Introduction
Nowadays, the indication for surgery for a herniated disc is very cautious. As a rule, only acute (median) mass prolapses (= mass prolapses), mostly in the lumbar spine with signs of paralysis, are directly advised for surgery. One of the reasons for this is that there is a great chance of recovery through conservative forms of therapy. In addition to acute paralysis, symptoms of failure to hold water and stool (cauda syndrome), there is also a relative indication for surgery if the pain caused by the herniated disc cannot be sufficiently controlled by conservative treatment.
Indications for surgery
If a long-applied conservative therapy of the herniated disc causes no or only insufficient pain relief, there is a so-called “relative indication for surgery”. In general, surgical therapy cannot prevent a new herniation. Even a proliferating scar tissue can question the surgical measure, since even after surgery scar tissue can develop again, which then presses on nerves or spinal cord like a herniated disc. In this case one speaks of a postnucleotomy syndrome.
1. minimally invasive procedures
Since traditional, open surgical procedures are generally associated with risks and a longer stay in hospital, so-called minimally invasive surgical procedures have been developed. These minimally invasive procedures can be performed on an outpatient basis and under local anesthesia, provided that the general conditions are right. Risks that cannot be excluded by anaesthesia are reduced here.
However, minimally invasive procedures cannot be carried out at every stage of the herniated disc. Classically, this procedure is performed for simple and relatively new disc protrusions and prolapses. A sequestration (protrusion of disc tissue) is usually not treated minimally invasive.
Pre-operational procedures also represent an exclusion with regard to this form of surgical measure. This means: patients who have already been operated on a disc prolapse should not be treated again with this method. Among the classic minimally invasive procedures are
- Chemonucleolysis
- Laser ablation of the intervertebral disc
- Percutaneous nucleotomy
- Microsurgical surgery
Chemonucleosis is the chemical liquefaction and subsequent suction of the inner gelatinous ring of the intervertebral disc.
Laser ablation of the intervertebral disc is a further therapeutic measure of the herniated disc. Similar to minimally invasive therapy, this procedure is only suitable for uncomplicated, fresh herniated discs. This measure is also based on the principle of volume reduction in the area of the intervertebral disc, which is carried out using a medical YAG (Yttrium Aluminate Garnet) laser.
This procedure is similar to chemonucleosis in that a volume reduction by suction of the inner gelatinous core is also carried out here. Unlike chemonucleosis, however, no enzyme is used to liquefy the nucleus, but the herniated disc is removed mechanically. Since large skin wounds and large operation fields after the operation of the herniated disc usually involve a longer recovery phase for patients, minimally invasive surgical procedures are used to try to keep the operation field as small as possible.
Especially in the case of uncomplicated disc herniations in the lumbar spine, this procedure can be used and operated well. Through a small incision, the herniated disc is cut out minimally invasively using a microscope. More difficult disc herniations cannot be treated by means of minimally invasive methods (see above).
These are, for example, herniated discs affecting neurofamina, herniated discs that have existed for a long time or are spread over several levels. In these serious cases, a larger, open access route must be chosen, which allows a broader view of the surgical area. To make this possible, at least part of the ligamentum flavum is removed on one or both sides.
This is called “windowing”, which allows access to the intervertebral disc and the nerve root in question. If the nerve roots of two adjacent levels have to be displayed, it may be necessary to remove a vertebral half arch or the entire vertebral arch. This allows all relevant structures to be viewed and made accessible for treatment.
The herniated disc can be completely or partially removed. The convalescence (= recovery) is inevitably longer than with the microsurgical procedure due to the more extensive preparation. At the treated site, as with all other surgical procedures, scar tissue inevitably develops, the extent of which varies from person to person.
In unfavourable cases, this scar tissue tends to proliferate, which in turn takes up space and exerts pressure on the nerves. In such cases, further surgery may be necessary to reduce the scar tissue (postnucleotomy syndrome). A postnucleotomy syndrome can only be surgically tackled in exceptional cases.
Therefore, only conservative treatment methods are available to combat chronic pain. Within the framework of chronic pain therapy, we have developed a program with the pain specialists in our team. Progressive muscle relaxation, which is aimed at people suffering from chronic back pain, has proved particularly suitable in this area. Painful spinal instability can also develop after the removal of a disc floor. Here too, follow-up operations may be necessary, e.g. stiffening surgery.
