Lumbar Disc Prolapse

Management

(a) Lateral disc protrusion conservative: Most bouts of leg pain settle spontaneously by taking simple measures:

- Analgesics

- Avoiding heavy lifting and bending. Picking up objects from the floor should be performed by bending the knees and keeping the back straight

- Using an orthopaedic mattress or hard board under the mattress

- A plaster jacket or spinal brace helps some patients

- Bed rest, but only if pain prevents any movement

- Traction may help, but pain can return when traction is removed.

indications for operation

- Severe unremitting leg pain despite conservative measures.

- Recurrent attacks of leg pain, especially when causing repeated time loss from work.

- The development of a neurological deficit.

Root retractor technique: Fenestration usually provides good access. Retraction of the root and dural sac exposes the disc protrusion and allows removal with rongeurs. Any protuberance from the facet joint causing root pressure or narrowing of the root canal is also removed. 'Microdiscectomy' with an operating microscope allows disc removal through a smaller skin and muscle incision and may reduce the period of hospital care.

Disc protrusion

Root retractor

Ligamentum flavum

Disc protrusion

Laminai edge widened

Laminai edge widened

Ligamentum flavum results: Over 80% of patients obtain good results after operation. The remainder may have recurrent problems due to a further disc protrusion at the same or another level. Root damage occurs in < 1 %

After disc operation, patients are advised to avoid heavy lifting, preferably for an indefinite period. Persistance in a heavy manual job may lead to further trouble.

In general, patients with clear-cut indications for operation do well, whereas those with dubious clinical or radiographic signs tend to have a high incidence of recurrent problems.

(b) Central disc protrusion

In contrast to lateral disc protrusion, compression of the cauda equina from a central disc constitutes a neurosurgical emergency. Delay in root decompression results in a reduced chance of motor and sphincter recovery.

Large disc protrusions may require a one or two level laminectomy rather than a fenestration, to minimise the risk of further root damage.

Motor, sensory and sphincter function should gradually recover over a two year period but results are often disappointing. Although most regain bladder control, few have completely normal function and in many, sexual difficulties persist.

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