Lumbar herniated disc

The cartilaginous structure located between two vertebrae, which also acts as a connecting link between them, is the vertebral disc. It consists of a buffer and distributor of the loads to which our spine is exposed.

The external annulus fibrosus and the collagen that it is made up of are part of the spinal disc and look similar to the concentric shape of the layers of an onion. Also, in the central part is the gelatinous nucleus pulposus.

In the case of lumbar hernia, the extrusion of the disc occurs in one of the intervertebral spaces comprised between the 5 lumbar vertebrae, with the L4-L5 and L5-S1 spaces being most frequently affected.

aging spine is the main cause of lumbar disc herniation. Three men for every woman, mostly during their fourth and fifth decades of life, suffer from this type of herniated disc.

On the other hand, this pathology correlates with an excessive overload on the intervertebral disc. The area where it occurs most frequently is L4-L5 and L5-S1 since they are the discs farthest from the center of the spine that support the greatest axial load. However, the causes of why the discs of some patients degenerate before those of others, subjected to the same activity, are unknown.

Certain professions can be the origin of the lumbar herniated disc when they consist of manual handling of heavy loads, repetitive movements, or vibrations of the spine, frequently causing pain in the lower back. If the patient has been treated with a non-invasive procedure such as the use of orthopedic lumbar belts and does not progress adequately, it will also be necessary to perform this lumbar hernia microsurgery at our medical center in Madrid with our specialists in a herniated disc.

Finally, overweight, obesity, and weight gain during pregnancy can aggravate ruptures of the annulus fibrosus and lead to herniations.

Compression at L4 affects the tibialis anterior muscle, making walking on heels difficult, sensitivity in the anteromedial part of the leg and the affected reflex is usually patellar.

When compression occurs in the L5 nerve root, there is usually involvement of the extensor hallucis longus muscle (EHL), extensor digitorum communis, extensor digitorum brevis muscle, and gluteus medius. There is difficulty in extending the big toe (counterresistance). Sensory involvement occurs in the lateral foot and leg, and tendon reflexes are usually not affected.

When the affectation is in S1, the ailment reaches the triceps surae muscle (calf muscles and soleus), lateral peroneus, and gluteus maximus. Toe walking is usually not tolerated. The sensory involvement is in the sole of the foot and the affected reflex is the Achilles.

Less frequently, hernias occur at upper lumbar levels. In these cases, when the L1, L2, or L3 nerve roots are affected, the pain is focused on the anterolateral aspect of the thigh and the hip flexor and adductor muscles are affected.

For the diagnosis of lumbar disc herniation, it is necessary to carry out a detailed clinical history, with a detailed examination of the patient, and evaluate the complementary tests:

• MRI indicates whether there is a herniated disc or protrusion. Likewise, it defines whether there is spinal cord compression and whether it compromises the nerve in the centrolateral, foraminal or extraforaminal area.
• In the lumbar X-ray, the degenerative state of the intervertebral discs can be verified, which can condition the surgical alternative to be performed.
• The electromyogram is used to define the level and intensity of nerve root or spinal cord involvement in the compressed region. 
• MRI allows us to clearly see if there is a cervical disc herniation. Nowadays, it is the most effective test to detect this pathology since it offers a very clear image of the impingement of the nerve root.
• With the lateral and anteroposterior projections of an X-ray, we can check the degenerative state of the intervertebral discs and discover possible traumatic pathologies such as fractures or dislocations.
• We use the electromyogram to measure the level of involvement in the compressed area. 

When medical treatment with analgesics, anti-inflammatories, antineuritic drugs, and muscle relaxants does not produce sufficient pain relief, and it persists over time or is very intense, surgical decompression of the nerve or spinal canal is usually required.

The most frequently used surgery for lumbar herniated disc nowadays are:

• Advanced Spine Endoscopy.
• Microdiscectomy.
• Laminectomy and discectomy by open surgery.

Undoubtedly, endoscopic treatment for the lumbar herniated disc is the least aggressive and with fewer intra- and postoperative complications. It has a rapid recovery and the patient usually leaves the hospital on the same day.

Extensive training and experience in the advanced endoscopy technique of the spine are required to achieve an excellent result, as well as in the different approaches to extracting the herniated disc.

In the microdiscectomy, a broader approach is performed than in the endoscopic treatment, approximately 3 centimeters. Greater aggressiveness is produced on the muscles and ligaments and, consequently, the postoperative period is more painful.

Open spine surgery is the least recommended option, as long as it is not necessary. It involves a larger opening and is the most aggressive technique of the three possibilities to recover the lumbar herniated disc.

Our traumatologists specializing in lumbar herniated disc surgery in Madrid will always first choice for minimally invasive lumbar hernia microsurgery for all our patients.