.. ion of the origin of the pain. The goal is to reduce inflammation in the foramen through direct application of strong anti inflammatory medications. This option is not very popular for the obvious reason that the prospect of injection is intimidating to most people. The overall success of the injections is generally short lived with most symptoms returning within three to four days.
Long term relief from epidural injections, for more than three months, is only gained in under five percent of the recipients(Traynellis, 1997). The persistent nature of lumbar disc injury is such that it affects every aspect of a persons life from tying one’s sneakers to getting in and out of a car, to standing on line at the grocery store. Such constant pain draws people to search for relief in any form they can. When conservative treatments do not provide relief, the only answer is to opt for the surgical repair of the disc. The surgery, however is not guaranteed to be effective due to the many complications of the area, thus there is somewhat of a “taboo” aura associated with back operations.
One of the main problems associated with a disc operation is the inconclusive nature of the diagnostic images. A surgery candidate will undergo a computed tomography scan (CT scan) and a magnetic resonance imaging (MRI) test to help determine the cause of sciatica. Although the images can clearly show disc prolapses, the evidence does not directly correlate to clinical symptoms(Wittenberg1998). The doctor can make a highly educated guess as to the cause of the pain, but he cannot be positive as to where the symptoms arise. This can get increasingly complicated in a case with herniations at more than one level. The pain could possibly arise from all, some, or one of the levels of irregular disc, making surgery more complicated.
This idea is reinforced by a study done at Ruhr University in Germany that randomly tested people who had no history of chronic back pain by giving them all evaluative MRI’s. The study showed that sixty eight percent of the people who had no history of chronic back pain showed positive images for at least minimal disc irregularity. This concluded the theory that although MRI’s are a reliable source to determine abnormalities and structural changes, there is no definite correlation between image findings and clinical symptoms. Still, surgery is a necessary treatment for many severe cases, and is generally successful in at least reducing the amount of pain. The traditional surgery to repair a ruptured disc is referred to as a laminotomy.
This procedure included a large posterior incision to expose the spine. The lamina of the vertebrae was shaved and partially removed in attempt to reach the affected area. The surgeon would then manually remove the pieces of disc herniation that were irritating the nerve. This operation was fairly successful, but had a few drawbacks. The surgery was very invasive, and generally required at least two weeks of post operative hospitalization.
The possibility of scar tissue forming on the spinal cord itself also proposed a possible explanation for a failed procedure. Within the last five to ten years, the emergence of a much less invasive micro surgery for disc prolapses has made the laminotomy obsolete as a surgical procedure. The microdiscectomy puts to use the modern technology of arthroscopic and endoscopic techniques to perform disc excisions. This surgery has produced great results in success rates as well as recovery time. A microdiscectomy requires only about a two and a half inch incision posterior to the disc, and only needs minimal shaving of the lamina to reach the affected foraminal space.
The surgeon inserts a microscpope into the area, which projects the image onto a screen. He can then operate with much greater precision. A patient of a microdiscectomy needs usually about on or maybe two nights of hospitalization, and is encouraged to return to non stressful normal activities as soon as possible, usually about two weeks(Flagg, 1997). While a microdiscectomy partially removes the protruding disc, it leaves the rest of the disc intact. In a case where the entire disc must be removed, surgeons opt for a surgery called a fusion.
This operation consists of the removal of the disc, and the use of pedicle screws to keep the spine in place, with the goal to have the vertebrae fuse together. This surgery is more involved than a microdiscectomy, and is open to more variation. The discussion continues on the degree of angle at which the screws should be inserted as well as the degree of lordosis and kyphosis at which the spine should be fixated. Research has shown to be contradictory as one study shows that the procedure should be done in kyphosis, or a slight rounding of the back, to prevent foraminal stenosis or narrowing(White et Al, 1999). A second study shows that fusion done in lordosis, or a slight arch in the lumbar region, would prevent flat back problems(Casey et Al, 1999). Despite these claims, still others contend that there is no evidence to support either fusion in kyphosis or lordosis and that there is no overwhelming advantage to either one(Molz, 1999).
The cutting edge of fusion procedures includes the use of inter body fusion cages to replace the disc. Instead of directly fusing the bones together, a prosthetic piece is implanted between the vertebral bodies. The goal here is to provide a stabilizing structure to reduce the pressure of the vertebrae fusing directly together. There have been many different types of cage designs since its initial introduction a few years ago. Some of the different cages are cylindrical in shape, requiring to be screwed into place, while others are cuboid in shape requiring to be placed in the disc space.
Studies were done to measure the flexibility and mobility allowed by the inter body devices. The evidence showed that the most effective fusion device is the Stryker cage, which is a ridged bullet shaped polyethetetherketone implant. It had the greatest effect on stabilization and mobility after undergoing many cyclic loading tests, and was concluded as the most effective interbody fusion cage(Kettler et Al). Fusion surgeries are most often performed posteriorly, but they can also be performed anteriorly as well. Some surgeons are dissatisfied with the long term results of the posterior procedure and favor an anterior operation.
The anterior approach shows better results with result to restoring the anterior vertebral column to its normal height, thus creating more foraminal space, and restoring sagital alignment. The negative side of the anterior surgery is the risk of complications of the invasive surgery. The approach is made by a transabdominal incision and is very complicated as result of the many problems that can occur. Any number of problems such as damage to the left iliarlumbar vein can occur, and could possibly produce fatal results. As a result, this procedure is not frequently performed, and requires highly prepared surgeons.
Despite the many complications, there have been no deaths associated with the anterior approach, and there is a ninety six percent chance of fusion rate in the patients(Samudrala, 1999). With all the information present, the picture is not crystal clear as to what the solution to back pain is. Most doctors would agree that surgery should be the last option in most circumstances. In my opinion, the best way to approach a back injury, would be to explore every option possible before surgery. There is a good chance that you will find some form of treatment that would help your pain. If surgery can be avoided it should be, however, I do believe that surgery is a safe option. The main question is the extent of the injury, and the quality of your life because of it.
It is not worth avoiding surgery simply because you are afraid of it, especially when everyday activities are agonizing. It is nearly impossible to enjoy life with the constant pain shooting down your leg. If surgery is the necessary solution to the problem, than the most important part of your decision will be the choice of doctors. In my opinion, someone undergoing any operation would be putting himself at a greater risk, if they did not pursue the most successful doctor. If the financial resources are available, it is well worth the research or travel to put yourself in the most capable hands.
In conclusion, I think that the sufferers of lumbar disc prolapses and sciatica are faced with a tough road, however, I believe that with patience and persistence, their former quality of life can return, and relative normalcy can be restored. Bibliography Works Cited Casey,M et Al: The effect of Harrington Rod Contouring on Lumbar Lordosis. Neorosurgical Focus. v12: p75-83, 1999 Di Nubile, A: Treating Low Back Pain. The Physician and Sportsmedicine v25-8 ,p51, 1997 Drivdahl, Christine: The use of Alternative Health by a Family Practice Population.
Journal of the American Board of Family Practice. v19: p54-56, 1998 Flagg, Susan: Bounce Back from Surgery. Prevention. v49 p37-38, 1997 Gadsby, JG: Transcutaneous Electrical Nerve Stimulation for Chronic Low back Pain. Cochrane Review Abstracts.
December 1997 Hatori, Masahito: Clinical use of Etoldac for Treatment of Lumbar Disc Herniation. Current Medical Research and Opinion. v15: p193-201, 1999 Ketter, Annette et Al: Stabilizing Effect of Posterior Lumbar Interbody Fusion Cages Before and After Cyclic Loading. Neurosurgical Focus v14:p43-56, 1998 Molz, Fred: Effects of Kyphosis and Lordosis on the Remaining Lumbar Vertebral Levels Within a Thoracolumbar Fusion. Journal of Southern Orthopaedic Association.
v26: p60-68, 1999 Samudrala ,Srinath: Complications During Anterior Surgery of the Lumbar Spine. Neurosurgical Focus. v7: p6-18. 1999 Shanahan, Donal: Anatomical Review of the Lumbar Spine. The Lancet. v348: p38-40, 1997 Traynellis, Robert: Epidural Injections for Sciatica.
Neurosurgical Focus. v17: p26, a997 White,A et Al: Clinical Biomechanics of the Spine. JB Lippincott Co. August 1997 Wittenberg, RH: The Correlation Between Magnetic Resonance Imaging and the Clinical Findings After Lumbar Microdiscectomy. Int Orthopaedics v22: p241-244, 1998 Anatomy and Physiology.