Presentation Treatment and Outcome.
Lumbar backache and leg pain due to lumbar disc disease is one of the
most common problems that modern man is affected with. In a person's life
at one stage or another one will suffer from either backache or leg pain
due to this condition.
The spine consists of vertebrae
which are connected to each other by the soft lumbar disc between the
The disc is contained within
a strong bag, the annulus under very high pressure
This disc has the consistency of cooked crayfish and is contained in
a bag under very high pressure. Therefore should this bag rupture part
of this disc will prolapse out and compress the nerve that runs down into
the leg (sciatic nerve) resulting in pain. On the other hand the disc
can also degenerate without causing leg pain but eventually resulting
in severe backache. These two conditions although arising from basically
the same underlying pathology are different aspects, needing different
treatment and may run different courses
CLINICAL PRESENTATION OF THE PATIENT
.The typical clinical syndrome of a ruptured disc would be someone who
develops backache as the disc bulges and stretches its containing bag.
The disc then ruptures compressing the nerve and the pain then shifts
and runs down the leg, often with the backache getting better. If this
compression of the nerve is very severe, the nerve may become paralyzed
and at this juncture the leg pain may disappear but the motor function
of the nerve is now lost and the patient may present with a paralysis
in the leg or in the foot, paradoxically thinking he is better.
Whereas most of these ruptured discs present with pain and mild weakness
in the leg, there are situations where the consequences are much more
severe requiring emergency intervention.
This may happen when the disc ruptures in the centre part of the spinal
canal compressing the lower spinal cord which then may result in paralysis
of both legs with loss of sensation and very importantly also loss of
The lumbar spinal cord and nerves
crossing the discs
It is surprising how often a situation like this may be either misinterpreted
by the patient or even by doctors and symptomatic treatment continues
without realizing the significance of what has happened. If urgent surgery
is not performed the patient may not regain function under these circumstances.
In the more usual case the patient presents with pain, rather than a
paralysis, and/or a mild weakness. However, even in situations where the
back and leg pain is very severe, the vast majority of patients will improve
over a week or 10 days, never even getting to a specialist and just being
treated symptomatically by their general practitioner. Patients get better
because the ruptured disc will shrink somewhat and the inflammation in
the compressed nerve will settle down and thereby improve the symptoms
of the patient. That small group of patients who will not settle down
or in whom the initial pain is so severe that they cannot live with it
or when there is paralysis, will eventually land up with the neurosurgeon
and at this stage further tests will be performed.
It is very important even if the problem looks like a clear-cut prolapsed
disc, that a good clinical examination be performed because there are
other conditions which may simulate a lumbar disc. In the younger person
this will be the most likely cause. In the older person one will think
more in terms of degenerative spinal disease (osteoarthritis) or even
metastatic spread of cancer from somewhere else. Other conditions such
as tumors in the spinal canal, hip pain or blocked arteries of the legs,
must also be considered as conditions which may cause pain in the leg.
Once a full clinical examination has been performed the neurosurgeon
will usually have a good idea of what he is dealing with.
SPECIAL INVESTIGATIONS- MR SCAN
At this stage then a magnetic resonance scan will be performed.
It is very important that when someone is sent for a scan that a preliminary
diagnosis be made otherwise the scan may be misleading and conditions
may be identified which are not appropriate in the setting of the patient's
symptoms (complaints). The MR scan can usually show the problem very clearly
and appropriate treatment can be advised.
The MR scan shows a huge disc
prolapsed (black round object) compressing the spinal nerves in the spinal
Before surgery is performed it is very important to make it clear to
the patient the implications and long term prognosis of a lumbar ruptured
In the first instance it must be made clear that when one operates on
this disc, one does not give the patient a new back and that this is part
of the natural degeneration of the spine with a significant chance that
there may be a recurrent disc rupture at the same level or that the disc
may further degenerate, resulting in severe backache. Often one hears
in conversation that people are advised not to have surgery because once
you have had surgery, the back will never recover.
Secondly one must also make sure that before one embarks on surgery,
all other avenues of conservative treatment have been exhausted and that
the patient is not likely to recover from his pain.
Thirdly, clearly if the patient has got significant paralysis or bladder
function involvement, there is no question that surgery must be performed
to decompress the compressed nerve roots as a matter or urgency
The purpose of the surgery is to remove the ruptured disc and as such
remove the compression of the nerve or spinal cord so as to relieve the
pain and restore the function to the nerves.
In the usual case of someone presenting with leg pain for the first time
due to a ruptured disc, a procedure called a microdiscectomy will be performed.
This entails making a small 3 cm cut on the back and then using the operating
microscope, the dissection is carried down to the vertebra where a small
hole is made in the bone and this piece of disc material removed and the
nerve freed from compression.
A large piece of prolapsed disc
being removed, compressing the nerve
The patient will usually be in hospital for 2-3 days and in most cases
of an office job, return to work at 2-4 weeks.
However, as stated before, this hole in the bag through which the disc
ruptured never properly heals and therefore there is always a chance of
a disc recurrence at that level. The disc will also further degenerate
resulting in complete collapse of the disc space and subsequent backache.
These situations may occur in about 15% of individuals and they will require
further procedures to deal with the problems
If a patient presents with a second disc rupture his chances are even
higher to have a third recurrence. Therefore at this stage a supplemental
procedure must be performed. In the past following the removal of the
recurrent disc, a spinal fusion of that level would have been performed
However, spinal fusions also carry their own risks, especially in younger
people, of increased deterioration of the adjacent disc.
Spinal fusion of the lumbar
spine with instrumentation
NEW DEVELOPMENTS IN THE MODERN ERA
In the modern era, artificial disc replacement has become a major addition
to the surgical options. The artificial disc will be placed in the disc
space through an abdominal incision, as one has to place this in front
of the spinal cord and cannot get there from behind. The artificial disc
then maintains mobility in the spine and as such protects the adjacent
disc from accelerated degeneration and further surgery.
Artificial disc prosthesis implanted
at the L4/5 lumbar level
SPINAL DEGENERATION AND STENOSIS
As stated before one must realize that the spine ages with the individual
and will not remain in a pristine state compared to a young person. Some
people are more prone to developing spinal problems and in older age,
backache due to spinal degeneration or narrowing (spinal stenosis) causing
spinal cord compression, are the more usual conditions to deal with.
Unfortunately often in chronic backache the degeneration is widespread
and no specific procedure can be performed to relieve that. These patients
can then find relief from medication , physiotherapy, biokinetics , epidural
dural injections and facet blocks.
In the condition where spinal stenosis develops with severe spinal cord
compression, the MR scan will show the typical picture with compression
of the spinal nerves.
The MR scan shows the defect
in the white column which is the compression of the spinal nerves in the
A so called laminectomy, where the narrowing is relieved by removing
the laminae (the roof) of the spinal canal is performed .This is sometimes
one of the most satisfying procedures that we perform in older people.
They often cannot walk more than 20 meters and they have to stop and rest
before they can carry on. The dramatic relief following a laminectomy
is most satisfying to the patient
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