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Herniated disc

A herniated intervertebral disc causes pain in the lower back or neck that may radiate to the leg or arm (sciatica, radiculopathy). When surgery is needed, microdiscectomy is performed as a day case, without a hospital stay.

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Microdiscectomy
No hospital stay
Minimally invasive

A herniated intervertebral disc is the most common spinal condition up to the age of 60. Professor Salmas and his surgical team, which includes a specialist neurosurgeon, achieve excellent results in the surgical treatment of herniated discs. Of 500 patients operated on over the last 10 years, only 5 needed a second operation, which led to full recovery, while 495 were fully treated with the first operation (99%). There were no neurological complications in any patient. The method used was microscope-assisted microdiscectomy without bone removal. Patients left hospital in excellent condition 2 to 5 hours after the operation, with no pain at all. The key advantage of our surgical team is a zero complication rate, which we guarantee.

General information

The intervertebral discs play an important role in the spine, acting as shock absorbers between the vertebrae, supporting the weight of the body and allowing a wide range of movement in all directions.

The intervertebral disc consists of a central, avascular nucleus pulposus – a thick gel made of proteins, polysaccharides, a few cartilage cells and a large amount of water (88%) – surrounded by concentric layers of fibrous tissue and collagen, the annulus fibrosus. When the physicochemical condition of the nucleus pulposus is normal (usually at a young age), the disc can withstand heavy loads without any particular problems.

Over time, the nucleus pulposus and the annulus fibrosus lose many of their properties, and for this reason even small forces and loads can tear the annulus fibrosus and allow the nucleus pulposus to escape or leak out. Depending on where the escaped material ends up, the pressure can cause pain in the lower back (lumbar region) and possibly pain and neurological symptoms in the legs.

The symptoms of a herniated intervertebral disc usually start without any particular injury, for example when lifting a small weight or suddenly twisting the lower back. It is a very common musculoskeletal condition, found most often in the lumbar spine between the ages of 35 and 50, an age at which the disc has already undergone significant degenerative changes; by contrast, spinal stenosis is most common over the age of 60.

Degeneration and herniation of the intervertebral disc

Through the natural process of ageing and wear, the discs lose much of their fluid, which under normal conditions gives them elasticity and strength. As a result, the discs become stiffer and flatter. This process, known as degeneration, begins at a young age and often appears early on imaging tests (X-rays, CT and MRI scans).

When repeated axial pressure is applied to the spine, the disc, and in particular the annulus fibrosus, may tear or crack. In the lumbar spine, the bulging disc can compress the nearest spinal nerve root. In addition, the escaping nucleus pulposus material can in turn irritate the nerve and cause local inflammation. The result is a sharp pain that radiates from the lower back to the buttocks and legs. Finally, it is important to note that degenerative change in the disc (discitis) is not necessarily a progressive condition per se and does not always lead to a herniated intervertebral disc.

Many terms are used to describe the various disorders of the intervertebral disc and the pain that accompanies them, such as “disc herniation” and “herniated disc”, which are used interchangeably.

Unfortunately, health professionals do not agree on the exact definition of these clinical conditions or on these terms, while patients are confused when they hear different terms for the same problem.

Rather than worrying about the exact terms describing their problem, it is more useful for patients to gain a clear picture of their precise medical diagnosis. The medical diagnosis identifies the real cause of the patient's pain in the lower back and legs.

To reach a diagnosis, the orthopaedic surgeon follows three specific steps

Taking a personal medical history
A full physical examination
One or more diagnostic tests (if needed).

Symptoms of a herniated intervertebral disc

Although a herniated disc in the lumbar spine can be extremely painful, for most patients the symptoms do not last. About 90% of people who experience the symptoms of a lumbar disc herniation recover within six weeks at the latest, even without medical treatment.

The symptoms are thought to subside mainly for three reasons

The body's defences attack the herniated material as foreign, causing it to shrink and thus gradually decompressing the compressed nerve root.
Over time, the nucleus pulposus dehydrates as part of ageing, reducing its overall volume. This makes it less likely to bulge out and press on a nerve or the spinal cord.
Back extension exercises may move the herniated disc material away from the nerve roots, or even back inside the annulus fibrosus. However, this theory is a matter of debate in the medical community.

It is generally believed that symptoms improve because the smaller size of the herniated material reduces the chance of irritating the nerve, while much of it is also reabsorbed. Although a herniated intervertebral disc needs attention when it becomes painful for the patient, it has been found that a herniation seen on imaging is often not accompanied by pain or other symptoms.

However, when a herniated disc causes neurological symptoms, it is highly urgent and needs assessment by an orthopaedic surgeon or neurosurgeon, because it may require immediate surgery; otherwise permanent neurological damage may remain that cannot be corrected afterwards, although it could easily have been prevented.

This is the main reason why a herniated disc requires prompt diagnosis and assessment.

So if you have lower back pain radiating to the leg, you should visit a specialist centre such as our practice without delay.

Common symptoms

As mentioned, a herniated disc often compresses a nearby nerve, causing pain that radiates along the whole course of the nerve (that is, the area supplied by that particular nerve). A herniated lumbar intervertebral disc is the most common cause of sciatica, that is, pain and reduced sensation in the back of the leg. Some of the most common features are:

Leg pain: The pain in the leg is usually more intense than in the lower back. If the pain involves the sciatic nerve, it is called sciatica.
Neurological symptoms in the leg: Reduced sensation, numbness and weakness are some of the symptoms the patient may report.
Symptoms that vary in location: Depending on the size of the herniation and its location in the spinal canal, symptoms may affect the lower back (lumbar region), the buttocks, the front or back of the thigh, the foot or the toes, and they typically affect only one side of the body.
Inability to lift the front of the foot (Foot drop): Sometimes a large herniation can press on the nerve to such an extent that it causes weakness or paralysis of specific muscles (tibialis anterior) that lift the foot upwards; this is a worrying symptom in itself.
Lower back pain (Low back pain): Pain in the lower back (lumbar region) is present in most cases, but not always, and is accompanied by stiffness. It subsides after a few days of rest (bed rest).
Pain that worsens with movement and certain positions: The pain may get worse after standing or walking for long periods, sneezing or even laughing hard.

Two main causes of pain: nerve compression (radiculopathy) and discogenic pain

When identifying the cause of pain in the lower back that involves the intervertebral disc, two terms are used:

Radiculopathy (radicular pain from nerve compression)

When a patient has a symptomatic herniated intervertebral disc, the disc itself is not painful.

Instead, the material (nucleus pulposus) that protrudes or leaks from inside the disc presses on and irritates the nearest nerve root leaving the spinal cord. This produces a pain called radicular pain, which, beyond the lower back (low back pain), also radiates to other parts of the body, particularly the legs. When it involves the nerve roots that make up the sciatic nerve, it is called sciatica.

Discogenic pain

When a patient has marked degeneration of the intervertebral disc without a disc herniation, the pain is localised to that area and is due solely to disc degeneration, without radiating to the legs (axial pain).

Any of the above symptoms can affect the cervical, thoracic or lumbar spine. However, in most cases they occur in the lumbar region (the “lower back”), since it bears most of the loads placed on the spine every day.

It should be borne in mind that the terms “herniated disc” and “degenerated disc” refer to imaging findings on X-rays, CT or MRI scans, which, although very important, are not enough to identify the exact cause of the pain. Rather, the clinical picture and the physical examination of the patient by the orthopaedic surgeon will confirm or rule out any suspicion and lead to an accurate diagnosis.

Rare but dangerous symptoms – cauda equina syndrome

Loss of bladder control (urinary incontinence) or bowel control (faecal incontinence), together with numbness over the back of both thighs (in a saddle distribution) and weakness in the legs, is called cauda equina syndrome. It is a serious and urgent condition caused by a large herniation pressing on the nerve roots that leave below the conus medullaris (the cauda equina). The patient must be treated surgically within 48 hours in an effort to reverse the neurological damage.

Diagnosis

The clinical diagnosis follows a specific sequence, which includes:

The medical history
The physical examination
Imaging tests

Medical history

Patients who see the orthopaedic surgeon with the symptoms described above should be asked about:

The type of pain. The patient is asked to describe the characteristics of the pain, including where it is and which activities bring it on.
Other health problems, such as osteoporosis
Information about the patient's work and daily life.
Family history.

Finally, any history of anxiety disorder or depression should be discussed with the treating doctor.

Clinical examination

This is the most important step in the diagnosis and includes inspecting and observing the patient's movements, as well as palpation combined with certain special tests. More specifically:

Neurological examination: To determine whether there is a specific neurological deficit, the orthopaedic surgeon examines the legs for signs of reduced sensation, numbness or weakness. The patient is usually asked to walk on tiptoe and on the heels, and finally the reflexes of both legs are checked.
Range of motion: The patient is asked to bend forwards and backwards as far as the pain allows.
Lasègue test: With the patient lying on their back and the knees straight, the orthopaedic surgeon raises each leg, which provokes pain in the lower back (lumbar spine), usually between 30° and 70°.
A full neurovascular check of both legs.
Palpation of the lower back.
Observation of the patient's gait.

If none of the symptoms mentioned above is found and the pain is tolerable for the patient, further imaging is often not needed and a follow-up visit is scheduled.

Imaging

Imaging is carried out both to rule out some of the rarer causes of lower back pain, such as fractures, tumours and infections, and to better describe and confirm the findings of the preceding clinical examination.

X-rays: To rule out a possible fracture (e.g. in patients with osteoporosis or a history of trauma), tumour or infection.
MRI scan: Usually gives the most detailed information on whether a herniated disc is present, its location and size, and the compression it causes. It is often performed for pre-operative planning. It helps to rule out spinal stenosis.
CT scan: In cases where MRI is contraindicated.
Myelogram or myelography (CT): A contrast agent is used to show the spinal cord and spinal nerves. It can give detailed information about the herniation, but it is an invasive test.
Electromyogram (EMG): Can identify which nerve root is affected.

Non-surgical treatment

In most cases of lumbar disc herniation, symptoms subside within six weeks, and for this reason conservative (non-surgical) treatment is recommended at first, except in cases where the symptoms include serious neurological problems.

Relieving and controlling pain

Controlling severe pain is an urgent need when the first symptoms appear. The initial options include:

Medication: Non-steroidal anti-inflammatory drugs (NSAIDs) are a class of medicines that bring considerable relief to the patient. In addition, some muscle relaxants can reduce muscle spasm in the lower back.

Hot and cold packs: These help relieve painful muscle spasms after the first 48 hours.

Bed rest: Resting in bed can relieve the patient but is recommended only for the first few days, as staying in bed longer can lead to further stiffness. After the first few days, patients are advised to avoid heavy manual work and to take rest breaks during activities.

Additional treatments

Physiotherapy: Important for showing the patient specific spinal extension exercises during the rehabilitation phase. In addition, the programme can teach patients safer ways to carry out their usual daily activities.

Epidural steroid injection: This can provide long-lasting relief of symptoms. However, it often does not solve the problem, and symptoms return.

Finally, acupuncture (now an official indication of the US Food and Drug Administration) and chiropractic are also mentioned; they can be useful to the patient, but following specific indications and for a limited number of patients. It is in the patient's interest to consult an orthopaedic surgeon first for the diagnosis and to rule out neurological deficits, as well as for treatment, which may include the established conservative and surgical methods.

Surgical treatment

When the pain and other symptoms persist and do not subside after a period of six weeks, surgical treatment is recommended. Lumbar disc herniation is the most common reason for spinal surgery in adults.

Surgery may be recommended if:

The patient has severe pain that prevents them from maintaining a normal level of daily activity, such as standing and walking.
The patient experiences progressively worsening neurological symptoms, such as weakness and/or numbness in the legs.
There is loss of bladder or bowel control (these last two symptoms are an indication for emergency surgery within 48 hours, not a six-week wait).
The patient does not benefit from conservative treatment (NSAIDs, physiotherapy)

In some cases (as mentioned) surgery may be recommended even before the six weeks have passed.

Lumbar microdiscectomy

In lumbar microdiscectomy, a small part of the bone over the nerve root is removed together with much of the herniated disc material that is pressing on and irritating it, giving the nerve more space. Through a small incision, a window about three to four centimetres in diameter is opened in the spine, and through this space anything that may be compressing the nerve root is removed.

More specifically

A small incision of about 3–4 centimetres is made in the midline of the spine at the level of the herniated disc in the lumbar spine.
The back muscles (erector spinae) are lifted and moved away from the lamina of the vertebra. Since these muscles run vertically, it is preferable to move them rather than cut them.
The surgeon enters the spinal canal by removing a small piece of the ligamentum flavum and, with the help of a surgical microscope, can remove all the tissue (osteophytes, herniated disc material) around the affected nerve root.
A small piece of the facet joint is often removed to make access to the nerve root easier and to increase the space around the nerve.
The nerve root is then gently moved aside and the herniated disc material that protrudes and presses on it is removed.

Since most of the joints, ligaments and muscles are left intact, microdiscectomy does not change the mechanical structure of the lumbar spine.

In general, improvement in the patient's symptoms caused by a herniated intervertebral disc becomes apparent within the first 2 to 3 hours. As long as the pain is tolerable and the patient can function adequately, it is usually better to delay surgery for a short time to see whether the symptoms subside with conservative treatment.

If the pain and other symptoms in the leg do not ease with conservative treatment, the minimally invasive microdiscectomy described above is indicated.

Immediate emergency surgery is necessary in cases of cauda equina syndrome or progressively worsening neurological deficits. Finally, severe leg pain can also be an indication for surgery.

https://www.uscspine.com/treatement-options/back-treatment/microdiscectomy/

Success rates

The success rate of minimally invasive microdiscectomy is about 99% in our operations.

Microdiscectomy for herniated intervertebral disc – herniated disc – radiculopathy

General information

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Frequently asked questions

Herniated disc: frequently asked questions

Didn’t find the answer you were looking for? Call us on 210 7793103.

Does a herniated disc always need surgery?

No. Most patients improve within a few weeks with conservative treatment. Surgery is needed when the pain persists or there is weakness or altered sensation.

When is a herniated disc an emergency?

When there are problems with passing urine or opening the bowels, numbness around the perineum, or progressive weakness in the legs. Immediate medical assessment is then needed.

How long do I stay in hospital after microdiscectomy?

Microdiscectomy is usually done as a day case, without a hospital stay, or with a one-day stay. Most patients walk on the same day.