Herniated disc, its causes, symptoms and treatment – PELD

At a Glance:

1. What is a slipped, herniated disc or lumbar disc disease?

Slipped disc or spinal disc herniation is a condition wherein the soft inner portion of the disc protrudes out through a tear in the tougher exterior. This protrusion into the spinal canal puts pressure on the spinal cord or a single spinal nerve. Technically, it is called as prolapsed intervertebral disc.

The spine or the backbone is made up of small sized, ring-shaped bones known as vertebrae. A softer jelly-like part called a vertebral disc is present within and between each vertebra acting like a shock absorber. Each disc comprises a fibrous exterior and a softer inner portion known as the nucleous pulpossus. Due to wear-and-tear or an injury, a tear in the fibrous outer part causes the soft inner portion to protrude leading to slipped, prolapsed, or herniated vertebral disc. In most of the situations, the intervertebral disc prolapses occur in the lumbar spine in the lower back and cervical spine in the neck.

2. What are the symptoms of herniated disc?

Many people do not experience any symptoms from a herniated disk. However, in some persons, a herniated disk acts as a focus of irritation to the nerves in the vicinity of the affected vertebra either by direct pressure or inflammation resulting in symptoms like:

• Numbness or weakness in part of buttock, leg or foot
• Sciatica or nerve root pain – Pain in the back, buttocks etc
• Tingling, pins and needles sensation in legs
• Difficulty in passing urine and stools

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3. What are the causes of herniated disc?

Age-related wear causes disc degeneration, making it prone to tear or rupture with slight strain or twist. Other than this, intervertebral discs can prolapse suddenly because of excessive pressure due to:

• Lifting large, heavy objects in an inappropriate position such as including twisting and turning while lifting.
• A traumatic event such as a fall on the buttocks from a significant height or
• A blow to the back due to some object or landing on one’s buttocks.

4. How to diagnose herniated disc?

Diagnosis of a herniated disc is made by the doctor after taking a complete history of the problem followed by a relevant physical examination and investigations. The examination includes checking the back for tenderness and performing leg movements to determine the cause of pain. A neurological exam may be carried out to check:

• Nerve function – Ability to feel touch, vibration or pinpricks
• Muscle strength
• Reflexes
• Walking ability

The following tests may be undertaken as per the need:

Imaging tests:

• X-ray spine
• Computerized tomography (CT)spine
• Magnetic resonance imaging (MRI) spine
• Myelogram: X-ray with a dye that is injected into the spinal fluid to determine the pressure on the spinal cord or nerves

Nerve tests:

• To measure the electrical impulses along nerve tissue.

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5. How to treat herniated disc?

In many cases, disc prolapse resolves on its own and symptoms disappear within 6-8 weeks or longer. The treatment options are:

• Conservative management: In the absence of any significant spinal cord or nerve root compression or impaired function, a conservative approach is followed for disc prolapse. Medications likepainkillers, anti-inflammatory, corticosteroid injections followed by physical therapy and acupuncture may usually be advised.
• Surgical management: In the event of failure of conservative treatment or symptoms that are severe or long-lasting, the slipped disc may be removed surgically and the procedure is called discectomy. The surgical approach may be open surgery ie Traditional open microdiscectomy or less invasive techniques like PELD (Percutaneous Endoscopic Lumbar Discectomy) as the case may be.

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6. How to differentiate endoscopic spine surgery vs. open surgery?

Endoscopic spine surgery is an advanced surgical procedure in which the operation is carried out using an endoscope, a camera-based tube with a diameter of 8 mm. In endoscopic spine surgery, a surgeon uses an endoscope for visualization and inserts small-sized instruments through micro incisions to perform the surgery on the spine, also known as Minimally-Invasive Spine Surgery (MISS). Majority of the cases of spinal disc herniation and constriction of the spinal canal requiring surgery can be treated endoscopically. 

The traditional open surgery performed under general anesthesia involves access to the surgical site through an incision that is as long as 5 to 6 inches. The surgeon has to pull the muscles aside to visualize the spine and remove the damaged part of the disc, place screws or any bone graft materials for stabilization of the spinal bones. The retraction or pulling aside of the muscle in the open surgery can potentially damage both the muscle and the adjacent soft tissue. As a result not only the recovery period is lengthier but also post-operative complications are also higher due to a larger incision and damage to soft tissues like blood loss and the risk for infection.

Endoscopic or minimally invasive spine surgery, on the other hand, reduces the extent of injury to the muscles and adjacent normal structures in the spine. Endoscopic visualization and navigation of the operative area in spine offers other advantages such as fewer complications due to smaller incisions and shorter length of stay in the hospital. 

7. How to treat herniated disc using PELD, an endoscopic spine surgery?

PELD (Percutaneous Endoscopic Lumbar Discectomy) is an endoscopic spine surgery to remove the slipped disc material. It is a day care procedure wherein a small incision is made through the skin without the need for cutting the bone or muscle. The procedure is performed under local anaesthesia and the patient is awake and aware of the entire procedure.

PELD is an endoscopic surgery done through percutaneous route (an incision through the skin). The surgeon makes a percutaneous incision and inserts a needle between the vertebrae and into the middle of the disc that dilates the path into the disc space. Through this dilated path, the surgeon then inserts the endoscope. Under endoscopic guidance and visualization, he removes or melts herniated disc material with the help of forceps, radio frequency probe or laser.

Full endoscopic spine surgery is the most patient-friendly procedure in which spinal herniation and bony constriction can be removed while at the same time neighboring tissues are preserved. The procedure relieves the pressure acting on the nerve, stops the inflammatory response and brings the pain to an end.

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8. What are the advantages of PELD?

The advantages of PELD are:

• Minimal anesthesia-related complications as PELD is be carried out under local anesthesia only
• Lower risk when compared to open surgery
• Faster pain relief directly after surgery
• Procedure more tolerable for elderly and diabetic patients
• Smaller incisions (5-6 mm), cosmetically better and minimal scar formation
• Minimal blood loss
• Lesser or almost no injury to the muscle, adjacent tissues or bone
• Helps in the preservation of normal disc structure, thereby preventing post-operative spinal instability
• Restores stabilizing structures like ligaments, muscles and bones
• Lesser post-operative pain
• Day care procedure, the person is discharged on the same day
• Faster recovery and quick return to work and social life

9. Recovery after PELD, how long does it take?

• Since PELD can be done under day-care, one can expect to go home on the day of the procedure.
• The surgeon may recommend a comfortable, adjustable corset to be worn during the first few weeks after the endoscopic surgery.
• An individualized rehabilitation program in cases of muscle weakness may also be recommended by the surgeon.
• A return to normal activity is generally expected within 4 – 6 weeks following the operation in most cases.
• However, for several weeks after surgery, it is recommended to avoid long periods of sitting and bending, twisting, and lifting heavy weights.

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10. Is PELD right for me?

A neurosurgeon will decide if you are eligible for PELD based ondisc disease and overall health of the individual. Talk to your doctor if you have the following symptoms:

• Persistent pain in the lower back
• Inability to stand up or difficulty in walking
• Radiating leg pain or muscle weakness
• Bowel or bladder problems
• Numbness around the genitals and anus or lower limbs

11. How to choose a facility for PELD?

Among the several factors while choosing an appropriate facility for undergoing PELD procedure, the experience and expertise of the treating surgeon are of paramount importance. Spine surgery can be carried out by  Orthopaedic Surgeons or Neurosurgeons who are adequately trained in the same. In terms of infrastructure, a state-of-the-art operation theatre should include facilities for endoscopic navigation and visualization. Appropriate support services for preoperative and postoperative care including rehabilitation should be considered as well. Some factors that may be considered to assess the expertise of the treating surgeon include:

• How many number of PELD surgeries has the surgeon performed and what are the success rates?The tendency towards having lower complication rates especially in the case of complicated surgeries of the spine is higher when a surgeon has undergone specialized training in the procedure.
• Does the surgeon routinely conduct spine surgery and how many persons has the surgeon operated on? Focused practice of spinal surgery is likely to result in adeptness and expertise in the newer surgical techniques than someone who performs spine surgery occasionally.

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Conclusion:

Degenerative diseases of the spine or slip disc can be managed in two ways: Conservative therapy and surgical intervention. The choice of treatment largely depends on case-to-case scenario considering the underlying medical condition and the requirements of the patient. PELD is a preffered treatment modality for herniated lumbar disc. The procedure offers better clinical outcomes compared to open discectomy sugery. With PELD, one can recover faster and safer from herniated disc diseases.

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References:

• Mayo Clinic. Herniated disk. Available at https://www.mayoclinic.org/diseases-conditions/herniated-disk/diagnosis-treatment/drc-20354101. Accessed on 05th June 2019.
• Ortho Info. Minimally Invasive Spine Surgery. Available at https://orthoinfo.aaos.org/en/treatment/minimally-invasive-spine-surgery/. Accessed on 05th June 2019.
• NHS. Rehabilitation after lumbar discectomy, microdiscectomy and decompressive laminectomy. Available at https://www.ouh.nhs.uk/patient-guide/leaflets/files/100720laminectomy.pdf. Accessed on 05th June 2019.
• NICE. The Changing Financial Landscape of Renal Transplant Practice: A National Cohort Analysis. Available at https://www.nice.org.uk/guidance/ipg556/resources/percutaneous-transforaminal-endoscopic-lumbar-discectomy-for-sciatica-pdf-3213367382725. Accessed on 05th June 2019.