Approximately 80 to 90 percent of people with classic symptoms of a herniated lumbar disc—sciatica and back spasm—respond within six weeks to rest and pain medication. This conservative approach to treatment likely works because it gives the swelling around the nerve root a chance to subside.
Surgery for a herniated disc may be unavoidable in people who experience impaired bowel or bladder function, persistent or increasing sciatica, progressive leg weakness and recurring episodes of incapacitating pain from sciatica.
• Diskectomy The traditional surgical treatment of a herniated disc, called open diskectomy, is used in two situations: when at least six weeks of nonsurgical treatment offers no pain relief or when there is a “neurological deficit,” a problem that causes nerve dysfunction.
The surgeon relieves pressure on the pinched nerve by making an incision into the distended annulus fibrosus (the tough outer layers of the disc) and removing the protruding nucleus pulposus (the gel-like center). General anesthesia is required. The surgeon usually removes a small part of the vertebra (laminotomy) to gain access to the herniation site.
In general, diskectomy produces improvement more rapidly than conservative treatment. However, the long-term results of surgical and nonsurgical treatment are about the same. How well you do during the first three months of conservative care may help you decide about surgery. If your pain is tolerable, you may be able to get by without it. But if the pain is intolerable, surgery becomes a more attractive option because it can dramatically reduce the pain.
One day of hospitalization may be required after having an open discectomy (a procedure in which the surgeon makes a large incision in the patient’s back to gain access to and operate on the spine). Over the next several weeks the treated disk gradually heals as scar tissue fills the empty space. Almost all people can return to work six to eight weeks after the operation. Repeat surgery is not as effective at relieving pain as the first surgery.
• Microdiskectomy With this procedure, the surgeon uses an operating microscope to view the disc and nerves before removing herniated disc material. Microdiskectomy appears to have a success rate similar to that of open diskectomy. Doctors may recommend this surgery to people who have leg pain for at least six weeks but who do not experience relief with conservative treatments such as oral corticosteroids, nonsteroidal anti-inflammatory drugs (NSAIDs) and physical therapy.
• Spinal fusion In some cases a spinal fusion is performed at the time of a discectomy. Spinal fusion involves using spinal instrumentation and bone graft to fuse together two or more adjacent vertebrae. This procedure is not always reliable, and guidelines as to when it should be done are not as clear as those for discectomy.
It may be recommended for a person with chronic back pain who is experiencing leg pain caused by a herniated disc. Spinal fusion may also be recommended when a repeat operation is necessary because the first one was not effective in relieving pain or herniation recurred. Unfortunately, spinal fusion alters the way the spine moves and may promote degenerative changes as well.
• Artificial discs Although artificial discs have been available in Europe for more than 20 years, the Food and Drug Administration did not approve their use in the United States until 2004. The first artificial disc available in this country, called the Charité, was authorized for use in single-level disk problems (where one disc is affected) after clinical trials showed that the device preserved motion and was as effective as spinal fusion in relieving pain, with shorter healing and rehabilitation times. In 2006, the FDA approved a second artificial spinal disk, the ProDisc-L.
Additional artificial discs are being tested in clinical trials in the United States. It will take five to 10 years, however, to determine whether artificial discs can maintain long-term motion and prevent disc degeneration near the surgical site.
Candidates for disc surgery should have degeneration in only one disc in the lumbar spine with little or no arthritis in the corresponding facet joints; have undergone at least six months of conservative treatment, such as use of pain medication or physical therapy, with no improvement in symptoms; not have significant leg pain; and be in overall good health.