If you have a symptomatic herniated intervertebral disc in the lumbar spine that is not getting better with time and conservative treatment, then surgery might be considered.
The typical symptoms of a herniated disc are pain, numbness, or weakness or some combination of the above. The symptoms that push people to consider surgery are pain and weakness. There is some evidence to show that doing surgery within six months of the onset of symptoms will give a better result than waiting longer. With this in mind, I recommend that people try conservative treatment for at least six to eight weeks and consider surgery if the symptoms persist or get worse. The idea is to have surgery before too much time passes (6 months). In addition to the fact that you are having pain and posture changes to accommodate the pain, there are technical reasons too. The main technical reason is that the herniated disc will be easier to mobilize and remove if taken care of early. Discs that have been herniated for long periods of time seem to get scarred in place and are more difficult to mobilize and tease out.
There are several surgical approaches to disc removal, but they can essentially be broken down into two categories.
- “Blind” – (22526) Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; single level
- “Direct Vision” – (63030) Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar
I think that that the more minimal the surgery, the earlier one needs to have it done. This is simply because the disc herniation will be more mobile earlier in the process.
Here is an example of a very minimally invasive procedure:
There are a few drawbacks with this “blind’ percutaneous approach. One is if the disc herniation is large, it won’t fit through such a small tube. Two, the disc herniation cannot be extruded too much and certainly cannot be sequestered.
Three, it must be in the right area that can be accessed safely.
There are limitations to this approach imposed by the location and size of the disc herniation.
This procedure is referred to as “blind” since it is placed in the disc using fluoroscopic x-ray. There is no direct or camera visualization of the anatomy the tube passes through, one relies on the fluoroscopic x-ray pictures.
This is one reason that these procedures are best performed under conscious sedation.
An awake patient will tell you if a nerve is being compressed or injured by an instrument that’s not exactly in the right place.
Another “blind” procedure is the introduction of a holmium laser fiber by itself through a small tube or canula. The laser beam can be directed straight ahead or 90 degrees by the type of fiber used. Trimedyne has some special fibers to perform this surgery. These fibers are smaller than the Disc FX and rely on vaporizing the abnormal tissue with the heat of the laser.
The success of these procedures mainly depends on selecting the correct patient with the right problem and the experience of the surgeon doing the procedure. For whatever reason, there is no training for these “blind” procedures in any spine fellowships in the U.S. that I am aware of.