Approximately 80 to 90% of people with classic symptoms of a herniated lumbar disk—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. The limitation on physical activity helps the herniated disk material remain in place, reducing the risk of it fragmenting. A disk fragment that lodges in the spinal canal and presses on a nerve can cause significant loss of function.
Surgery for a herniated disk may be unavoidable in people who experience impaired bowel or bladder function, persistent or increasing sciatica despite bed rest, progressive leg weakness, and recurring episodes of incapacitating pain from sciatica.
Diskectomy. The traditional surgical treatment of a herniated disk, called diskectomy, is used only when at least six weeks of non-surgical treatment offers no pain relief or when there is a problem in nerve function that causes a loss of movement, known as a neurological deficit. The surgeon relieves pressure on the pinched nerve by making an incision into the distended annulus fibrosus (the tough outer layers of the disk) and removing the protruding nucleus pulposus (the gel-like center). General anesthesia is required. Depending on the location of the herniation, the surgeon may need to remove a small part of the vertebra (open laminectomy) to gain access to the herniation site.
In general, diskectomy produces improvement more rapidly than conservative treatment. The long-term results of surgical and nonsurgical treatment, however, 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, then surgery becomes a more attractive option because it can dramatically reduce the pain.
One day of hospitalization may be required after having an open diskectomy (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 subsequent several weeks, the treated disk gradually restabilizes 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.
Spinal fusion. In some cases, a spinal fusion also is performed. This procedure involves using bone grafts to fuse together two or more adjacent vertebrae. It should be considered when chronic back pain was present before the herniated disk led to leg pain. Spinal fusion is not always reliable, and guidelines as to when it should be done are not as clear as those for diskectomy. Fusion may be recommended when back pain is greater than leg pain and is chronic. It is also recommended when a repeat operation is necessary because the first one was not effective in relieving pain or because herniation has recurred. Unfortunately, spinal fusion alters the way the spine moves and may promote degenerative changes as well.
Artificial disks. Although artificial disks have been available in Europe for more than 20 years, the FDA did not approve their use in the United States until 2004. The first artificial disk available in this country, called the Charité, was authorized for use in single-level disk problems (where one disk 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 disks are being tested in clinical trials in the United States. However, it will take five to 10 years to determine whether artificial disks can maintain long-term motion and prevent disk degeneration near the surgical site.
Candidates for disk surgery should have degeneration in only one disk 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.
Minimally Invasive Procedures
There are several less-invasive surgical alternatives that involve a smaller incision than traditional surgery.
Microdiskectomy is performed by the surgeon using very small precision instruments placed inside an endoscope (a small lighted tube) and inserted through a miniscule opening in the back. The surgeon can view the disk and nerves through the endoscope as well as remove herniated disk 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 do not experience relief with conservative treatments such as oral corticosteroids, NSAIDs, and physical therapy.
Percutaneous arthroscopic diskectomy involves inserting a probe into the spine to scoop out the disk.
Intradiskal electrothermal therapy (IDET) involves inserting a wire into the back that transmits heat into the collagen fibers of the disk, destroying pain receptors in the area. IDET initially appeared promising, but more recent reports have been disappointing.
Laser diskectomy uses a laser to burn out the disk. This procedure has been the subject of considerable debate, as the results of the procedure have varied greatly. Some studies show no greater improvement in symptoms after laser diskectomy than in similar cases where no surgery was performed; in others, it is as successful as standard surgery.