LUMBAR DISC SURGERY

Lumbar Disc Disease Overview

 Low back pain is a very common complaint in the aging population. Fortunately, most episodes of low back pain are self-limiting and resolve within approximately six weeks, regardless of treatment.

In most cases of lower back pain, no specific imaging studies or treatment is needed. It is important to first rule out any serious causes of low back pain that need further evaluation by a doctor. "Red flags" (or clues that something more serious could be causing the low back pain) include the following warning signs:

Age younger than 20 years or older than 50 years

Major trauma

History of cancer or recent infection

Pain worse at night

Change in bowel or bladder control

Use of intravenous drugs

Progressive neurologic deficit or weakness

Along with serious conditions suggested by the above warning signs, there are many other causes of low back pain. In fact, many patients with low back pain are never formally diagnosed with a specific cause.

Lumbar disc disease refers to a collection of degenerative disorders that can lead to low back pain as people age. It is also know as lumbar spondylosis. There are three main processes that make up lumbar disc disease:

Internal disc disruption

Degenerative disc disease

Segmental instability

This article discusses lumbar disc disease, along with its clinical features, typical diagnostic steps, and treatment options.

Cause

In many cases, a herniated disk is related to the natural aging of your spine.

In children and young adults, disks have a high water content. As we get older, our disks begin to dry out and weaken. The disks begin to shrink and the spaces between the vertebrae get narrower. This normal aging process is called disk degeneration.

Risk Factors

In addition to the gradual wear and tear that comes with aging, other factors can increase the likelihood of a herniated disk. Knowing what puts you at risk for a herniated disk can help you prevent further problems.

Gender. Men between the ages of 30 and 50 are most likely to have a herniated disk.

Improper lifting. Using your back muscles to lift heavy objects, instead of your legs, can cause a herniated disk. Twisting while you lift can also make your back vulnerable. Lifting with your legs, not your back, may protect your spine.

Weight. Being overweight puts added stress on the disks in your lower back.

Repetitive activities that strain your spine. Many jobs are physically demanding. Some require constant lifting, pulling, bending, or twisting. Using safe lifting and movement techniques can help protect your back.

Frequent driving. Staying seated for long periods, plus the vibration from the car engine, can put pressure on your spine and disks.

Sedentary lifestyle. Regular exercise is important in preventing many medical conditions, including a herniated disk.

Smoking. It is believed that smoking lessens oxygen supply to the disk and causes more rapid degeneration.

Symptoms

For most people with a herniated disk, low back pain is the initial symptom. This pain may last for a few days, then improve. It is often followed by the eventual onset of leg pain, numbness, or weakness. This leg pain typically extends below the knee, and often into the foot and ankle. It is described as moving from the back or buttock down the leg into the foot.

Symptoms may be one or all of the following:

Back pain

Leg and/or foot pain (sciatica)

Numbness or a tingling sensation in the leg and/or foot

Weakness in the leg and /or foot

Loss of bladder or bowel control (extremely rare) This may indicate a more serious problem called cauda equina syndrome. This condition is caused by the spinal nerve roots being compressed. It requires immediate medical attention.

Not all patients will experience pain as a disk degenerates. It remains a great challenge for the doctor to determine whether a disk that is wearing out is the source of a patient's pain.

Nonsurgical Treatment

Unless there are neurological deficits — muscle weakness, difficulty walking — or cauda equina syndrome, conservative care is the first course of treatment. Because it is not clear that nonsurgical care is any better than letting the condition resolve on its own, the focus is on providing pain relief.

Your doctor may prescribe nonsurgical treatments including a short period of rest, anti-inflammatory medications to reduce the swelling, analgesic drugs to control the pain, physical therapy, exercise or epidural steroid injection therapy. If you are told to rest, follow your doctor's directions on how long to stay in bed. Too much bed rest may give you stiff joints and weak muscles, which will make it harder to do activities that could help reduce the pain. Ask your doctor whether you should continue to work while you are being treated.

Your doctor may start treatment and, with the help of a nurse or physical therapist, begin education and training about performing the activities of daily living without placing added stress on your lower back.

The goals of nonsurgical treatment are to reduce the irritation of the nerve and disc and to improve the physical condition of the patient to protect the spine and increase overall function. This can be accomplished in the majority of herniated disc patients with an organized care program that combines a number of treatment methods.

Some of the first treatments your doctor may prescribe include therapies such as ultrasound, electric stimulation, hot packs, cold packs and manual ("hands on") therapy to reduce your pain and muscle spasm, which will make it easier to start an exercise program. Traction may also provide limited pain relief for some patients. Occasionally, your doctor may ask you to wear a lumbar corset (soft, flexible back brace) at the start of treatment to relieve your back pain, although it doesn’t help heal the herniated disc. Manipulation may provide short-term relief from nonspecific low back pain, but should be avoided in most cases of herniated disc.

At first, the exercises you learn may be gentle stretches or posture changes to reduce the back pain or leg symptoms. When you have less pain, more vigorous exercises will likely be used to improve flexibility, strength, endurance and the ability to return to a more normal lifestyle. Exercise instruction should start right away and be modified as recovery progresses. Learning and continuing a home exercise and stretching program are important parts of treatment.

Common nonsurgical measures include:

Rehabilitation

You don't need to endure an intense cardio program or lift heavy weights—simple stretching and aerobic exercises can effectively control your herniated disc pain.

Stretching programs like yoga and Pilates improve strength and flexibility, and offer relief of acute pain in your leg and low back.

Your doctor may also prescribe dynamic lumbar stabilization exercises. This program features exercises that work the abdominal and back muscles to address posture, flexibility, and strength.

Moderate aerobic activities, including walking, biking, and swimming, also help relieve pain. Some aerobic activities might be better suited to your specific condition. Talk to your doctor about what exercises will best help you.

When beginning an aerobic exercise program, start slow—perhaps 10 minutes the first day—and gradually increase your time each day. Eventually, you should aim for 30 to 40 minutes of activity 5 days a week.

Exercise can be an enjoyable and satisfying way to treat symptoms associated with a herniated disc. You and your doctor can work together to develop a program that you can stick with and will reduce your pain. Ultimately, exercise will help you feel better, and it should help relieve your pain from a herniated disc.

Physical therapy. Specific exercises can strengthen your lower back and abdominal muscles.

Physical therapy often plays a major role in herniated disc recovery. Its methods not only offer immediate pain relief, but they also teach you how to condition your body to prevent further injury.

There are a variety of physical therapy techniques. Passive treatments relax your body and include deep tissue massage, hot and cold therapy, electrical stimulation (eg, TENS), and hydrotherapy.

Your physical therapy program will usually begin with passive treatments. But once your body heals, you will start active treatments that strengthen your body and prevent further pain. Your physical therapist will work with you to develop a plan that best suits you.

Rest. Usually 1-2 days of bed rest will calm severe back pain. Do not stay off your feet for longer, though. Take rest breaks throughout the day, but avoid sitting for long periods of time. Make all your movements slow and controlled. Change your daily activities so that you avoid movements that can cause further pain, especially bending forward and lifting.

Epidural steroid injection. In this procedure, steroids are injected into your back to reduce local inflammation.

Of the above measures, only epidural injections have been proven effective at reducing symptoms. There is good evidence that epidural injections can be successful in 42-56% of patients who have not been helped by 6 weeks or more of other nonsurgical care.

Overall, the most effective nonsurgical care for lumbar herniated disk includes observation and an epidural steroid injection for short-term pain relief.

Medication and pain management

Anti-inflammatory medications. Medicines like ibuprofen or naproxen may relieve pain.
Medications used to control pain are called analgesics. Most pain can be treated with nonprescription medications such as aspirin, ibuprofen, naproxen or acetaminophen. If you have severe persistent pain, your doctor might prescribe narcotics for a short time. Sometimes, but not often, a doctor will prescribe muscle relaxants. However, you want to take only the medication you need because taking more doesn't help you recover faster, might cause unwanted side effects (such as constipation and drowsiness) and can result in dependency. All medication should be taken only as directed. Make sure you tell your doctor about any kind of medication you are taking, even over-the-counter drugs and supplements, and if he/she prescribes pain medication, let him/her know how it is working for you.

Nonsteroidal anti-inflammatory medications (NSAIDs) are analgesics and are also used to reduce swelling and inflammation that occur as a result of disc herniation. These include asprin, ibuprofen, naproxen and a variety of prescription drugs. If your doctor gives you anti-inflammatory medications, you should watch for side effects like stomach upset or bleeding. Chronic use of prescription or over-the-counter NSAIDs should be monitored by your physician for the development of any potential problems.

Other medications are available that also have an anti-inflammatory effect. Corticosteroid medications --- either orally or by injection --- are sometimes prescribed for more severe back and leg pain because of their very powerful anti-inflammatory effect. Corticosteroids, like NSAIDs, can have side