Why Only One Level for Lumbar Disc Herniation Surgery?

Why is only one segment operated on for lumbar disc herniation surgery?

Hello, Doctor! Thank you for taking the time to answer my questions amidst your busy schedule.
I am 177 cm tall and regarding my condition: I have been experiencing lumbar disc herniation with pain for several months.
I had acute episodes in December and on January 27, where the pain was so severe that I was unable to walk and had to lie on the road.
I experienced several days of limited mobility.

For my usual symptoms, I feel soreness and numbness in my right foot, calf, and entire lower back.
My right leg feels weaker, making it difficult to sit or stand for long periods.
Bending over to wash my hair, putting on socks, sitting up from bed, crossing my legs, sneezing, and coughing can all trigger numbness in my legs and soreness in my back.
I also have allergic rhinitis, and changes in the weather often exacerbate the pain.
In terms of treatment, I have seen several doctors, both Western and traditional Chinese medicine, near my home.
In December, I was unable to walk and thought I had tendonitis, so I received anti-inflammatory injections.
I regularly went for massage, acupuncture on my back and leg acupoints, electrical therapy, and heat therapy.
I took anti-inflammatory medication and muscle relaxants for two months until I consulted a neurosurgeon, who identified the cause of my condition.
An MRI revealed herniation at two levels (L4-L5 and L5-S1) and advised against nerve compression.
They recommended microsurgery, which requires a five-day hospital stay and several weeks of recovery, along with wearing a soft back brace for 3 to 6 months.
The surgery will only involve the removal of the herniation at L4-L5, as the L5-S1 level is not compressing the nerve, so there will be no need for two incisions.
I have some questions for your advice:
1.
What is your diagnosis?
2.
How long can nerve compression last before it causes irreversible spinal cord damage? What is the optimal timeframe for surgery?
3.
Since the L5-S1 level is not compressing the nerve, is there a chance it could also herniate in the future, requiring a second surgery? Is it common in clinical practice to only operate on one level when there are two herniated discs?
4.
There is a belief that post-surgery, one may experience back pain for life.
Is this a common situation among patients during follow-up visits? Are there any other minor side effects?
5.
After surgery, regarding recovery, will I be able to return to normal activities? I hope I won't be restricted from lifting more than 3 kg, running, or climbing stairs for life.
Thank you for your help! I appreciate it!

Qiuqiu, 20~29 year old female. Ask Date: 2006/03/23

Dr. Qiu Yushu reply Neurosurgery

Hello! 1.
Your symptoms do appear to be consistent with a herniated disc, which can be confirmed with an MRI.
2.
If your symptoms are significant, surgery will be necessary.
3.
After the surgery, you should be able to return to normal activities, but you will still need to avoid lifting heavy objects and engaging in vigorous exercise.
Dr.
Yu-Shu Chiu

Reply Date: 2006/03/23

More Info

When it comes to lumbar disc herniation surgery, the decision to operate on only one level, despite the presence of multiple herniations, is often based on several clinical considerations. In your case, the MRI findings indicate herniations at both the L4-L5 and L5-S1 levels, but the surgical recommendation is to address only the L4-L5 level. Here are some reasons why this approach is commonly taken:
1. Symptom Severity and Nerve Compression: The primary reason for surgical intervention is to relieve nerve compression that is causing significant symptoms, such as pain, weakness, or numbness. If the L4-L5 herniation is the one causing the most severe symptoms, it makes sense to address that level first. The L5-S1 level may not be contributing significantly to your current symptoms, which is why the surgeon may choose to leave it untreated for now.

2. Surgical Risks and Recovery: Each surgical procedure carries inherent risks, including infection, bleeding, and complications related to anesthesia. By limiting the surgery to one level, the surgeon reduces the overall risk to the patient. Additionally, recovery from surgery can be demanding, and focusing on one level allows for a more manageable rehabilitation process.

3. Potential for Conservative Management: In cases where one level is symptomatic and the other is not, the non-symptomatic level can often be managed conservatively. This might include physical therapy, medication, or lifestyle modifications. If symptoms do develop from the L5-S1 level in the future, a second surgery can be considered at that time.

4. Avoiding Unnecessary Surgery: Surgeons are generally cautious about performing unnecessary procedures. If the L5-S1 herniation is not causing significant issues, operating on it could expose you to unnecessary risks without providing substantial benefits.

5. Long-term Outcomes: Research has shown that many patients who undergo surgery for one level of herniation can achieve significant relief of symptoms and improved function. If the other level becomes problematic later, it can be addressed at that time, often with good outcomes.

Regarding your specific questions:
1. Diagnosis: Based on your symptoms and MRI findings, you have lumbar disc herniation with nerve root involvement, particularly at the L4-L5 level.

2. Nerve Compression Duration: The duration of nerve compression that can lead to irreversible damage varies, but generally, prolonged compression (weeks to months) can lead to permanent changes. Early intervention is usually recommended if significant symptoms are present.

3. Future Herniation: There is a possibility that the L5-S1 level could develop issues later, especially if it is already degenerated. Regular follow-ups with your healthcare provider are essential to monitor this.

4. Post-Surgery Symptoms: Some patients do report chronic pain or discomfort after surgery, but this varies widely. Many patients experience significant improvement, while others may have residual symptoms. It's essential to discuss these concerns with your surgeon.

5. Post-Operative Activity: After recovery, most patients can return to normal activities, including lifting light weights and engaging in physical exercise. However, it is crucial to follow your surgeon's advice regarding activity restrictions during the recovery phase.

In conclusion, the decision to operate on only one level during lumbar disc herniation surgery is based on a careful assessment of symptoms, risks, and potential benefits. It is essential to maintain open communication with your healthcare team to ensure the best possible outcomes for your condition.

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