Frequently Asked Questions


What is a herniated disc?
Is there a difference between herniated, ruptured or slipped disc?
What is a bulging disc?
Are there problems in the back that can pinch a nerve?
Is there a chance that I can get better without surgery?
What can I expect from surgery?
When is surgery necessary?
Are artificial discs available?
Will additional surgery be necessary?
Can a disc fragment be removed without an incision?
What about the enzyme injection?
What can I do to maximize my recovery?
How do we decide to use physical therapy?

 

What is a herniated disc?

To understand the herniated disc, one must understand that the disc is made of of two main components: 1.) a tough outer ring of ligament that goes out from the vertebrae which is called the annulus and 2.) a soft jelly center which is called the nucleus. The annulus pulls the bones together and holds the nucleus in. If the nucleus is torn by extreme force or by wear and tear, it ruptures outward or, in other words, herniates. This happens silently without pain or with only back pain. If the nucleus herniates against a nerve, the patient may experience pain, numbness, weakness, or problems such as bladder urgency or loss of leg coordination.

Note: If there is a loss of bowel or bladder control or sexual impotence, the patient should see a doctor immediately since nerves can be damaged permanently.

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Is there a difference between herniated, ruptured or slipped disc?

Each term conveys a slightly different meaning to different experts, but they may be used by some interchangeably.

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What is a bulging disc?

A bulging disc occurs when the disc swells circumferentially due to a loss of internal pressure or structure, and it cannot hold itself tightly together. Treating specialists will need to determine the significance of the bulge because even small bulges can hurt.

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Are there problems in the back that can pinch a nerve?

Yes, problems in the back which will pinch a nerve can occur. The herniated disc is the most common and the most understood. Spurs next to a worn-out disc, spurs on an adjacent joint, or a gradual narrowing of the spinal canal can also cause pressure on the nerve. The pressure may range from mild to severe. Sometimes these factors come together to cause special difficulties. For example, a person with a small canal may have some additional encroachment upon the canal by a bulging or small herniation of a disc. In another person, a small spur in the wrong place may squeeze the nerve against an otherwise normal or bulging disc.

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Is there a chance that I can get better without surgery?

There is definitely a chance a person can get better without surgery. When there is spinal injury, the body and the mind will attempt to fix the problem. If a ligament is torn, the body will attempt to repair the ligament. If a nuclear fragment is in the canal, the body may try to reabsorb it, which it often does. Certain types of slippage and collapse won't go back, however, and certain types of nerve pressure result from things for which the body has no answer. That is when surgery is necessary. With the patient's understanding and approval, the individual surgeon must decide when the risks of surgery are outweighed by the benefits. This decision is very complicated. Every competent surgeon will want to protect the patient from surgery, if the chance for spontaneous recovery is likely or reasonable.

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What can I expect from surgery?

The patient should expect to have less emotional pain, better day-to-day function, and a hope that the benefit from surgery comes at a reasonable cost of discomfort and inconvenience.

Surprisingly, individual goals will vary from patient to patient. Though everyone wants "to get better," many patients want the solution without the necessary understanding and preparation. They may also want sympathy, a totally normal back (which almost never happens), or the guinea pig status of having the next shiny new implant.

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When is surgery necessary?

Surgery is performed when all alternatives have been tried, the risks are reasonable, and the patient agrees to accept those risks. Though this sounds like common sense, the decision is actually very individualized. For one patient, any risk at all immediately disqualifies surgery. For another, any risk of not operating, such as residual numbness or weakness, drives the patient to an early surgical choice.

Some problems with the greatest early pain have excellent prognoses without surgery. Others which sneak up slowly without pain-but with weakness, numbness or lack of coordination-may be destined to become steadily worse or to create new problems, like bladder urgency or loss of limb coordination, if something is not done. The selfless surgeon is the best professional to say what he or she can do to help, surgical-wise or not. Be wary of any practitioner who promises too much, whether it is a surgeon or another specialist.

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Are artificial discs available?

Yes, they are available. However, the indications are narrow and the expectations are limited. There are many designs, but only one is approved by the FDA thus far. Like any orthopedic implant, the artificial brings its own combination of complications and technical challenges. The patient to whom total disc replacement has been suggested should be very cautious. The technology is in its infancy and the problems, and the solutions to those problems, have not been sorted out. The artificial disc is an excellent example of new technology that has not found its ultimate place.

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Will additional surgery be necessary?

Only a very cautious and experienced appraisal of the facts can decide on the likelihood whether more surgery will be necessary. Many backs that look degenerative on x-ray films function well for awhile. Others that look good may have lots of symptoms because something was overlooked. One important principle in orthopedics is to be as conservative and thorough as possible in order to prevent complications and also to prevent the need for more surgery for as long as possible.

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Can a disc fragment be removed without an incision?

Yes, a disc fragment can be removed without an open incision. A disc fragment can be removed through a surgery called "percutaneous (through the skin) discectomy." This is when a tiny tube is placed into the center of the disc under local anesthesia and the disc is placed under suction so that the fragment will come back through the tube rather than through an open incision. Dr. Stark believes this surgery is not as effective as conventional open laminectomy. A micro-laminectomy has a success rate of approximately 90-95%, whereas apercutaneous discectomy has a success rate of around 70%. This 20% difference is significant. It means the difference of having a one in three chance of failure or having a one in ten chance of failure. For this reason, Dr. Stark chooses to do a well-directed laminectomy under magnification.

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What about the enzyme injection?

An approach that was very popular around five years ago for a herniated disc was the chymopapain injection, which involves the use of an enzyme placed in the center of a disc. This enzyme dismantles the molecular structure that holds water within the disc. As the disc is effectively dried up, it becomes smaller and the pressure on the nerve is relieved. Theoretically, this is an attractive technique because no surgical incision is made. However, there have been many side effects, some of which have been severe. Sometimes the enzyme injection was too effective and caused an excessive flattening of the disc, resulting in low back pain and surgery. Because of these side effects, the chymopapain injection is reserved for very specific circumstances.

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What can I do to maximize my recovery?

Recovery hinges on each of the individually affected tissues. To optimize recovery, the patient must have a basic understanding of what was done during their surgical procedure. If a patient knows that he or she had a skin incision, it must be told that this usually takes ten days to heal. If a patient knows that he or she had some bruising of the muscle, it must be told that recovery of these areas is usually rapid but does not require special attention. A patient with bruised and sore muscles following low back surgery will first need to wait for the swelling and soreness to resolve and then will need to work on strengthening the muscles once again.

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How do we decide to use physical therapy?

We prescribe physical therapy for a variety of purposes. Physical therapy includes treatments such as heat, message, and traction to relieve sensitivity and soreness. Physical therapy also has muscle strengthening exercises to relieve atrophy and weakness. These exercises help to relieve the stresses on the low back and compensates for weakness in other areas.

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