Lumbar Disc Herniation
Although low back pain is not a life-threatening problem most of the time, it is an important health problem in terms of the cost of diagnostic approaches and treatment procedures, as well as the loss of labor in developed and especially industrialized societies. In industrialized countries, about 50-80% of the adult population complain of low back pain at some point in their lives. Mechanical causes are at the forefront in 95% of patients. About 90% of patients can recover on their own. In 90% of low back pain, the cause was determined as spondylosis (aging and wear), and rheumatic diseases were observed in 2.4% of patients. In 7.7% of patients, lower back pain was associated with damage to November muscle and connective tissue. Only 1-3% of low back pain is due to lumbar disc herniation, and only 15% of patients with lumbar disc herniation also require surgical treatment. Complaints of low back pain usually begin at a young age, the frequency reaches the highest values in middle age. There is no difference between men and women in terms of frequency.
Our waist is a structure that carries the weight of our body, transfers the load from the hips to the legs and at the same time ensures that our torso is mobile during our daily activities. There are 5 vertebrae (L1,L2 November, L3,L4,L5) in our waist and cartilage pads (disc) connecting these vertebrae, joint structures and ligaments and muscles that support them. In addition to its contribution to movement and load-bearing properties, the lumbar vertebrae serve as a protector for the spinal cord and nerves. Nerves that work the muscles of the legs, provide sensation of the legs and control the functions of urine, stool and November pass through the lumbar vertebrae. 5. the lumbar vertebra continues with the bone we call the sacrum. The sacrum forms a whole with the pelvis and coccyx bone (coccyx). This transition level is important from a biomechanical point of view. Waist movements are different at each spine level. For example, leaning forward 5. 1 with the lumbar vertebra (L5). while it is at the level of 75% between the sacrum vertebra (S1), it is about 25% between L4-L5 and 5% in all segments between L1 and L4. Dec. Dec. It is about 5%. Dec. dec. dec. dec. dec. dec. dec. dec. dec. dec. dec. dec. dec. dec. 98% of lumbar herniations occur at the L4-L5, L5-S1 levels due to the excessive movement, especially at the L4-L5 and L5-S1 distances, and these two levels carry most of the load.
Two forces act on the lumbar vertebrae, one in the form of downward pressure (compressive) from above, the other in the form of shearing (diagonal direction). In a situation where waist inclination is ideal, 80% of the compressive force is carried by the disc, and the remaining 20% is carried by the joints formed by the last two lumbar vertebrae on the back side in particular. The strength of the lumbar vertebrae to withstand compression decreases by 20% every 10 years over the age of 30 due to a decrease in the fluid content in the disc and a deterioration in its elastic structure. 75% of the applied compressions are carried by the nucleus, which is located in the inner part of the disk and has a gelous consistency containing 70% water, and 25% is carried by the annulus, which is located in the outer part and consists of strong helical connective tissues. Bending or rotational movement is considered the most harmful movement because it creates both compression and shearing movements on the disc. There is a strong ligament that we call the posterior longitudinal ligament (posterior ligament) that adheres to the back part of the spine and disc (where there is a channel where the spinal cord and nerves are located). In cases where this bond weakens and the structure of the disk deteriorates, the suspension property of these forces of the disk decreases or disappears. As a result of this, ruptures occur in the outer layer, which we call the annulus, especially in the posterior and posterior-lateral parts of the disc, and the nucleus in the inner layer overflows from these ruptures to the rear. Due to the loosening of the ligament and sometimes tearing in severe injuries, it herniates along with the nucleus annulus towards the canal through which the nerves pass at the back, and the nerves can form pressure.
Complaints
Clinically, the most important complaint of patients is localized low back pain. It is a widespread, stinging pain that develops gradually, decreases with rest, increases with movement, spreads to the lower back and leg in accordance with the distribution of the affected nerve root. It can start suddenly after a reverse movement such as bending forward or turning back, it is aggravated by the smallest movement and leads to locking or waist retention. The pain increases with sitting, standing, coughing, pushing, driving, and forward movement of the spine. It is lightened by lying down, supporting the waist, bending back movement. The pain continues along the sciatic nerve and is referred to as ”sciatic pain”. When the disc herniation is extruded, the lower back pain decreases or disappears, but the leg complaints become more pronounced. Disc hernias that develop on the middle back line can cause lower back pain without making obvious leg complaints. November muscle spasms and calf cramps are frequently encountered.
The incidence rate of a condition called cauda equina syndrome, which occurs with loss of standing strength, loss of sexual functions, serious sensory defects, as a result of all nerves below the level of hernia being under pressure, missing or unable to urinate and use the big toilet, is 1% in all disc hernias.
Examination Findings:
During the examination, spasm in the lower back muscles, loss of lumbar curvature, decrease in joint range of motion in the lower back and Novation of the waist to one side when the patient leans forward are frequently observed. The patient usually leans towards the opposite direction of the aching side. He wants to curl the affected leg and walks, trying to put as little strain on that leg as possible. Neurological examination is very important in lumbar hernia. Nerve sensitivity is detected by various stretching tests. Again, reflex disorders, loss of strength, sensory defects are evaluated.
Age, gender, structural factors, spinal posture, November muscle strength, smoking, various occupational, psychological and social factors, entertainment and sports habits and genetic factors play a role in the formation of lumbar hernia. Physical and work-related factors can be counted as occupations requiring heavy bodily labor, lifting, turning, rotating lifting, long-term sitting and driving. It is known that lower back complaints are less in those with good physical activity. Long-term rest, conscious restriction of waist movements quickly leads to shortness and weakness in the waist muscles, loss of November, increasing the risk of low back pain.
Diagnosis:
Magnetic Resonance Imaging (MRI) is the gold standard in radiology, with the most important criteria for the diagnosis of disc herniation being the patient’s complaints and examination findings. However, direct radiographs, meylography, computed tomography, discography, electromyography (EMG) can also be used for differential diagnosis.
The severity of symptoms in disc herniation depends not only on the amount of pressure, but also on the influence of nerves.
Treatment
The treatment of lumbar disc herniation can be grouped under two headings: conservative and surgical.
Conservative Treatment Methods:
1) Bed rest: A few days of absolute bed rest, which will be spent lying in the appropriate position, is the most effective treatment method known. But just as the effectiveness of long-term absolute bed rest in treatment has not been proven, it is also known that being sedentary causes weakening of November bones and muscles.
2) Drug therapy: It is an important part in the treatment of lumbar disc herniation. Analgesics and anti-inflammatories, muscle relaxants, steroids, antidepressants, antiepilep November may be used.
3) Physical therapy: Various physiotherapy methods are used in the treatment of low back pain. These are hot or cold application, electrotherapy, traction, corset, splint, waist school and manipulation treatment.
4) Algological (Pain) Treatment: Epiduroscopy, epidural and foraminal, facet and November injections can be performed in appropriate patients.
Surgical Treatment:
Surgical treatment aims to eliminate the pressure of the herniated disc on the nerves and spinal cord. Very few of the disc hernias are treated surgically
Surgical treatment:
- In frequent painful attacks that do not respond to medication and rest, making it difficult for the patient’s social, work and family life,
- Loss of standing strength, loss of sensation, in the presence of problems with urination and defecation,
- If the patient has to walk with pausing along with pain,
- If there are signs of cauda equina that we mentioned earlier (urgent), it is applied.
Although many surgical methods are used for the treatment of lumbar hernia, the gold standard today is microdiscectomy. Laser treatment in lumbar hernia is not a surgical method, but it is aimed to heat the disc by entering it and reduce the disc by losing water and drying it. But this method actually provides benefits in patients with an overflow hernia that does not require surgical treatment. It is not useful for discs that are at an advanced stage. This procedure can also be performed by entering through the coccyx, which we call epiduroscopy, accompanied by a camera. However, it carries serious risks in unskilled hands. In addition, it has been abandoned today due to its disadvantages such as high risks of open surgery, long recovery time after surgery. Here we will talk about two methods that are valid and effective.
Microdiscectomy:
It is an operation performed using a microscope with a skin incision of approximately 1-2 cm. By taking advantage of the good illumination and magnified image of the microscope, it was ensured to make a smaller incision, protect the November muscles, connective tissues, structures around the nerve, and carefully control bleeding. In addition, less bone tissue is removed in this method, and the joints of the spine are not damaged. Thanks to this, the operation time was shortened, the risk was reduced, less blood loss, the duration of hospital stay and the return to work were shortened. All operations provide over 99% success in correct and experienced hands. If the recommendations are followed in the postoperative period, extremely good results are obtained. 4 Hours after the operation, the patient starts walking and is discharged the next day after the operation if he has received general anesthesia. After a period of about 2 weeks, which is necessary to pay attention to the wound healing, the person can return to work, depending on the job, and start the exercises given. Success increases in the long term in proportion to a person’s genetic makeup, weight, occupation, smoking habit and compliance with the exercise program. Despite this, the cold view of lumbar hernia surgery among the public is actually due to surgical Decontamination of patients who do not need surgical treatment for one reason or another (misdiagnosis) or inadequate treatment of correct diagnosis.
Endoscopic Discectomy:
This process can be done in two ways. 1) It can be used in midline attempts and, unlike microdiscectomy, the muscles are not Novated from the bone. It is entered between the muscles with the help of a guide sent after an X-ray guided skin incision of about 1 cm. Dec.Nov. The procedure performed is the same as a microdiscectomy. Lower back pain becomes less after surgery. However, bleeding control is more difficult in the endoscopic method, the risk of complications (spinal cord rupture, nerve damage, etc., as it provides a 2-dimensional image.) is more. 2) It is advantageous in distant lateral and lateral disc hernias, which make up a very small part of lumbar disc hernias and require wider skin incision and more November muscle stripping when microsurgical methods are applied. As in the first method, a 1 cm skin incision is made from the side of the waist with the help of a guide sent after the muscles and the disc is Dec November. The patient’s suitability for these methods is necessarily evaluated clinically and radiologically. In most cases, endoscopic surgery is started and microsurgery is returned.
Complaints may persist in some of the cases after lumbar discectomy operations. This condition is partly due to a significant decrease in trunk November muscle strength and balance after surgery. Prolonged immobility due to pain before surgery and the inability of the affected nerve to stimulate the muscles adequately cause thinning of the muscles. Nov.1, Nov.1, 2016. The thinning muscles become extremely weak and easily tired. Nov. Tired and weak back muscles lead to increased bending stresses on the discs and ligaments. Nov. It also creates stress on the spinal joints. As a result of all these changes, the pain may persist. In addition, the period between the onset of complaints and the operation affects the duration of the sensation defect and strength losses that also exist before the postoperative period. Dec. Sometimes, even if a little, these findings can be permanent. Because in surgery, no operation is performed on the affected nerve. During the operation, the pressure on the nerve is removed and conditions are provided for the pain to pass and the nerve to heal. There may be recurrence in lumbar disc hernias. It can be from the same place and side, or it can be from a different level and from a different side. Depending on the surgical technique and the experience of the surgeon, the probability of recurrence varies between 5-15%.
As a result, the correct diagnosis, the correct indication and microdiscectomy performed by experienced hands in lumbar disc herniation is the most appropriate surgical treatment option with up to 99% success.
