Lumbar Disc Herniation 101


The most common spine problem that a patient will seek medical attention involves the lumbar disc.   Diagnostic problems involving the lumbar disc are complex in presentation and therefore each patient’s  symptoms are somewhat unique. Some patients have back pain and some have pain in one leg or perhaps in both legs. Numbness, weakness, back spasm, leg pain with no back pain, sudden onset or slow in developing, pain may be severe or subtle. Every patient is different and a good history is fundamental to figuring out the specific disc problem and how to treat it. Patients can be really confused and certainly anxious because disc problems can cause some serious pain and dysfunction. But rest assured, if you are having some of the symptoms  listed above, an experienced Spine specialist can usually figure out the problem by just listening to you and examining you. 

Doctor, “Is my disc ruptured or slipped”? “Do I have a herniated  or a bulged disc”? “My Mom had sciatica, and got better with some emu oil”. Most patients have already received some free advice from a relative or friend before they seek a professional opinion. And that’s okay, heck I would too! So let’s talk about the subtleties of the lumbar disc. 

As I said before, it is all about the history. Lumbar disc problems rarely are the result of trauma like a fall or a car wreck. Those types of injuries are more likely associated with a fracture if severe or perhaps a muscle strain if less severe. Most disc problems are the result of wear and tear and genetics. Most patients just kind of notice a little stiffness for a few days and then suddenly they wake up in severe pain looking for some help. The most distinguishing feature that your spine specialist will look for is leg pain known as radiculitis or radiculopathy and commonly known as sciatica. If that is the case then you are more likely to have a herniated or ruptured disc pinching a nerve rootlet in your back and causing the leg pain. Numbness, weakness difficulty standing and walking and even difficulty with your bowel and bladder can be present. In these instances, a more urgent approach may be recommended. X-rays and an MRI of your lumbar spine are important and surgery may be necessary if the symptoms are severe and associated with nerve dysfunction. Other options like an epidural injection, or physical therapy and oral medications may be the initial recommendation and can get often settle things down without surgery. 

If the patient presents with symptoms limited to back pain without leg pain, then a simple back strain may be the cause and the treatment is more cautious. Often times the problem may not be a back problem at all. Diagnostic studies can be delayed to see if the symptoms will settle down over a week or two. If symptoms persist or worsen, then more aggressive options may be necessary. A  degenerative disc or bulged disc that is not putting pressure on a nerve may be the diagnosis. Even these conditions can lead to surgery if they persist for many months and don’t improve with non surgical treatment. 

Lumbar disc problems can truly be painful and getting some expert advice and just understanding the problem helps out tremendously. Your Spine Specialist in Alabama will look for the simplest and least invasive way to get you better. Just remember it all starts with a good history and examination from an experienced professional. 

So you have severe back pain or severe leg pain or perhaps a combination of both. Very likely you have tried to get better with physical therapy and spinal injections. Perhaps you have had a previous back surgery to repair a disc herniation and the pain has returned. Your spine surgeon has recommended a spinal fusion. You have heard that some people have it done from the front, others from the back. You have researched spinal fusion on the internet and have seen that there are different approaches to do the surgery. So how does your surgeon decide the best approach for you? Let’s discuss.

Your spine surgeon may recommend a spinal fusion as a part of your surgical plan if you have certain conditions. Recurrent disc herniation, spondylolisthesis, scoliosis, and severe degenerative disc disease are common reasons to consider a fusion to correct your condition. In the modern fusion era, spinal fusion surgery offers different techniques that are designed to limit exposure and reduce recovery time. Most patients stand and walk the day of surgery. Some patients can even go home the same day and very few patients need more than a day or two in the hospital. 

The most common spinal fusion is done posteriorly or through the back. This method seems logical. After all, the spine is in the back. Posterior approaches allow the surgeon to perform spinal nerve decompression for disc herniations and spinal stenosis. Typically pedicle screws are placed for a posterior lumbar fusion (PLF). An interbody fusion can also be done to allow fusion to occur in the disc space. Transforaminal lumbar interbody fusion (TLIF) and posterior lumbar interbody fusion (PLIF) are well established techniques. The bottom line is a posterior approach is best if you need direct nerve decompression for conditions like severe spinal stenosis. 

An anterior approach or ALIF allows for direct access to the disc space without having to displace the nerves. Usually the approach is assisted by a general surgeon or vascular surgeon to expose the front of the spine. Degenerative disc disease, especially at L5-S1 and L4-5, can be addressed through the anterior approach. Restoration of disc height and placement of large surface area implant devices are advantages of the anterior approach. As a general rule, anterior approaches are less painful and easier to recover from. Anterior approaches are a good option for single level degenerative disc disease or in cases where restoration of disc space height is necessary. 

A newer technique known as extreme lateral lumbar interbody fusion or XLIF requires an incision on the flank. This technique offers similar advantages and has similar indications as an ALIF but can be an easier way to access the upper lumbar areas like L3-4 and above. Finally, in some cases an anterior and a posterior approach is recommended. In cases that require multi level fusion or in patients with more complex problems a combination anterior/posterior approach may be the best choice to address the problem. 

An experienced spine surgeon will employ all these different techniques and provide a good opinion on what is the best choice for your case. Remember the goal is to fix the problem with the least invasive technique that allows the fastest recovery time. Animations of all these techiniques are on my website.