What Is It?
When the disc wall becomes disrupted either from injury or as a consequence of ageing, disc material can escape from its usual space between the vertebrae and enter the spinal canal. If a large amount of disc is herniated into the spinal canal, it can pinch nerve roots and cause buttock and leg pain. The disc material can also cause inflammation of adjacent nerve roots. Typically, the pain (sciatica) radiates through the buttocks, back of the leg, and down to the ankle or foot. Numbness, tingling, and weakness may be present depending on the severity of the nerve compression. Back pain may or may not be present.
Ninety percent of patients with sciatica from a disc herniation improve on their own without surgery. Treatment initially consists of 2-3 days of bed rest, anti-inflammatory medication (aspirin, Aleve, or Advil), followed by increasing activity levels as tolerated. Sciatica treatments that have not been shown to provide improved relief over no treatment at all include passive spinal manipulation (chiropractic), Vax-D, traction, and physical therapy. None of these methods can take the pressure off the pinched nerve. In smaller disc herniations, epidural steroid injections may be helpful.
Surgery for Lumbar Disc Herniation
For the 10% of people who still have sciatica after at least 6 weeks of conservative treatment, surgery becomes an option. The only time surgery becomes a true emergency is when genital numbness starts and bowel and bladder control is lost. If there is a worsening of leg numbness or weakness, surgery may be indicated sooner than 6 weeks. If there is significant ankle weakness, surgery sooner than 6 weeks is also necessary since delaying nerve decompression has been shown to have a less favorable outcome. Other than these reasons, the purpose of surgery is to relieve buttock and leg symptoms and is therefore usually elective as to its timing. When the patient decides the pain is bad enough, surgery is scheduled.
BENEFITS: The success rate in obtaining relief of radiating leg pain with surgery is about 95%. That leaves 5% who still have leg pain after surgery for unknown reasons. Relief of the back pain is less reliable. Disc surgery should not be done with the expectation of improved back pain, though it does often occur.
RISK OF SURGERY: There is a 5% chance that over the 20 years after lumbar diskectomy, the same disc will re-herniate causing recurrence of the same leg pain. One long-term study has suggested that between 5-15% of patients may require future surgery at the level of the herniation for future problems, including fusion to treat back pain. There is a 1% chance of infection. A small number (<2%) will develop new numbness, tingling, or weakness which was not there before surgery. Most of these patients improve on their own within a matter of weeks to months. Other risks are less than 1%. It is extraordinarily rare to require blood transfusions after surgery.
The skin incision in most cases is 1-2 inches long. The muscles of the back on the side of the herniation are retracted to expose the spine. The compressed nerve is gently retracted off the herniated disc and the offending disc fragment is removed. Any other loose fragments within the disc space are also removed. No attempt is made to remove all of the disc material, as this would cause the spine to be unstable and painful. The incision is then closed with dissolvable sutures beneath the skin. No staples or stitches need to be removed. Patients enter the hospital on the morning of surgery and go home the same day or the following morning, depending on how they feel. They are free to get up the afternoon or evening of surgery to use the bathroom. The day after surgery, a regular diet is resumed, activity levels are increased, and pain pills control the pain.
THE INCISION: The dressing on the incision should be changed daily for 5 days using a small bandage. After that, no dressing is required. The incision should remain dry without any drainage, redness, or other signs of infection.
SHOWERS: You can resume regular showers/baths and get the incision wet after 3 days from surgery. The skin healing has sealed the incision by then. Take the bandage off before showering but leave the steri-strips on. The steri-strip tapes will fall off the incision on their own. If they are still attached at 4 weeks, they may be removed.
Initially, standing and laying flat are the most comfortable. You can sit as much as you want so long as you don't mind the discomfort. Sitting becomes less painful after a few weeks. Walking is encouraged. At week 3-4 physical therapy will be started for abdominal and back strengthening and conditioning.
WORK: By week 6, most patients are ready to return to unrestricted work. For those who have less physically demanding jobs, part-time work can be resumed at week 1-3 and advanced to full-time as soon as symptoms allow. Back pain from the incision improves by week 3 or 4 and is nearly gone by week 6. Before 12 weeks, there should be no lifting more than 30 pounds and limited bending and stooping. After 3 months, there are no restrictions.
DRIVING: Driving can be resumed as soon as you feel safe. Take a test-drive in an empty parking lot first to be sure your reaction time from the accelerator to the brake is quick enough to make an emergency stop. Short trips (5-10 minutes) are recommended at first to assess your comfort level.
SEX: The incision should be completely healed before regular intimacy is resumed. Pressure on the early incision will be painful. Being a passive partner in a comfortable position can be safely tolerated after week 4. After 6 weeks, there are no restrictions.
Long Term Results
LEG PAIN: Most people have excellent and lasting relief of leg pain. Occasionally, there may be episodes of mild recurrence of pain, which is associated with increased activity and from scar formation in the surgical site. If this occurs, it is usually at a low level and is managed by stretching exercises and anti-inflammatory pain medication. Significant and sudden increase in leg pain can signify a recurrence of the herniation.
BACK PAIN: This may develop as a result of the disc injury and subsequent surgery. Treatment starts with trunk-strengthening exercises, which can be initiated in physical therapy and continued daily at home. Rarely does anything beyond therapy need to be done. Severe or new back pain a few days to several weeks after surgery can signify a disc space infection and should be reported to your doctor.