to one leg or two legs, numbness in the feet, motion restriction, difficulty in walking and sitting. When a herniated disc is severe, additional symptoms such as myolysis or unrecoverable weakness, impotence, getting tired quickly, urinary incontinence, inability in walking may occur. While a reason for low back pain may be a simple muscle spasm, it may have a more significant reason. Even though the most common reason for low back pain is mechanic low back pain and it can be treated with non-surgical methods, if you have low back pain complaints for at least 3 months, you should be examined by a physician.

HOW IS HERNIATED DISC DIAGNOSED

The most reliable diagnosis of the herniated disc is made with an examination carried out by a physician. In that case, complaints of the patient and examination findings are the most important diagnostic criteria. The examinations for final diagnosis are MRI (the most common one) 7 computed tomography, x-ray and EMG (electromyography). If the physician gets suspect of herniated disc due to patient’s complaints and examination findings, s/he may request these examinations, if s/he thinks that findings do not require surgical intervention, s/he may not request examination, s/he may follow the process or may direct the patient to another branch. Each low back pain case or herniated disc suspect does not require advanced examination.

HOW ARE THE HERNIATED DISC CASES NAMED? ARE THERE VARIOUS TYPES?

Discs and accordingly herniated discs are named according to their vertebrae. There are 5 lumbar vertebrae in our body. These are named as L1, L2, L3, L4, L5 from the top the bottom (L=Lumbar). Lumbar vertebrae are followed by “sacral vertebrae”. Undermost lumbar vertebra (L5) is followed by sacral vertebra (S1). Discs are named according to the vertebrae between which they locate (for example L4-5 disc). Herniated disc cases are named according to the disc in which they occur (e.g. L4-5 herniated disc or L4-5 disc herniation). Also, they can be named according to the herniation location. If the disc is herniated in the part marked with red circle and compresses the spine, it is called “midline disc herniation”, if the disc is herniated in the part marked with yellow circle and compresses the nerve root, it is called “foraminal disc herniation”, if the disc is herniated in the part marked with blue circle (out of foramen) and compresses the nerve root, it is called “extraforaminal disc herniation”. The location of the herniation is important as it may change the complaints of the patient and the operation.

WHAT ARE NON-SURGICAL TREATMENT METHODS FOR HERNIATED DISC?

Early Stage: Treatment of herniated disc is depending on the severity of compression of herniation on the nerves. If there is just low back and leg pain and there is not any insensibility, significant power loss, urinary incontinence, erection problem, it means that herniated disc is at the early stage. In that case, it is recommended to prescribe the patient medication which is pain killer, edema healer, and myorelaxant, bed rest and instruct the patient to avoid movements forcing the waist.

The recommendations for the patient are as follows: The patient should never lift the load of more than 2 kg. It is prohibited to bend forwards, side and to bend the waist. If the patient will take an object on the ground, the patient is instructed to squat. It is recommended to place a pillow at the back while sitting and to walk every 20 minutes. If the patient’s profession requires sitting for a long time, the patient is recommended to walk every 20 minutes. It is prohibited for the patient to slope up. If the patient takes an object above, it is recommended to step on a chair or ladder. The patient is instructed to keep the waist warm and not to wait in front of an open window or ventilation. The patient is recommended to have bed rest during the time s/he is at home. Very solid ground is harmful, on the contrary as it is known. A quality bed and a position in which the patient can feel relax are better. If the herniated disc gets severe: If the complaints last despite the above-mentioned recommendations, physical treatment can be applied. Physical treatment should be supervised by a specialist. During physical treatment, the pain may increase in the first a few days, but the patient should continue the treatment. Despite all treatment, if the pain of the patient does not stop, spinal injection treatment or “nucleoplasty” may be applied. Nucleoplasty is based on heating the disc, destroying the nerves in the disc and collapsing the herniation by opening the space in the disc with radiofrequency waves by entering with a needle to the herniated disc under x-ray in severe herniated disc cases. Nucleoplasty is carried out in one session under local anesthesia without anesthetizing the patient completely under hospital conditions and it does not require hospitalization. It has very low risk, however, it does not guarantee to treat the herniation completely and success rate is not very high. In addition, it may not be applied for every type of herniated disc. Also, corset use, traction, manual treatment, laser treatment for the skin and ozone therapy, which are not proved to be superior to rest, medication and physical treatment can be applied. In the event that these treatments are carried out in an unconscious and uncontrolled way or if the time is lost with these treatments while the patient is required to be operated immediately, unrecoverable problems may occur.

WHEN IS THE OPERATION CARRIED OUT FOR HERNIATED DISC? SHOULD THE OPERATION BE CARRIED OUT IMMEDIATELY?

If the patient still has complaints despite the above-mentioned treatment of which effect is medically proved, if this pain restricts social life of the patient, if there is significant sensation loss, power loss, myolysis, erection problem, difficulty in walking, the compression on the nerves should be removed with operation. If the patient has urinary incontinence or power loss, the operation should be immediately carried out. These findings show that compressed nerve cells are about to die (or even dead). In that case, even hours are essential for the intervention. Otherwise, the patient may remain paralyzed for life long or may use a urinary catheter as s/he may lose control of the bladder.

WHAT MAY OCCUR IF I DO NOT UNDERGO OPERATION?

Some cells in our body cannot rejuvenate themselves after they died. Nerve cells are this kind of cell. Therefore, paralyze or spine injuries may cause permanent damages. The actual problem of the herniated disc is the compression of and damage to the spine or nerves spreading from the spine to the legs or genitourinary organs. In case that the patient does not undergo the operation in time, power loss, sensation loss, urinary incontinence, burn-tingling in the legs, erection problems and difficulty in walking may be permanent. Unfortunately, there are some misbeliefs such as “if I undergo the operation, I become permanently disabled, I cannot get up for a long time, I have to use corset or my herniation reoccurs and I have to reoperated” in the public. With new operation techniques and devices, these concerns are not true anymore. In cases requiring an operation, if the patient does not undergo operation, the problems may be bigger.

HOW IS HERNIATED DISC OPERATION CARRIED OUT?

Today, there are 3 types of herniated disc operation?

Open discectomy (discectomy=removal of the disc): It is usually carried out under general anesthesia. The operation is carried out through a 4-6 cm incision made on the skin on the herniated area. The muscle tissue is separated from the bones on effected the disc. Surgical instruments called ecartor detract the muscle and skin from the surgical area and, so that, the surgeon can see the spine and disc. To have a better viewpoint, some of the bones and ligaments are removed. So, the herniated disc is reached without damaging nerve roots. The surgeon removes the disc, structures surrounding the disc and disc parts protruding from the disc wall. This method is not preferred much today.

Microdiscectomy: This procedure is usually carried out under epidural anesthesia, which is applied to anesthetize bawdiness or general anesthesia. The operation is carried out with a microscope. When compared to open discectomy, muscle tissue is separated with a smaller incision (approximately 1,5-3 cm) and viewpoint is better thanks to microscope. This allows the patient to have a more comfortable and painless post-op period. Separating less muscle tissue provides less muscle spasm and pain after the operation. The microscope used during the operation reduces complication risk by viewing the tissues larger, in 3D and in detail. Veins, nerves, and discs are seen more clearly. The risk of damage to tissues such as veins and nerves is less. Clearing the disc having a compression effect is safer. The incision is closed with an inner suture and a small dressing is applied. Today, microdiscectomy is considered as the safest and most effective method.

Endoscopic disc surgery: It is carried out by entering through midline or side in the waist area. With endoscopic intervention, the incision is smaller when compared to other methods. It is carried out by viewing the surgical site on the monitor with a 5 mm endoscope inserted through an about 1.5 cm incision into the herniated disc area. The operation is carried out under local and epidural anesthesia. To determine if the herniation can be removed in an endoscopic way, the space between vertebrae, the distance where the hernia is present, location and size of the hernia are very important factors. Therefore, endoscopy may not be a successful intervention for every type of herniation.

AFTER HERNIATED DISC SURGERY

• Depending on the surgeon’s opinion, the patient can be rise 2-3 hours after the operation, 8 hours after the operation or the next morning.
• Generally, the patient is discharged within the first 24 hours.
• After discharge, the patient can go home sitting in a vehicle.
• If possible, the patient should sit in the front seat with 110 degrees to minimize the pain risk.
• During the first 2 weeks, if you have to take ladder, you should step one by one by putting one foot next to the other.
• You can have a meal sitting.
• When you sit to have a meal, take due care to have back support, and if possible to sit on a chair.
• Also, take a due care to move as instructed during sitting and getting up.
• For the first a few days, you may complain of pain, burning feeling and stinging.
• Don’t worry in that case.
• Take a rest in bed.
• Pay attention o to have a bed suitable for waist health.
• Afterward, do not lay on chair or sofa.
• When getting up in the bed, turn aside, take a sitting position with the support of the arms and get up.
• After the operation, go for a control examination as stated.
• The physician will inform you about taking a shower.
• While discharging, unless otherwise stated, you should not continue to use medicine when your medication finishes.
• For the toilet, you should definitely use flush toilet.
• Pay attention to wear the shoes sitting.
• Do not wear high heel shoes.
• Mid-high shoes will be suitable.
• When taking an object above, step on a high place.
• While sitting, do not release yourself as if falling.
• Take the sitting position slowly and in a controlled way.
• While getting up, get support from your knees or handrest of the chair.
• After 7 days, take a walk outside (firstly short distance (20-30 min) after 30th day (45-60 min)).
• If you have an office job, you can start to work after 3 weeks – 1 month.
• Those having more heavy working conditions can get back to work after 45 days.
• For the first 45 days, do not carry any load, and after 45 days pay attention to not to carry the load more than 5 kg.
• While lifting a load, squat and hold the load close to your body.
• Do not gain weight, and if you have excess weight try to lose it.
• It will be suitable to take professional support from the dietetics department.
• After the operation, avoid bodily contact sports.
• Prefer jogging, or if possible swimming.
• Do not drive for 1 month after the operation.
• Afterward, you can drive for short distance in the city.
• If you drive, you can drive for a long distance after 45th day.
• However, take a break for 10 minutes every 1.5 hours and take a walk.
• You can have a short-distance flight after first 7 days.
• Longer flights (across the ocean) should be done after 45 days and the patient should take a walk in the aircraft every 1.5 hours.
• Those working in office jobs should use a chair with orthopedic waist support and take a walk once in an hour for 5 minutes.
• You should start instructed waist exercises after the 60th day.
• In the beginning, you may feel pain during movements.
• However, the pain will stop by time.
• The exercise brochure has been prepared by Turkish Neurosurgical Society.

DOES HERNIATED DISC REOCCUR?

A herniated disc may reoccur after the operation. In the researches, it has been revealed that this rate is 5-11%. This rate is similar in all methods used for herniated disc surgery methods. However, a common mistake should be emphasized. What is relapse or recurrence? Our patient is confused about this concept. Because concept of relapse is not explained well. As you know, while the herniated disc is defined, it is defined according to the numbers and location of lumbar vertebrae. For example, let’s say the patient has undergone an operation for the right L4-5 disc hernia. If the patient has herniation in right L4-5 disc again, it is considered as relapse. A herniation occurring in the same distance at the left (i.e. on the opposite side of the operated area) or in another distance (e.g. L3-4 disc), it is not a relapse. This means a new herniated disc case and it is not named as relapse. In herniated disc surgery, the disc is not cleaned completely regardless of the method. More clearly, in a herniated disc surgery for L4-5 herniated disc compressing L5 nerve, the right side is entered. While some surgeons remove the herniated part, some remove both the herniated part and part of the disc which can be reached. In any case, as the disc is not removed completely, there is a risk of recurrence and this risk is low. There are other conditions where it is required to remove the disc by entering from both sides, however, this is not a classical herniated disc case and the operation carried out, in that case, is very different (sometimes, it may be required to place objects such as screw, cage. As a result, a herniated disc may reoccur and require operation. However, this case does not require to avoid herniated disc surgery and to cause permanent damage to the nerves. The patient should pay attention to life after the operation and comply with the recommendations to minimize the risk.