Lumbar Disk Disease

Definition:

The lumbar region of the back, goes from the lower part of the chest (ribs) down to the pelvis (hips).

Most people have five lumbar vertebrae with disks between each and between the first lumbar vertebrae and the last thoracic vertebrae above, and the last lumbar vertebrae and the sacrum (back part of the pelvis) below. The incidence of lumbar disk disorder increases the lower down the back one looks. This is because the lower vertebrae have to support more weight and stress, and are less mobile. When ruptures in the disks occur, they are associated with flowing out of the disk material, most often in a postero-lateral direction.

Symptoms:

Symptoms may vary in time, intensity, duration, location and the patient's ability to tolerate stress and/or pain. Pain is the most common symptom and usually begins in the lower back and may radiate into the buttocks, hips, and legs. The pain when radiating down the leg, is mostly found on the posterior, or postero-lateral aspect of the thigh and leg, and is accompanied by numbness and tingling that radiates into the part of the foot that is served by the sensory fibers of the affected nerve. The pain is characteristically aggravated by sitting or standing for extended periods of time, walking, coughing, sneezing or straining. Other symptoms include, but are not limited to: muscular weakness, muscular aching (particularly with movement), loss of control of the bowels or bladder, difficulty sleeping, muscle spasms or muscular spasticity. In sciatica due to nerve root compression, frequently the patient can trace the distribution of pain down the affected leg to the foot.

Diagnosis:

To make a correct diagnosis, the physician uses a combination of information. This information may be from the patient in the form of a history and physical, from diagnostic studies (ex: MRI, nerve conduction studies) or from a combination of the above (myelogram with a post myelogram CT). The physician tries to tie together information from the above sources and to see if they correlate and support the findings of each other (ex: a disk herniation at a particular level may manifest itself in a particular pattern of pain distribution).

Treatment:

The treatment plan most often begins with a conservative program of education (ex: proper posture in standing, sitting, walking and working, and avoidance of flexion strains will minimize the incidence of problematic disk disease), physical therapy, stretching exercises, pain medication and rest. If these conservative measures do not work (after an appropriate trial time of approximately two to four weeks), or if the degree of nerve compression is in danger of causing permanent nerve damage or a loss of control of the bowel or bladder, then a surgical treatment is indicated. Most often, the surgical intervention involves a lumbar laminectomy (opening the back part of the spine), a diskectomy (removal of the inner portion of a herniated disk), and/or foramenotomies (opening the holes on the sides of the spine) to free up any compression of the spinal cord or nerve roots. This procedure takes about one hour per disk level. Because this procedure is done under general anesthesia, the patient will need to stay in the hospital over-night. Patients that are able, are encouraged to be up and active (walking or sitting with supervision) to help decrease stiffness and swelling, which are both sources of pain. Most patients are able to go home the day after surgery and are encouraged to remain up and active.

Risks:

Any time a patient is considering a surgical option for a back/disk problem, they need to understand the risks associated with the procedure, and weigh them against the potential benefits. The surgeon will explain what are the risks, their frequency of occurrence, and compare them to the desired benefits. The risks include, but are not limited to: infection, bleeding, loss of life, loss of control of the bowels or bladder, sexual disfunction, recurrence, paralysis, weakness, numbness, epidural fibrosis, cerebral spinal fluid leak, nonrelief pain, meningitis, lumbar instability, poor wound healing and other serious complications. An example where a patient can influence the risk of bleeding, is to inform the surgeon what medications they are on, because some medications such as aspirin can increase the possibility of bleeding.

Benefits:

Generally, the benefits have to be decided on individually, but involve: potential pain relief with potential improvement in strength and sensation.

Recommendations after surgery:

1) Take pain medication only when needed and only as prescribed. 2) Try to keep the bandage over the incision clean and dry (if it should become soiled or wet, it should be removed and replaced with a clean dry one). 3) Be up and active (it has been our experience that patients heal faster with less discomfort if they walk soon after surgery and do not remain in bed). 4) Return to the surgeons office in seven to ten days to have the staples/stitches removed (this appointment will be set up before the patient is discharged from the hospital). 5) Notify the physicians office if: the wound starts to drain, becomes red, swollen or infected, if the patient develops a fever, if the level of pain, numbness or tingling increases, or if there are any questions.

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