As an orthopedist, Dr. Carlson stays actively involved in continuing medical education by teaching spine surgery techniques around the world. Dr. Carlson recently served as the Chief of Surgery at Mary Immaculate Hospital in Newport News, VA. He has received many awards, including being named one of America’s Top Orthopaedic... more
Lumbar disc herniations can be found in 40% of asymptomatic patients, and in the neck, almost 30% of asymptomatic patients will have a disc herniation on their MRI. These seem like astounding numbers, as most people think that all disc herniations cause severe pain or nerve dysfunction and will need surgery.
As we age, our discs will lose their ability to flex and move, which causes them to be more likely to rupture rather than bend. So, patients over 40 years old will be more likely to have a disc herniation. It is fortunate that there is some extra room in the spinal canal to allow the nerves to move away from a ruptured disc. In the cervical spine there is far less room, as the spinal cord fills most of the spinal canal. The spinal cord is the bundle of nerves as they travel from the brain to the rest of the body. In the lumbar spine, the formal spinal cord ends and the spinal nerves fan out and have much more room. In the lumbar spine, the nerves can be moved by a disc herniation without compromising their ability to function. There are some critical areas where the nerves are more easily compressed than others, and these areas are more likely to give pain when they are compressed by a disc herniation.
There is also quite a bit of evidence relating the natural process of healing in disc herniations. Almost 73% of patients in one British study showed significant improvement in the first 12 weeks after being diagnosed with sciatica presumably from a disc herniation. Anti-inflammatories, steroid injections and exercise will help to move the nerve away from the disc and decrease the irritation of the covering on the nerve. This decreases the initial pain and allows the body to heal. Maintaining an exercise program can keep the bones in line and prevent the nerve from being compressed and may provide a long-term improvement in the patient’s symptoms.
There are, however, patients that either do not respond to medication and physical therapy or have a significant neurologic problem that leads to a need for surgery. Patients that are unable to participate in a structured therapy program due to pain that cannot be managed with medications should consider an operative treatment to prevent the complications of being sedentary, including blood clots and pneumonia. Patients with a worsening neurologic deficit should also consider surgery. If a patient has significant weakness in an arm or leg related to the nerve being compressed in the neck or lower back, the quickest way to return to normal function is surgical. Removing the pressure off of the nerve root by removing the ruptured disc material will allow the patient to be more active and give the nerve root the best chance of recovery. Patients always ask about permanent damage to the nerve root and whether waiting for surgery increases that chance. The simple answer is that as long as there is compression on the nerve root and the symptoms persist, the more likely there is to be long-term injury to the nerve. Our bodies have a biological ability to heal injury, so there is no absolute answer to the question, but suffice it to say, a healthy nerve root is not compressed and not painful.
There has been a recent study published in Spine January 2012, showing that even in the surgical group there are patients that will be the best candidates for an operation. These researchers looked at patients with disc herniations in a 4-year time period and randomized them to a surgical or non-surgical treatment protocol. Although the surgical group did better than the non-surgical group in general, those patients that were married, those without other problems in their hips and joints, and those patients with worse symptoms seemed to benefit the most from surgery. It does make some sense that having support at home to recover from surgery is essential to a quality outcome, so having a spouse around can be quite helpful. Patients with other joint problems may not be able to improve as much due to the other medical issues complicating their recovery and those patients with the worse symptoms are always the happiest to have those symptoms relieved. The best recovery will occur in those patients that are fully invested in getting better, that will listen to their surgeon, and that will allow their bodies to recover fully.
Not all disc herniations will need surgery. Surgeons need to involve the patient in the decision-making process. The proper patient and proper diagnosis will improve the outcome for the patient after surgery. This selection process begins with the patient’s selection of a fellowship-trained spine surgeon who has the knowledge and expertise to determine which discs and which patients will do best with surgical and non-surgical treatments. The patients’ physical examination and the interpretation of imaging studies helps surgeons determine the proper need for surgery. Imaging studies are just pictures of the body and do not show a patient’s pain. Interpreting these images creates a pattern of expected pain that can then be correlated to the patient’s current symptoms.
Patients need to be able to express their expectations to their surgeons and make sure that the proposed surgery is able to get them to their goals. Surgeons need to be up front with patients in their expectations for a successful surgery. We all want to feel good and pain elimination is the ultimate goal for any spinal surgery. Fitness levels need to be discussed with patients and providers. Lots of patients express a desire to return to the activities that were doing 20-30 years ago. There may be multiple issues that need to be addressed with the patients’ health that may not include the disc herniation. Patients that are now overweight, out of shape, have no time to pursue athletic activities, and are now on medications for heart issues may desire their “pre-children” bodies but really have a long process to work through to get there.