Surgical Options for Persistent Disc Herniation Pain

If physical therapy and manual therapy do not improve a herniated disc, is surgery necessary?

Hello, Doctor: I usually exercise very little, but from January to the end of February 2014, I underwent intensive training in running.
Suddenly, in early March 2014, I experienced severe pain in my entire left leg.
Initially, I thought it was a sports injury and took painkillers, which alleviated the pain somewhat.
Later, only a specific point on the left side of my buttocks continued to hurt.
In April, while squatting, my entire left leg again experienced severe pain.
I consulted a rehabilitation specialist and began physical therapy (including heat therapy, electrical stimulation, infrared treatment, etc.), but the pain remained localized to the left side of my buttocks (with no other pain).
The doctor found this puzzling and ordered an X-ray, which revealed that the spinal disc space was too narrow.
Subsequently, I developed issues with walking or standing for extended periods (after more than 10 minutes, I would feel pain on the outer side of my left calf, but sitting for long periods was not an issue at that time).
In May 2014, I started experiencing lower back pain, and by mid-June, an MRI confirmed a herniated disc.
After 1-2 months of lower back stretching, I no longer had issues with standing or walking for long periods.
I continued with the stretching, but starting in August 2014, I could no longer sit for long periods (after sitting for 10-20 minutes, I would experience sciatica symptoms, with numbness and pain on the outer side of my left calf, and pain in my toes; resting for 10 minutes while standing would alleviate the symptoms).
I continued with lower back stretching for six months (the weight I was using for stretching reached the limit—half my body weight, and I maintained this for about 1-2 months), but there was almost no improvement (stretching continued until November 2014), so I stopped.
In December 2014, I purchased an inversion table and have been using it since (with no improvement).
I have seen three different manual therapists since the onset of my condition, but there has been no improvement.
In November 2015, I returned to another rehabilitation clinic to restart lower back stretching, reaching the limit again, but with no improvement.
Since August 2014, I have primarily struggled with the inability to sit for long periods (aside from this issue, I have had no other significant problems in daily life).
During this time, I consulted several major hospitals' orthopedic and neurosurgery departments, all of which recommended surgery (National Cheng Kung University Hospital suggested minimally invasive surgery, while Chi Mei Medical Center, E-Da Hospital, and a hospital in Kaohsiung all recommended minimally invasive surgery combined with a dynamic spinal stabilization system if insurance covered the out-of-pocket expenses).
I would like to ask the physician: 1.
Is minimally invasive decompression surgery sufficient? 2.
Is it really advisable to combine minimally invasive surgery with a dynamic spinal stabilization system? 3.
What are the differences between having a dynamic spinal stabilization system and not having one? Will it need to be replaced in the future? Or if it malfunctions, will I need another surgery? Thank you for your response!

Shen Xiansheng, 40~49 year old female. Ask Date: 2015/12/27

Dr. Lai Zhaokang reply Neurosurgery

Hello, based on your symptoms, if the MRI has confirmed a herniated disc compressing the nerve, causing sciatica and significantly affecting your daily life, and conservative rehabilitation has been ineffective, it may be time to consider surgery.

1.
You mentioned a minimally invasive decompression surgery; is that sufficient?
2.
Or do you really recommend a combination of minimally invasive surgery and a dynamic stabilization system?
3.
What is the difference between having a dynamic stabilization system and not having one? Will it need to be replaced in the future, or could there be a malfunction requiring another surgery?
As a physician specializing in spinal neurosurgery with long-term experience, I can clarify the following for you:
1.
In simple terms, decompression means removing the pressure on the nerve.
2.
Minimally invasive refers to a surgery with small incisions.
3.
Dynamic stabilization means that after decompression, if there is a defect in the spine, a dynamic implant is used to provide support to your lower back.
Dynamic stabilization is contrasted with rigid fusion (permanent fixation).
If you choose dynamic stabilization, it will not be a permanent fix.
Therefore, it may wear down over time depending on your age and usage.
The lifespan of the system will depend on how well you maintain it, as you are a living person and the system is artificial and lifeless.
I hope my explanation helps you understand.
Wishing you a speedy recovery.
Director of Spinal Neurosurgery, Changhua Hospital, Dr.
Lai Chao-Kang.

Reply Date: 2015/12/27

More Info

When dealing with persistent pain following a herniated disc surgery, it’s essential to understand the various surgical options available and their implications. Your situation, characterized by ongoing discomfort and functional limitations despite multiple interventions, raises several important considerations.

1. Microdiscectomy vs. Microdiscectomy with Dynamic Stabilization: Microdiscectomy is a minimally invasive procedure aimed at removing the herniated portion of the disc that is pressing on the nerve root. This procedure is generally effective for alleviating nerve compression and associated pain. However, in cases where there is significant instability in the spine or recurrent herniation, surgeons may recommend combining microdiscectomy with a dynamic stabilization system. This system involves the use of devices that help maintain spinal stability while allowing for some degree of motion, which can be beneficial in preventing future issues.

2. Indications for Each Procedure: The choice between a simple microdiscectomy and one that includes dynamic stabilization largely depends on the specific characteristics of your spinal condition. If imaging studies indicate that there is instability or if you have a history of recurrent herniation, the addition of a stabilization system may be warranted. This approach can help mitigate the risk of future disc herniations and provide a more stable environment for healing.

3. Dynamic Stabilization Systems: These systems are designed to support the spine while allowing for natural movement. They can vary in design and material, but generally, they are intended to reduce stress on the affected disc and surrounding structures. One of the key benefits is that they may help in maintaining spinal alignment and function post-surgery. However, it’s important to note that these systems may require monitoring over time, and in some cases, they could necessitate replacement or adjustment.

4. Potential Complications and Considerations: As with any surgical procedure, there are risks involved. Complications can include infection, nerve damage, or issues related to the hardware used in stabilization. It’s crucial to have a thorough discussion with your surgeon about these risks, as well as the potential need for future surgeries if complications arise.

5. Conservative Management: Before proceeding with any surgical option, it’s advisable to explore all conservative management strategies. Physical therapy, pain management techniques, and lifestyle modifications can sometimes yield significant improvements. Given your history of persistent symptoms despite various treatments, a multidisciplinary approach involving pain specialists, physical therapists, and possibly neurologists may provide additional insights and management strategies.

6. Follow-Up and Monitoring: Post-surgery, regular follow-up appointments are essential to monitor your recovery and the effectiveness of the chosen intervention. Imaging studies may be required to assess the status of the spine and any hardware used.

In conclusion, the decision regarding surgical intervention for persistent disc herniation pain should be made collaboratively with your healthcare team, considering your specific symptoms, imaging findings, and overall health status. It’s important to weigh the benefits of each surgical option against the potential risks and to ensure that all conservative measures have been adequately explored before proceeding with surgery. Always feel empowered to seek second opinions and ask questions to fully understand your treatment options.

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