Hernia

The human body has a total of 24 vertebrae; between each set of two vertebrae there is an intervertebral disc. This entire system forms the backbone from the head down to the pelvis. The intervertebral discs enable movement between the vertebrae in relation to each other and act as shock absorbers when we walk or jump. The disc is in fact an oval shim with a concentric laminated outer edge and a soft core. The laminated ring (the annulus fibrosus) is a retaining structure for the soft inner core (the nucleus pulposus). The soft core consists to a great extent of water taken up from the surrounding tissue. During the night, the core absorbs water and during the day the water is squeezed out again by the force of gravity. This is why people are taller in the morning than in the evening.

As we get older (already from age 25 onwards!) the core starts to lose its elasticity and begins to dry out (we shrink). The annulus surrounding the core also loses elasticity and can develop small tears if subjected to heavy stress. This is experienced as an acute lower back pain or lumbago (see the section on "Disc degeneration").

Ultimately, the tear can become so large that the nucleus will almost break out of the disc. Due to this bulging, the disc now exercises pressure on the adjacent nerve, which causes not only lower back pain but also pain that radiates down the leg, or sciatica.

With the appropriate care, in 80% of all cases such tears heal within 6 weeks.

Discal hernias proper (hernia is Latin for rupture) occur when the disc breaks down entirely and the soft core, the nucleus, completely exits its retaining ring. At that point pain in the leg will be the primary symptom. Hernias sometimes qualify for surgery. In such cases, the goal is to remove the herniated soft core to release the pinched nerve.

As soon as the annulus begins to tear, the disc is damaged and can create a weak spot in the spine. This does not mean that patients should avoid all activity, but rather that they should adapt their sports and other activities to the situation. The same applies after herniated disc surgery.

Surgical treatment options for a herniated disc

  • Micro-Endoscopische Discectomie
    Micro-endoscopic discectomy: This procedure aims at endoscopically removing the herniated portion of the disc. This technique is the standard treatment used in our clinic for herniated discs. We are able to remove the annoying disc portion with a minimally invasive approach involving an incision of only 16 mm. The procedure is ideally carried out under general anaesthesia. This is the most comfortable option for both the surgeon and the patient, who will be lying down in an uncomfortable position for a good hour or so (see description of the surgical technique). Upon request from the patient or for medical reasons, the procedure can also be performed under locoregional anaesthesia. This is done by combining peridural and rachianaesthesia. Ultimately, by means of a system of successively wider tubes, a "working tunnel" is created in the patient's back, through which a camera and a cold light source are introduced to optimise the surgeon's view of the operating area. The surgeon follows the progress of the procedure on a monitor. All necessary actions can be performed through this "working tunnel". The herniated fragment is removed, thus freeing the nerve root (see operation film). Then the surgeon checks whether there are any loose fragments of nucleus pulposus left. If yes, they too are removed in order to prevent any hernia recurrences in the near future. After that the "working tunnel" is removed and the skin is closed up with a skin adhesive.

    The patient can leave the hospital 24 hours later. He or she will be able to walk around, climb stairs and perform personal care tasks. Lifting is not permitted for one month after the operation to allow the annulus to grow back together.

    Sometimes (in 5% of all cases) there is a recurrence – usually in the first few weeks. In those cases, another small piece of nucleus breaks out through the still weak portion of the annulus. If this results in disabling pain, the same procedure may need to be repeated. If yet another hernia occurs, the surgeon will usually suggest a disc replacement operation (arthrodesis or disc prosthesis) to prevent further hernias from happening in the future.
  • Microdiscectomy
    This used to be the "golden standard" and is still used in most hospitals. Ultimately it is the same procedure as described above, but with a larger incision (3 to 6 cm) and using a surgery microscope. For the surgeon, the advantage is that he or she has more room for manoeuvre. There is no advantage to the patient. The wound is larger, the trauma to the back muscles is more significant, the hospital stay is longer, rehabilitation takes longer, and it is more expensive (because of the extra time spent in hospital). This technique may nonetheless be proposed to patients for certain medical reasons which the surgeon will explain.
  • Total discectomy
    In this procedure the surgeon tries to remove the entire intervertebral disc with a bilateral approach. We do not use this technique in our clinic, as we find that the disc that has been removed must then be replaced. We use this technique only with second hernia recurrences, whereupon the entire disc is indeed replaced (arthrodesis or disc prosthesis).

As these techniques are successful in 90% of all cases (with success being defined as at least 50% pain reduction and patient satisfaction), we see no reason to propose more invasive, higher risk and more expensive procedures to patients in connection with the surgical treatment of herniated discs. Currently, there is NO scientific evidence that any other surgical technique is better than that presented here.

Read more about it in the illustrated EOS article The weakest link.