A lumbar MRI will show your bladder

Lumbar disc herniation

The lumbar spine is subject to very heavy loads. These lead to incorrect and overloading, especially in the lower area, which can manifest itself in pain, but also in functional disorders of the nerves.

The simplest form is disc protrusion. This is a bulging of the intervertebral disc that can cause back pain (lumbago) and / or pain in the leg (sciatica or lumbar sciatica).

If the outer firm fiber cartilage tears, the soft inner intervertebral disc nucleus emerges into the spinal canal. The patients then often feel very severe back pain. If the worn-out piece of intervertebral disc presses on a nerve root, lumbar sciatica occurs, often associated with sensory disturbances, but sometimes also paralysis in the leg or buttocks. In the case of very large herniated discs, the nerve fibers for the urinary bladder or the rectum can also be affected. In these fortunately rare cases, there is an acute loss of control of the bladder and bowel. Immediate treatment in a specialized clinic is necessary for this emergency.

 

Fig 1.

Representation of a herniated disc between the 4th and 5th lumbar vertebrae on the right in the magnetic resonance tomogram (left transverse, right sagittal section)

 

The main focus of therapy is conservative physical treatment. Through the use of different techniques, the little-noticed abdominal and back muscles are specifically trained and the pain is relieved with medication. The step bed storage can be a relief. Here the patients find a position that relieves them of stress, which at the same time reduces the pressure in the intervertebral disc and leads to a reduction in nerve root irritation. Heat applications as baths and also as healing mud packs are also very helpful.

 

The most important component, however, is physiotherapy, in which you learn to actively relieve your back through targeted use of the muscles. In most patients, these measures lead to a significant reduction in symptoms, so that an operation is not necessary.

 

Conservative treatment can be carried out on an outpatient basis as well as under inpatient conditions. Your own motivation is very important. Physiotherapy treatment helps people to help themselves. Permanent pain relief is only possible with consistent continuation of the exercises learned.

 

The most important part of the diagnosis is the anamnesis. Your information often provides specific information about the cause and location of the disease. The second pillar of the diagnosis is the clinical examination, which often gives an indication of the exact location of the disc damage. Technical investigation procedures are based on these two pillars.

 

Usual investigation procedures are

  • Magnetic resonance imaging (MRI)? Examination method of choice to visualize the spinal cord, nerve roots and intervertebral discs
  • X-ray examinations of the spine to diagnose malformations, deformities and severe degenerative changes
  • Functional recordings of the spine to diagnose instability
  • CT examinations to assess the bony structures of the spine
  • In the case of contraindications for an MRI (e.g. pacemaker, older metal implants, etc.), a myelo-CT (computed tomogram after injection of contrast agent into the spinal canal) may be necessary.
  • Electrophysiological examination to localize nerve damage
  • Discography to verify a painful disc

Immediate surgical treatment is necessary for the rare mass herniations of the intervertebral disc with severe constriction of the spinal canal, which lead to a loss of control over the urinary bladder or the rectum. Delayed treatment can lead to permanent functional disorders.

Surgical treatment is also urgent for acute paralysis. Here a longer delay can lead to permanent damage.

 

Another indication for treatment is persistent pain despite consistent physiotherapeutic treatment.

  • microsurgical disc surgery
  • minimally invasive disc surgery using the dilatation technique
  • endoscopic disc surgery

This technique is used in the case of pronounced signs of wear and tear on the spine with enlargement of the vertebral joints, strong thickening of the ligaments, osseous constrictions of the spinal canal and after operations on the spine that have already been carried out.

 

The bony and connective tissue constriction of the spinal canal is removed through a 3-4 cm long skin incision under the surgical microscope, the painful nerve root is exposed and the herniated disc is removed. In some cases, loose, severely altered parts of the inner nucleus have to be removed. Often, however, the intervertebral disc can be retained and the mobility of the spine can be further guaranteed in this area.

 

With this technique, the herniated disc is removed by means of a 15mm long skin incision through a working canal under high magnification. Due to the very small skin incision and the minimal strain on the muscles, the postoperative pain is significantly lower. There is also a hardly measurable loss of blood. Due to the minimal surgical trauma, patients can get up on the day of the operation and leave the clinic after a short time.

 

Fig 2.

Instruments for the minimally invasive surgical technique

 

Fig 3.

A: Dilate the transmuscular access with guide cannulas of different sizes

B: Operation over a placed operation sleeve with a diameter of 14mm

 

Fig 4.

X-ray control to check the correct position of the sleeve (intervertebral disc marked with an arrow)

 

Fig 5.

A: Removed herniated disc in forceps

B: Scar of 15mm length 2 months after the operation

 

Fig 6.

A and B: Magnetic resonance imaging (MRI) of a patient with severe lumbar sciatica and left foot palsy. It shows a sequestered herniated disc between the 5th lumbar vertebra and the 1st sacral vertebra (arrows)

C: Postoperative CT showing the minimally invasive approach to the herniated disc (only 8 mm wide opening in the vertebral arch).

D and E: The postoperative MRI shows the complete removal of the herniated disc. The patient was symptom-free immediately after the operation. The palsy of the foot has completely receded in the further course.

 

This intervention is mainly carried out in the case of herniated discs in the area of ​​the neuroforamen (the bony exit of the nerve from the spinal canal). The procedure takes place under local anesthesia and accompanying pain therapy. The herniated disc can be removed here through a very small incision under endoscopic control.

 

Fig 7.

A: Placing the guide needle for endoscopic disc surgery in the lateral position

B: Checking the correct position of the access in a 2-plane X-ray fluoroscopy

 

Fig 8.

Operation view with the endoscope in place

 

You can get up on the day of the operation accompanied by our physiotherapists. The stay in the clinic is relatively short. In the postoperative phase you will learn the most important rules of conduct and basic elements of spinal exercises. This should be continued in cooperation with your family doctor. Subsequent rehabilitation is recommended. Our social service will advise you here.

 

Complications are relatively rare with these interventions. However, should unexpected problems occur during or after an operation, these can usually be managed quickly and safely for the patient through the cooperation of the doctors at a maximum care hospital. Your attending doctor will advise you in detail on this.

 

Last change: 25.05.2011 10:48
© 2011 University Clinic of the Ernst Moritz Arndt University Greifswald