LUMBAR HERNIA - NeurosurgeryTOBB ETU Hospital Created: 2016-02-15 13:52:24
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LUMBAR HERNIA - Neurosurgery

In most disc hernias, a part of exterior fibers of annulus fibrosus had not torn and the disc material is totally within the disc; but, there is diffuse disc protuberance. Although it is less frequent, the cartilaginous tissue bulges out the torn sheath or a free fragment compresses spinal canal and nerve root.

LUMBAR HERNIA - Neurosurgery

What is disc?

There are 5 vertebras in our lumbar (lower back) region. Disc is a cartilaginous pillow which is located between two vertebras (intervertebral localization). This connective tissue makes contribution to the strength and mobility of the vertebra and it takes a portion of load on the vertebra. This intervertebral cartilaginous pillow is comprised of a thick and hard exterior layer (annulus fibrosus) and a softer gel-like interior layer (nucleus pulposus).

What is lumbar hernia?

Disc hernia or lumbar hernia is a condition where exterior layer of the disc tears and interior layer bulges out or herniates throughout this tear.

In most disc hernias, a part of exterior fibers of annulus fibrosus had not torn and the disc material is totally within the disc; but, there is diffuse disc protuberance. Although it is less frequent, the cartilaginous tissue bulges out the torn sheath or a free fragment compresses spinal canal and nerve root.


LUMBAR HERNIA - NeurosurgeryWhat is underlying reason of disc hernia?

Tear of disc capsule results usually from trauma or straining. The straining may result from fall, traffic accident or lifting heavy load, but it may also cause by inappropriate repeated movements and weight gain. The second type strain is usually comprised of minor events and thus, patients do not remember them.

What are predisposing factors of disc hernia?

Effect of repeated inappropriate and straining movements on lumbar hernia is not known. Therefore, heavy workers and heavy sportsmen are under risk. Subjects with congenital structural disorders in vertebral bones are also under risk. Weakness of connective tissue and muscles, which ensure integrity of spinal column, is somewhat a factor. The connective tissue and muscles acts in harmony with movements of spinal column. Irregular nutrition is an important factor. Lower back pain is more common in subjects who frequently gains and loses weight. Moreover, load on discs increases in overweighing subjects resulting with changes in disc structures and lumbar hernia.

Which measures can be taken in order to avoid lower back pain?

All postures other than physiologically appropriate position of the spinal column causes higher load on discs, ligaments, vertebral joints and muscles. It is also the case for sudden movements and lifting heavy load.

It is very important to prevent heavy load on spinal column and strengthening muscles doing appropriate exercises. Strengthening muscles will also ensure avoidance of posture disorders. You should keep your lower back as much vertical to the floor as possible during your daily life. You should also care to load equally on your feet and your shoulders and hips are aligned. Do not stay at same position for long time. Do not wear shoes with high heels or shoes without heel. Shoes with moderate heel will load less on lower back. Keep your back straight on backrest of the chair. Do not sit at same position for long time and you have better occasionally stand up. The best lying position is the one which keeps spinal column as straight as possible. Your bed should be flat and it should not be too soft. You should prefer small and flat pillows rather than thick and large pillows. Prone position is not appropriate since it pits the curve of the lower back. You should necessarily avoid lifting and carrying heavy load. You should crouch first to lift an object. Divide load into equal portions and carry them using two arms. Sport should be done for joy rather than competition. Swimming, jogging and bicycling are well for your lower back. Particularly, backstroke ensures optimum relaxation.

What are complaints of a patient with lumbar hernia?

Pain: most remarkable complaint of patients with lumbar hernia is pain. It is felt in the lower back or legs. The pain extending to legs is referred as "sciatic pain" since it is located within distribution area of sciatic nerve. The pain results from the reaction between cartilaginous tissue and the nerve secondary to the pressure caused by the cartilage since the herniated cartilaginous tissue contacts the nerve root.

Scoliosis: Body involuntarily inclines to one side in order to relieve the nerve root which is compressed by the herniated cartilage. This condition is referred as scoliosis. It results from contraction of muscles located around spinal column.

Strength and function loss: Weakness develops occurs usually in feet and sometimes in legs depending on duration of compression on nerve root. Weak side is better felt when the patient walks on heels and on fingertips. Advanced stages of disc compression is associated with severe loss of sense, loss of reflex and urination and defecation problems (i.e., urinary incontinence).

How is disc hernia diagnosed?

Your physician will ask your complaints and will make physical examination and later, nerve root compression is diagnosed and finally, direct X-ray, computerized tomography and most commonly MRI study will be ordered in order to make final diagnosis.

How is lumbar hernia treated?

Treatment of lumbar hernia requires multi-disciplinary approach. The treatment team involves physicians of neurosurgery, physical medicine and rehabilitation, algology and diet departments. In practical terms, treatment of lumbar hernia can be divided into two approaches including surgical and non-surgical therapies. Non-surgical therapies include bed rest, pain killer drugs and muscle relaxants, exercise, algological procedures and physiotherapy. It is important for you to follow bed rest as directed by your physician. Usually, clinical experiences demonstrated that patients discontinue bed rest when pain improves leading to incomplete improvement since fibrosis (the scar tissue) of cartilaginous capsule does not completely heal. The aim of bed rest is to remove effect of gravity force on spinal column resulting with elimination of load on the injured disc. When load on the disc is reduced, the bulged cartilage may return to the original position. In addition to the bed rest, your physician will start treatment with pain killers and muscle relaxants and your physician will recommended you an exercise program and sport which is best for you. Despite appropriate treatment with adequate time, some patients with persistent complaints may benefit from physical medicine and rehabilitation procedures and algological therapies (epidural steroid, selective nerve block and facet joint injection). If patient is overweighed, appropriate weight loss diet should be started under supervision of a dietician while those therapies are done.

EXERCISES TO PREVENT LUMBAR HERNIA

Exercises are planned to strengthen lumbar and abdominal muscles. You should regularly do your exercises after lumbar pain discontinues.

  • You should do your exercises on hard floor in a well ventilated environment and you should wear comfortable sportswear. You may have one small pillow under your head.
  • You should do your exercises every day and you should not get exhausted.
  • At the beginning, you should do exercise once in five repeats. You may increase frequency at interval of several days and you may increase frequency twice a day in ten repeats.
  • You should discontinue exercise and contact with your physician whenever pain develops.
  • Start the program with relaxation exercises.
  • Do not hold your breath during exercises. You should care to breath regularly (you may loudly count your breath in order to avoid holding breath).
  • You should ensure that your body completely relaxes when you switch from one exercise to the other.
  • Do not discourage yourself. Although you may not successfully do an exercise at the beginning, you will certainly achieve it after a while.

RELAXATION:

1-Take supine position should your lower back is straight and your knees are bent and your plantar region completely contacts with floor.


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2-Take supine position and rest your plantar region on wall should your hips and legs are vertical to the wall. Contact your back completely with floor. Push your feet on the wall and feel that the pressure extends to the whole body and relax slowly.


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You may put a pillow under your knees. Extend your arms alongside your body. Nose breath slowly and deeply and give your breath from your mouth slowly and in long time. Fist your hands and take a deep breath slowly and relax again. Feel your neck, arms, legs and lower back relaxes.

PELVIC TILT: Lie down on a flat floor should your arms extend alongside your body and your feet step on floor. Mildly elevate anterior portion of your pelvis and push your lower back to the floor. Count up to I 0 and relax (at the beginning, you may put your hand between lower back and the floor and check the movement).

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STRETCHING AND STRENGTHENING:

At supine position:

I- Grasp your right knee with two hands and pull your knee to your chest. Count up to I 0 and relax. Repeat same movement with your left knee. Finally, grasp both knee with two hands (knees are adjoined) and pull them to your chest. Count up to I 0 and relax.

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2- Extend your hands to your knees should your head and shoulders mildly elevates and keep the stretched position for a while and later, relax. Later, erect yourself to touch your right knee with your left hand and relax. Repeat same movement for other hand and knee. You should not hold your breath when you do this exercise and you should be careful not to contract your neck muscles.

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3- Bend one of your legs and elevate other leg straightly; keep this position for 5 seconds and get to the baseline position slowly. Repeat same movement for other leg.

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At prone position:

I- Put a thin and hard pillow under your abdomen in order to ensure that lower back is straight. Keep your hands on your hips and elevate your head mildly and keep this position for a short time. Later, relax completely.

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2- Rest on your forearms and lift your body up. Keep the position for a while and relax.

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3- Put your hands at level of your shoulders. Straighten your elbows slowly and wait for a while and relax.

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4- Extend and stretch your arms at both sides of your head. Push your plantar regions on the floor and raise your arms slowly. Take baseline position and relax.

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Four legs position:

I- Take four legs position taking support from your hands and knees. Push your head down to your chest and hump up your back. Meanwhile, you should breath. Later, you pit your back while you are raising your head.

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2- Keep same position while you are extending your leg backward and your right arm forward. You should not raise your leg and arm above your back. Repeat the movement with other arm and leg.

Which patients are recommended surgical treatment?

Surgical treatment is recommended if severe pain and findings of nerve root compression persist despite above mentioned treatment and free cartilaginous fragments are present. If nerve root entrapment becomes severe, injury of nerve fibers regulating the muscle strength may develop resulting with functionality disorders such as foot drop which are usually irreversible and lead to limited motion. Surgical treatment is recommended in case of free cartilaginous fragment and complaints and symptoms usually persist although improvement is achieved for a while. In addition, surgical procedure is performed under emergency conditions if severe movement loss and sphincter disorders such as fecal or urinary incontinence develop.

Surgical treatment of lumbar hernia:

It is not appropriate to postpone surgical procedure if the indication of operation is considered by neurosurgeon. Delays may sometimes lead to severe loss of strength and irrecoverable conditions. Appropriate surgical treatment based on timely and correct indication will offer complaint-free life. Aim of surgical treatment is to eliminate pressure on nerve roots and to alleviate complaints of the patient and increase life quality. In the surgical approach, herniated cartilaginous tissue is removed and current bone compression will be eliminated. Surgical treatment of lumbar hernia involve a small incision within a narrow and deep area and accordingly, micro-technique involving use of operation microscope should be preferred in order to avoid damaging nervous tissues. Operation microscope offers both perfect illumination and magnified vision of very sensitive nervous tissue and those advantages are necessary to perform adequate and correct surgery. Microscopic surgery allows patients to return to routine daily life within shorter interval. Patients are mobilized and discharged at early postoperative period unless there is contraindication. Usually, you are recommended to sustain bed rest for 7 to I 0 days excluding short-distance walk at home and your may start exercises after this period. Complete improvement is usually achieved in 30 days after exercises are started by patients with history of lumbar hernia. Therefore, we recommended the operated patients to avoid lifting heavy load and inappropriate movements.

In conclusion;

Preventive measures are not highly important for our overall health status but also for lumbar health. The most important thing is to have correct information and to protect our health. You should keep in mind that most patients with lumbar hernia can be treated with non-surgical treatment modalities. Patients requiring surgical treatment may survive a complaint-free life if adequate and correct surgical technique is used. Therefore, if one suffers leg or lower back pain which has impacts on daily life, it should be cared and one should seek medical advice.


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