Herniation and disk bulges are common in people. Not everybody that has a disk bulge has a nerve that is being pinched by it and not everybody that has a disk bulge or herniation needs surgery for it.
The disk has two different pieces to it; the outer thick, tough layer is called the annulus fibrosus and the soft, well-hydrated core layer is called the nucleus pulposus. This core layer is built to accept loads and compressibility.
If the outer layer, due to trauma, stress or maybe just aging, gets a tiny weak spot, then the inner core, when pressurized, will shoot out and that is when it starts to wreak havoc. It will find a nerve and compress it against another bone structure. Although that nerve may be fine for a time and may just start causing pain in the back, it eventually is going to cause pain if compressed for long enough and it may even cause weakness and numbness.
After looking over the MRI and concluding there is a disk herniation that is consistent with the symptoms that the patient is having, I would review all the non-surgical treatments first. I then present the patient with surgical therapies in case the patient’s condition does need surgery, empowering the patient with options and knowledge about how I would approach the procedure.
One of the most common reasons a patient will end up in our office is because they are having an acute onset of really sharp or even electrical type of leg pain. Other symptoms include not being able to sleep, having a hard time walking, and not remembering any inciting events.
Sometimes, patients wake up in the morning with a little pain in the low back, thinking that it is just a little crick in the muscles, so they do some stretching. Then over the course of the next couple of days they'll start to have a new and unusual type of pain shooting down the legs, down the buttocks and all the way down to the foot and into the toes. Additionally, they may feel some numbness as well. These are some of the classic signs of a lumbar disk herniation.
This doesn't mean patients need a neurosurgeon or need surgery, but these symptoms are very daunting and can put people in a tremendous amount of pain. This is a new kind of pain; not just back muscle spasm pain, but something that they want to get rid of as soon as possible because they can't imagine living with that kind of pain even one day longer.
The first step in diagnosing a patient with lumbar disk herniation or the above symptoms that would suggest a herniation, is to do a physical exam where the neurosurgeon would check a patient’s reflexes and strengths. Sometimes, patients may have a little weakness in their foot when standing on their tiptoes or lifting their foot or toe up and they may not even pay attention to the strength in their foot because all they can focus on is the pain.
At the in-clinic evaluation, the neurosurgeon will compare the weaker leg to the good leg and may even notice a foot drop. There are different grades of foot drops; some of them may be minimal. These are commonly associated with a disk herniation. A patient may not be a surgical candidate because the foot is a little weak or a little numb.
So how does a herniated disk usually show up? After speaking with thousands of patients that have had disk herniations, this is typically what happens: sometimes there is an event that occurs, like jumping down a couple of feet off of something and not using your legs to recoil, or it could be carrying something heavy or lifting a pipe or even shoveling snow or stepping off of a curb.
There are some things you can do to avoid it. Before you began having the symptoms that you're having, which are likely low back pain and possibly leg and foot pain, think back to what you did previously. Was there an event in which you stressed your low back? Was there an activity that would put some sort of compressive load? Or maybe you were bending at the hip without bending the knees? That is a setup for putting a significant amount of pressure and stress on your disk in the annulus, which is the outer layer of the disk. When you bend over and your pelvis stays flat and your spine is bending, you are putting a tremendous amount of pressure on your disk annulus where it is exposed and has the potential to tear and therefore put you at risk for a herniation.
After one of these events, you will typically feel something a little sharp and some painful tightness in the muscles. Many people go to sleep and then wake up the next day and their backs will still be hurting. As a result, they will do some stretching and maybe get a massage, take some ibuprofen and then during the course of a couple of days, that pain will migrate down into one of their legs. We call this sciatic pain and this is a sign that there's a nerve now that is irritated.
How does a nerve get irritated? Nerves are very delicate structures that don’t like to be touched or pinched and so when a nerve is compressed by some bone or fracture or disk herniation, it most commonly starts to get ticked off and it starts shooting electric-like pain down the leg. This can be constant, it can be throbbing most of the time and there can be some numbness associated with it. A typical L4/L5 disk herniation will affect the L5 nerve and that will typically go down to the lateral aspect of the calf. It also makes its way down to the toes, especially the big toe. If it's an S1 L5 S1 disk herniation, it might go down the buttock, down the back of the thigh, to the back of the calf and then down into the lateral aspect, even to the plantar bottom of the foot in some cases. Everyone's body is a little bit different but if you notice back pain starting and a migration after a couple days into one leg, there's a pretty decent chance that you have a disk bulge or a disk herniation or that somehow, you have irritated a nerve.
It doesn't mean you have to have surgery and there are lots of things that you can do to try to calm down that nerve. The main thing is to be mindful of your activities and especially do not lift anything heavy. I would get you on some sort of anti-inflammatory medication or steroids that can help with calming that down.
After doing a physical exam, I would get an MRI scan and x-rays of a patient’s back so that I can look inside the patient's body and find out what's really happening. At that point, I would have a good idea of what level the patient is at based on the pattern of the patient's pain, in the pattern of weakness and some other neurological findings.
When looking at the MRI scan, I would walk through the film with my patient and explain what is going on in the spine. It is vital for me to have the patient not only trust me, but also understand exactly what is happening and learn about his or her body, spine and nerves. Through that process, I then explain the steps of how to treat it. Generally, physical therapy and medication, which can calm the nerve down just enough to let that hernia settle down a little and get the leg feeling better, are a good start. I also work with outside providers such as physiotherapists that I trust and know can take care of my patients.
Generally, an opioid pain medication is not recommended for a disk herniation as it can bring with it a whole new set of other problems. Other options are steroid injections and some other non-surgical soft tissue approaches.
If a patient fails these treatments and the pain is uncontrollable and unremitting or there is a little bit of relief and pain returns soon after, I will renegotiate the problem. I will discuss surgical considerations with my patient so that he or she can get back to being active and living the life that the patient was living before the pain started.
There are different ways to approach disk herniation surgery. Some surgeons make big incisions and some use big retractors and dissect a lot of tissue off the spine. We use MRI scans and all the other imaging modalities to get them directly to the spot. There is no guesswork involved at all.
I perform this surgery through a dime-sized, 18mm incision on one side of the spine and work a small tube through the hole to get down to the muscle. I then work my way into the bone where I shave down just a few millimeters to find the nerve that’s evidently being compressed.
After going through the process of removing a fragment of disk and decompressing the nerve, the surgery is not over. There is a hole where the disk came out and that hole can be repaired to reduce the risk of something that is called reherniation. A patient could go through one herniation, have a successful surgery and then have another piece of disk pop out days, weeks or even months later. In order to avoid reherniation, (and if a patient’s spine will allow it), I will take the extra time in the surgery to do everything I can to prevent my patient from having this. This can be done by repairing the hole and closing the flap with a tiny suture.