Why does pain go down my leg if I raise my leg after lying down?
This is known as the ‘SLR’ or the ‘Straight Leg Raise’ test. This is a test which checks the nerve root for its free movement. When it is crushed or compressed by a herniated disc, it will not be possible for a patient to raise a straight leg while lying down on his back.
My back and my leg pains. I have pins and needles in my leg. I have burning pain on the outer side of my calf. What tests should I do?
Tests that are routinely advocated are plain x-rays to look at the bony changes that may be a causative factor in back and leg pain. Along with this, a common test is an MRI (Magnetic Resonance Imaging) scan. This is a non-invasive scan, does not expose the patient to any radiation, can even be done on a pregnant woman, and can clearly show the neurology. i.e. the spinal cord, its ending, and the nerve roots that come out from it, thereby enabling the doctor to see for compression of the roots over the spinal cord due to a herniated disc. Apart from this, the third most vital test to be done is the EMG nerve conduction study test. This test is a functional test and picks up the involvement of the nerve root and the damage suffered by it and can be correlated to its physical crushing in an MRI scan.
Where all in my limb can I have pain due to a herniated disc?
Pain follows neurological dermatomal patterns. Specific nerves supply specific areas of the skin and therefore pain can be perceived in those specific areas depending upon the nerve involved. For example, if the S1 nerve is involved, pain will be felt in the sole of the foot. If the L5 nerve is involved, pain will be felt on the outer side of the calf. When the L4 nerve root is involved, pain will be felt on the outer side of the knee and the upper thigh and the buttocks.
Why do I have back pain?
I have back pain because my spinal disc has degenerated. It has started to herniate and has triggered the pain fibres in the sinu-vertebral nerve which supplies the posterior third of the human disc outer shell, known as ‘annulus’. When herniation, protrusion, or sequestration which are the stages of disc herniation increasing in nature, they become prominent. The patient starts perceiving back pain.
When is surgery really needed in a spinal herniated disc patient?
Surgery is really needed when the patient feels pain. Pain can be perceived only when there is inflammation and inflammation will set in only when the immune privilege of the spinal disc fails and it is exposed to the human immune system. Apart from pain, neurological deficit is the second major indication for considering a patient for disc surgery.
Does smoking, lifting heavy objects, or gymming cause aggravation of my problems?
Yes. Smoking increases the carbon dioxide in your bloodstream and thereby diminishes the nutrition that is available to the disc. Weight lifting, gymming are known to cause concentric loading of a spinal disc, leading to internal tears. These are all predisposing factors for degeneration and subsequent herniation of a spinal disc.
At what age does the spinal disc become bad?
Early degeneration has been seen even in young people, as young as 18-20 years old. Possibly because of lifestyle changes, active sports lifestyle, bodybuilding, weightlifting, and genetic factors. All of these are known for early predisposition to degeneration of the disc.
Can more than one spinal disc be spoilt?
Yes. More than one spinal discs can be spoilt at the same time but need not be the cause of pain. A single one of those discs can progress to give pain. It is for the clinician to determine the level of involvement of a disc in causing pain.
Can I take part in jogging, bike riding or any strenuous exercises if I have a large herniated disc?
Please do whatever is comfortable for you without straining or further damaging your spine.
Do exercises help to put a disc back in its place?
Yes, exercises do help in putting a disc back in its place. Refer to the McKenzie’s extension program. This group of exercises was devised by a New Zealand physiotherapist and has proven to be relatively effective in patients whose discs have bulges but have annular integrity.
Can nature heal my problem?
Yes, it can heal your problem and it will definitely heal your problem, but there are two issues with these things. One, nature sometimes takes a very long time. It could be a few years, because if the disc fragment is osteocartiligenous and nucleus, resorption of that fragment will take many years to happen. Secondly, neurological damage, once it sets in, is irreversible. So keeping these two things in mind, sometimes the doctor opts for surgery, as this is the safest and best way to get his patient out of his problem.
I have undergone a spine surgery. Can my problem recur?
Yes, after disc surgery the incidence of recurrence of herniation of a disc within six months is close to 10-12 per cent internationally. Irrespective of the approach used, whether you undergo a microdiscectomy, open laminectomy and discectomy, tubular discectomy, transforaminal discectomy, or posterio-lumbar decompressive discectomy, all forms of surgery have the same rate of recurrence. The reason is not in the approach, but in the nature of the tear of the annulus. Annular healing is poor and therefore the weakened annulus gives way and a further fragment can migrate out through the tear. This is the basic reason why recurrence of disc herniation occurs.
Will I be bedridden by endoscopic surgery?
This is a definite no. We encourage the patient to get up within two hours of surgery and walk to the bathroom by themselves. This surgery is done in an awake and aware state and no known major complications of this surgery are known. Sometimes, after surgery patients may have a burning sensation or irritational pain in the lower limb. That is because of the freeing up of a tense nerve root, which undergoes ‘rebound swelling’ when it gets freed up. This irritation or pain in the leg might persist for a few weeks before it goes away.
I have been operated by other techniques such as open surgery, minimally invasive techniques, micro discectomies – what do I do?
Your endoscopic discectomy offers a distinct advantage as it bypasses all the scar tissue that is present from the posterior midline approaches and without further disturbance of bone or nerve one can successfully go anterior and remove the reherniated fragment.
I have been operated for fusion surgery with rods and screws in my back. I still have a lot of pain. What do I do?
Pain persisting after fusion surgery can be either because of non union, failure in breakage of implant, or a retained disc fragment posterior to the fusion mass or cage. It could also be inadequate increase in disc height, resulting in foraminal entrapment of the nerve root which could also have been missed at the time of the primary surgery. Under these circumstances, transforaminal endoscopic spine surgery or a UBE surgery offers access angles to relieve a trapped nerve or extract a retained disc fragment, thereby relieving the patient of pain.
What are the complications or side effects that can occur during or after endoscopic spine surgery?
In Transforaminal endoscopic spine surgery, the two major problems that can occur are 1. Nerve root irritation, which can persist over a few weeks to a couple of months. The patient might require some medication to relieve this. 2. A temporary nerve paralysis which again shows recovery. However, that recovery takes a long time and the patient might have some weakness in the limb. It might take up to one year’s time for the patient to recover fully. In other posterior endoscopic spine surgeries, the complication that can happen is a minor tear of the dura which then has to be endoscopically repaired, or the case has to be converted into a mini open case to repair the tear.
What are the various forms of spine surgery for spinal disc herniation?
Surgery for spinal disc herniation started with Mixter and Barr in 1934, where a standard posterior midline approach is taken, the bone and the intervening ligamentum flavum is cut, the dural tube is exposed, pulled on one side, and then the disc is removed. Over a period of time, micro endoscopic discectomy with the use of an operating microscope became a standard procedure as a very small incision was needed. Over the last few years minimally invasive spine surgery. i.e., doing spine surgery through a tube as a retractor of the muscles has developed. But all these posterior surgeries involve cutting of bone and ligaments, and stripping of muscle. Today the world has moved towards a truly minimalistic endoscopic spine surgery approach. Now endoscopic spine surgery can be done through the natural orifice known as the foramen without cutting of any bone. This is called Transforaminal Endoscopic Spine Surgery (TESS). Apart from this, Posterior Lumbar Stenosis Decompression (PSLD) and Unilateral Biportal Endoscopy (UBE), aka BESS endoscopy, have developed. These have a 3-4mm incision to allow a scope to be introduced and through a similar small working channel an operative instrument is introduced. So without major cuts in the skin or tearing of the muscle, the same result is achieved as the one from the surgery methods followed over the last century.
Why is endoscopic spine surgery better?
Endoscopic spine surgery is done in the awake and aware state of the patient by injecting local anaesthetic in the path through the foramen and into the disc. This surgery can be done with near zero blood loss, the patient has a small 7mm incision on the back, and this cut is only in the skin. All the tissues below the skin are dilated (pushed aside), and a tract is made. There is no cutting, stripping or tearing of the deeper muscles. Post surgery a patient can get up and walk within an hour and can be discharged the same day or the next day. There is really no pain that is felt by the patient while undergoing this procedure.
What is laser assisted endoscopic disc surgery?
In laser assisted endoscopic disc surgery, one uses a side-firing laser known as a holmium:YAG laser, which deposits a large amount of energy over a very small focused spot on the tissue, helping to evaporate tissue. As the tissue gets evaporated, it becomes easier for the surgeon to reach his eventual target and extract the offending segment which is troubling the nerve root or the dural tube.
What do I do if I have problems with multiple discs?
Stenotic posterior surgery through a stenoscope can be done at a single level at a single time and even multi level can be done at the same sitting. The same thing applies to UBE surgery. But Transforaminal endoscopic Discectomy is a procedure in which we prefer to stage a maximum of two levels at a time. This decreases the operative time. It is difficult for patients, especially overweight or elderly ones, to sleep on their stomach for a long time and therefore these procedures under endoscopic discectomies are staged by the surgeon. One procedure every day or every alternate day is done according to the requirements. The eldest person I’ve operated on was 89 years old. These are the kind of age groups where general anaesthesia can be fatal, recovery from it involves danger, and the patient can have a lot of co-morbidities such as heart failure, diabetes, blood pressure, which is expected at that age. It is therefore imperative to do these surgeries under local anaesthesia in a staged manner.
What are the failure rates in endoscopic spine surgery?
Worldwide, the failure rates for discectomy by any approach is around 10-12 per cent. The same holds true for all endoscopic spine surgeries.
In case of reherniation, what can be done?
Endoscopic spine surgery is a wonderful modality of surgery that affords you the privilege of reentering and reextracting a herniated fragment. A surgeon can at that time also take the call of conducting a fusion surgery through the endoscope to permanently fuse that segment, and remove all discal material, especially if it is badly degenerated. The spine is then fixed percutaneously through a minimally invasive technique thereby locking in the cage and the graft and allowing the fusion to occur.