Herniated disk in the lumbar spine Only 3-5% of acute back pain is caused by a herniated disk. As a herniation consists to about 95% of water and is hence reabsorbed by the body after a while, in 90% of all slipped disks no surgery is necessary. If however after 4-6 weeks there is no relieve of back or leg pain or additional neurological signs (muscle weakness, bladder or bowel dysfunction) appear, more detailed diagnostics are necessary to find appropriate treatment. Weakness or numbness in the leg or foot, however are warning signals for a more serious condition. Hence not every herniated disk must be removed surgically at once. As a rule decent conservative therapy with concomitant oral pain medication will due. Mostly pain will get better and surgery is no longer needed. In all cases you should keep strengthening you rump musculature after a disk herniation with special exercises. In comparison to most clinics (more than 95% of spine surgery departments in Europe) at the APES SPINE center the diagnosis of a herniated disk does not mean a big open back surgery with long in-patient rehabilitation. If a disk surgery is required, so far all herniated disks were treated by endoscopic surgery. Frequent symptoms Severe lower back pain radiating into the buttocks, legs or feet and which may be aggravated by sneezing or coughing Increase in pain when sitting. lying and/or bending down A feeling of numbness or even paresis in your leg Eventually also from numbness of the inner thighs, the anal or genital region, bladder and/or bowel dysfunction The clinical picture depends on to what extent adjacent nerves are compressed by the herniated disk. Hence, not all listed symptoms may prevail simultaneously. Rare symptoms the so called cauda equina syndrome is an emergency! mostly it is a mass prolapse that is so big that it reaches through the entire spinal canal and compresses the spinal nerves this can lead to bladder or bowel dysfunction and to paraesthesias in the anal region with or without disturbance of sexual function. Also pain and pareses in the legs are possible. if surgery is not carried out within the first 24 hours after onset of symptoms, there is a considerable risk of permanent damage in neural function. The sooner the nerves are decompressed, the better is prognosis. What is a herniated disk? Intervertebral disks are elastic cartilaginous joints of about 5 mm thickness between adjacent vertebrae. Their main function is to dampen impacts of daily life activities – they work just as a shock absorber. In their centre is the nucleus pulposus – a jelly-like tissue which is surrounded by a firm fibrous ring (the anulus fibrosus). A disk herniation is a relatively common condition. There are four main causes: an inherent weakness of the disk tissue a sudden twisting movement of the body heavy lifting or pushing lack of physical activity Due to lack of physical activity and constant sitting, the rear part of the intervertebral disk can be virtually „starved“. This causes a weakness in the disk tissue and fissures or protrusions of the disk may occur. Poor musculature can additionally increase the risk of a disk herniation. When a disk herniates, parts of the nucleus pulposus protrude into the spinal canal through fissures of the anulus fibrosus. It may then happen that the prolapsed tissue compresses the spinal cord or the efferent spinal nerves. In such cases the acute back pain comes along with neurological symptoms in the dermatome of the affected nerve root. Main cause is mostly a long-term undue stress from poor posture or inactivity which comes along with normal aging processes (degenerative disk disease). At times the actual disk herniation is preceded by bulging of the jelly nucleus into the fibrous ring (disk protrusion). What causes a lumbar disk herniation? On the base of a pre-existing damage of the intervertebral disk its actual bulging out is triggered mostly by a sudden twisting movement or heavy lifting. There are cases, however, where a disk herniation occurs without apparent cause. In more than 90% of the cases a disk herniation occurs in the lumbar spine – mainly between the vertebrae L4 and L5 or L5 and S1. Less frequently also the cervical or thoracic spine are affected (refer also to disk herniation of the cervical spine) (refer also to herniated cervical disks) How is the disk herniation treated? conservative treatment I In the best of cases it will do to give the back two weeks of physical rest and to treat pain with analgesic drugs. For strengthening of the muscles of the back and the abdominals a targeted physiotherapy is recommended. Concomitant thermal or electrotherapy and manual therapy may provide additional symptom relieve. In persistent cases injections of local anesthetics and corticosteroids directly at the compressed nerve root (periradicular infiltration) or at the spinal cord (peridural infiltration) may help in the short-term. Severe neurological symptoms may render a hospitalization necessary where analgesic and anti-inflammatory infusions are given. too much rest can harm 1) of 100 patients with acute back pain... Patients that resumed soon their daily activities Patients that rested longer are back to work after 10 days 57 36 are still at home after one month 17 31 1) Keel P, Weber M, Roux E, Gauchat MH, et al. Kreuzschmerzen: Hintergründe, Prävention, Behandlung (Back inTime. FMH 1998) In persistant pain targeted injections of anesthtetics and corticoids may offer short term relief. In cases of severe neurological signs a hospital stay with infusions may be required. Surgical treatment A herniated disk can be treated traditionally - which is an open surgery from the back under general anesthesia. Or it can be treated endoscopically in local anesthesia. The endoscopic discectomies are carried out by Dr. Schubert since 2001 One main focus of the APEX SPINE Center are endoscopic spine surgeries (e.g. TESSYS or maxmore). One main focus of the APEX SPINE Center are endoscopic spine surgeries. As opposed to other endoscopic techniques our special surgical procedure allows to remove all slipped disks regardless of their size and location. This is especially important for prolapses at L5/S1 and in the thoracic spine - they can be reached endoscopically only by transforaminal surgery. This means, the access to the herniated material is possible via the osseous opening of the vertebrae where the spinal nerves exit. Hence we don’t have to use the traditional posterior point of entrance which is associated which a much greater risk of injury. Dr Schubert constantly develops this technique further. He is internationally one of the leading spine surgeons who – additionally to all conventional spine surgeries – carries out routinely those endoscopic interventions at the cervical, thoracic and lumbar spine. Some of the techniques are worldwide unique in our spine clinic. Up to now more than 6.500 patients have been successfully treated with this special endoscopic technique by Dr Schubert. Dr Schubert regularly presents his experiences and results on national and international conferences and publishes his work in scientific journals. Hence the APEX SPINE Center has grown to an internationally acknowledged training center. On a regular base physicians from all over the world join us to stay informed or improve their skills with our surgical procedures. Additionally continuous education courses for spine specialists are offered where with live-surgeries and workshops all knowledge about the new techniques is passed on to interested colleagues.