LUMBAR DISC HERNIATION
Journal Title: Journal of Turkish Spinal Surgery - Year 2003, Vol 14, Issue 3
Abstract
Lumbar discectomy is one of the most successfull operations in a carefully selected patient with radiculopathy pain. But, in an inappropiate patient, the result is disappointing. Life time prevelance of low back pain in the population is eighty percent and 4 percent of these cases become chronic. Problems: • Ninety percent of the attacks of low back pain reselves within two months. But rate of recurrence is about seventy percent. • Rate of false positive findings in imaging studies such as CT and MRI high. • Is disc herniation the main cause of back or even leg pain in every patient? • Which patients will benefit from the surgery? • When must surgery be performed? Risk factors: • Vibration • Hard labor • Excessive temperature changes • Heavy weight lifting • Monotonous activities or job • Disturbing positions Males aged 35-45 are usually affected. L4-L5 and L5-S1 are the levels most commonly involved. Types of herniations: • Protrusion • Extrusion • Sequestration Localisation: • Posterolateral • Axillar • Foraminal • Central • Intradural Characteristics of root pain a) Radiation of pain is spesific for a certain nerve root b) Pain is more severe at the peripheric sites of the extremity c) Numbness and paresthesia is present at the distal regions d) Decreased nerve conduction velocity and fibrillations are noted in EMG e) Neurologic deficit may be present varying with the nerve root affected f) Nerve tensioning tests are positive 23 2003; 14 (3-4): 23-26Characteristics of reflecting pain a) Pain reflects usually to the proximal site of the extremity. It is rarely reflected to below knee level b) Pain is more severe at the proximal regions c) Numbness and paresthesia is not present d) EMG is normal e) Neurologic findings are not observed Natural history • Surgically treated group is better at postoperative one year. • No difference exists between the groups at postoperative four years Conservative management NSAID and bed rest for two to three days is advised. If there is no response, epidural injection of steroids should be considered. Indications of surgical treatment • Progressive neurologic deficit • Intractable pain resistant to conservative measures for six weeks Preoperative evaluation • Neurologic deficit • Tensioning tests • Leg raising test • Femoral tensioning test • Psychologic tests • Pain charts • VAS • MMPI Non organic findings • Excessive irritability with light touch at nonanatomic sites. • Pain with axial loading and pelvic rotation • Nonanatomic motor and sensory findings • Exagerated reactions during physical examination and pain, • Positive Laseque test while the patient lying turns to negative at sitting position Radiologic evaluation • CT • CT myelo • MR Predictive factors a) Neurologic deficit b) Positive tensioning tests c) Objective documentation (CT, MRI, Myelo) Results: 97% success if all three of the above mentioned factors are positive. 82% success if two are positive. 70% success if there is only one positive. Indications of fusion • Relapse of symptoms more than twice • Degenerative spondylolisthesis • Instability (translation more than 4 mm, angular deformity exceeding 20 degrees) Post operative care • The patient is allowed to walk at 6 to 8 hour postoperatively after standard discectomy. If there exists a dural tear bed rest for two to three days is mandatory.
Authors and Affiliations
Prof. Mahir GÜLÞEN, M. D.
Keywords
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