Surgical Lumbar Disc Herniation
Written by: James Demetrious, DC, DABCO – Diplomate, American Board of Chiropractic Orthopedists
Nonsurgical or Surgical Care?
Chiropractic care offers substantial relief to many patients with spinal disc herniations. There are times that patient suffering, activities of daily living, and quality of life can be improved through surgical intervention. What is the best course of care for large disc herniations? What are the inherent risks of managing large disc herniations and neurologic sequelae? What is in the best interest of our patients?
Progressive Motor Deficits
I was asked to consult on the case of a healthy 36-year-old female who attained relief from chiropractic care over many years for lower back pain. After the birth of her second child, she experienced increased lower back pain with S1 radicular symptoms. Chiropractic care, physical therapy, OTC medications, and a brief course of oral steroids provided intermittent relief. However, her symptoms progressively worsened, and she developed lower extremity plantar flexion weakness graded 4/5.
MRI of the lumbar spine was performed. The MRI revealed a large L5/S1 disc extrusion in the sub-articular zone that deformed the thecal sac with posterior displacement of the left S1 nerve root. Incidental findings included an L4/5 central disc protrusion and annular fissure (Image 1).
Image 1. Axial T2WI.
Incidental findings included an L4/5 central disc protrusion and annular fissure (Image 2).
Image 2. Sagital T2WI.
Patients must receive their diagnosis in terms they can understand. I discuss their findings and answer their questions to the best of my ability. I try to provide insight into factors that are important toward allowing them to make non-surgical versus surgical decisions by:
- Carefully describing their specific findings and expectations.
- Offering information regarding the prevalence of disc herniations and associated degenerative changes in the asymptomatic population. I discuss the possibility of resorption of large disc herniations described in the literature.
- Providing recommendations for alteration of activities of daily living to minimize further exacerbations and offer the patient time off from work.
- Stressing the importance of progressive motor deficits and neurogenic autonomic sequelae, function, and capabilities over time. I discuss the need to carefully monitor their symptoms for signs of progressive neurologic degradation and report those concerns to their doctors. I recommend that they seek immediate care at their local hospital emergency department if they experience signs of rapid neurologic degradation, weakness, bladder or bowel incontinence/retention.
- Sharing information related to alternate non-pharmacologic and non-surgical interventions.
- Having discussions related to pain management, surgical options, benefits, and risks of surgical interventions.
- Describing short and long-term effects of non-surgical and surgical interventions.
- Discuss their recovery and follow-up chiropractic/ancillary care.
A Favorable Surgical Outcome
In our case, I discussed all of the above and recommended a timely neurosurgical consultation. She elected to undergo surgical intervention. The surgeon indicated that he was able to successfully debulk the herniated disc material. Her outcome was outstanding. The patient reported immediate relief of lower back pain and radicular symptomatology. She reported improvement of lower extremity paresthesias and motor deficits.
Patients must be provided with clinical options so they can make informed decisions. They should be reassured and encouraged to discuss their findings and options with their family practitioner and surgeon. In such cases, I do my best to provide objective care, options, risks, and benefits to allow them to make a decision that meets their needs.
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The views and opinions expressed in this presentation are solely those of the author. We offer this only to educate and inform. Patients should seek the care of their doctors regarding their conditions.
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