DISC PROLAPSE & SPINE MANAGEMENT

What is Disc Prolapse?

An adult person’s backbone (spinal column) is composed of 26 bones. A disc is a cushion situated between two bones of the spinal column. It bears the load and works as a shock absorber during everyday activities. Prolapse or herniation means an abnormal protrusion of a body structure through its covering.

Disc, when protrudes out of its normal position, it causes pressure on nerves situated in the canal just behind it. Nerve compression causes severe radiating pain in the course of the nerve, down the leg (radiculopathy). Therefore, it is also called sciatica. In severe conditions, it can cause weakness, numbness in the leg, or loss of urine and stool control.

How is Disc Prolapse Affecting People?

Lumbar disc prolapse is the most common cause of low back pain and lumbar radiculopathy (sciatica). It affects mainly middle age and younger age group of the population. Degeneration (ageing) of the disc begins at the age of 15 years.

Degeneration causes a decrease in the water content of the disc leading to loss of flexibility and shock-absorbing capacity. This dry and hard disc is no longer able to function properly and develops tears in the wall of the disc. Through this tear disc, the material can herniate anytime during a small jerk or lifting weight or sometimes spontaneously.

Signs & Symptoms

Most of the patients present with low back pain radiating to one side of the buttock, back of the thigh, and back of the leg up to the heel. This radiating pain is called sciatica. Few patients present with predominant sciatica with minimal or no back pain. This pain increases while sitting, standing, and walking (not able to walk long distances).

This phenomenon is due to the fact that pressure within the disc rises in an upright position (sitting, standing, and walking) which further increases pressure on the nerves. On lying down on the bed, this pressure decreases, therefore, pain also decreases and the patient becomes comfortable. Sciatica is associated with tingling (pin and needle sensations) and numbness in the leg and (or) foot.

In patients with initial large disc prolapse or prolonged compression, there may be a weakness in the foot. In severe cases, patients may lose control of urination and defecation. When patients develop difficulty in urine and stool control, this condition is called “cauda equine syndrome”.

Risk Factors

Risk factors for disc prolapse are genetic factors, age, gender, smoking, and, to a minimal degree, occupational exposure. Job and dissatisfaction, physically strenuous work, psychologically stressful work, etc. are associated with low back pain or disability. In children less than 18 years of age, trauma is the main factor responsible for disc prolapse.

When You Should Visit The Doctor?

In cases of recent onset of low back pain in a young healthy patient, there is no need to visit a doctor because this is most commonly caused by a muscle strain which relieves in one or two weeks.

If there is no relief in back pain for more than two weeks in an adult person, back pain associated with sciatica or sciatica alone, you must visit a spine surgeon. If a patient has weakness in the leg or foot, difficulty in urination, difficulty in defecation, loss of sensation in the perianal area, it’s an emergency situation (cauda equine syndrome) and you must immediately visit a spine surgeon.

Other red flag signs, when you should visit a spine surgeon include back pain in younger than 20 years or older than 55 years, no relief after medicines for over 6 weeks, history of trauma, cancer, alcohol abuse, fever, and unexplained weight loss, progressive numbness or weakness in legs or hands and disturbed walking.

How Will Your Doctor Diagnose Disc Prolapse?

The main investigation modality to diagnose the disc prolapse is MRI. But your spine surgeons will advise you to investigate systematically, based on clinical examination and suspicion of the disease. First of all, an X-ray is usually advised to look for alignment of the spine, the stability of the spine, bone density, etc.

The next investigation is MRI which exactly diagnoses the level of the disc prolapse, severity of disc prolapse, degree of nerve compression, side of the prolapse, the need of the surgery, the urgency of the surgery, etc.

Medical Management

Approximately 90% of these patients have a small disc prolapse. Therefore, they become alright with medicines and exercise within 6 to 8 weeks’ time. Spine Surgeon usually prescribes a combination of medicines including anti-inflammatory medicines, muscle relaxants, neuropathic pain killers, and (or) steroids.

Steroids are usually prescribed in acute conditions with severe radicular pain to rapidly control the inflammation of the nerve. If a patient does not get progressive relief or develops neurological weakness during the course of medical management (6 to 8 weeks), he/she requires surgical treatment. During the course of the treatment, patients must avoid weight lifting, forward bending, prolonged sitting, standing, or any kind of exertion. The reason being, these activities may aggravate the symptoms or herniation which can lead to the development of cauda equine syndrome.

Surgical Management

At Shalby Spine Management Centres, we have adapted two of the most advanced surgical techniques. First is microdiscectomy in which we perform surgery under the magnification of a microscope.

This technique requires only a 2cm skin incision with minimal surgical trauma. This is a gold standard and the safest technique. The patient is able to walk in the evening of the surgery and can be discharged on the same day or the next day. A second technique is an endoscopic discectomy which requires only 6mm incision and can be performed under local anesthesia on a daycare basis. These are suture-less surgeries (there are no sutures on the skin).

What Should You Expect?

Following the surgical procedure, a patient is kept in the recovery room for observation while weaning off from general anesthesia for one to two hours. After recovery from the anesthesia, a patient may feel pain at the surgical site which is usually mild due to a small incision and controlled by intravenous analgesics.

Radicular pain (or) sciatica relieves immediately after the surgery in 99% of the patients. Therefore, patients are able to walk comfortably in the evening of the surgery. Usually, patients do not develop any kind of neurological deficit following the surgery which is the main element of fear and myth in society.

A patient can expect the discharge the next day morning. The dressing is usually changed just before discharge and doesn’t require to be changed further at home. The next visit is required in 2 weeks when the dressing is removed and exercises are started.

By Dr. Pravin Gupta, Spine Surgeon, Shalby Hospitals, Jaipur.

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