Lumbar Disc Herniation

Employing a technique unlike the traditional one, I have performed surgeries on “over 1000 patients in 23 years, using the microdiscectomy technique that protects the ligamentum flavum (yellow ligament)”, and that aims to minimize the tissue damage and reduce the post-op development of connective tissue. When we have examined the results of this technique both in forward and backward directions, we saw that we have -almost ideally- achieved targets aimed in surgeries.

  • Patients returned to their regular routines and contributed to economy.
  • Patients who underwent surgery with this technique had less herniation (%1,5).
  • When we performed another surgery on the patients who had a recurring herniation, we performed the surgery more easily, considering the yellow ligament protecting the nerves. These patients develop less scar tissue than those who undergo surgery with the traditional method.
  • We have achieved the same results in the patients with recurring herniation.

 

How does lumbar disc herniation develop?

The situation where an organ exceeds its own borders and violates the area of an adjacent organ is called “herniation” in general medical terms. The structure in the shape of a ring which is made of strong connective tissue and is called “annulus” in medical terms has an exclusive nucleus inside. The nucleus in its internal structure is tightly bound inside and is bound to the cartilage covering surface of the upper and lower spine. With this structure, it forms the most important part of the facet joints and allows the forces of the burden on the spine to radiate evenly and get absorbed and be prevented from reaching a damaging level. It naturally has a threshold of resistance against these affecting forces. When the threshold is exceeded, it leads to ruptures in the internal structure of nucleus and in the surrounding annulus. It loses the feature of absorbing the forces equally. The pieces that have formed inside the nucleus as a result of the rupture moves out when the weakened annulus bends outwards, in other words, it herniates and compresses on the adjacent nerve.

What is technique applied by Dr. Yunus Aydın in lumbar disc herniation?

After I started to use the surgical microscope on patients in 1990 and also watched the relevant videos of our professor Prof. Dr. M Gazi Yaşargil – of whom we are all proud and whom I was with during my stay in Zurich in those years – I made exclusive changes on the issue.

Unlike the traditional technique, in the surgery, I kept the structure called “ligamentum flavum” which actually ties the rear components of spine. For those who have a normal lateral indent into nerve, I have developed a microdischectomy technique by splitting only the upper vertebral connection of this structure and paying attention to protecting the fatty tissue over the meninges – thus causing least harm on normal anatomy.

To achieve this, instead of using the expensive ecarteur device of foreign origin, I have narrowed the width of the Taylor ecarteur used in the old technique, and turned it into a “mini Taylor ecarteur”, which actually offered the opportunity to be used in a scar of 1,5cm, and from then on the width of the ecarteur has further narrowed down to 1 cm. This certainly concerns brain surgeons but we should remember that it actually has a story. For instance, local manufacturers made the set which I had developed, and sold to those who needed. The manufacturers made money and the country earned foreign money.

To sum up, I enter through a hole of 1,5 cm in size, clear the herniated disc, let the patient walk 3 hours after the surgery and let him/her go home 5 hours after surgery.

Being one of the first surgeons to use a microscope in disc surgeries in our country, I have been criticized by colleagues in early stages as in the case of any new application. They asked me “Do your eyes not see well?”. This criticism is not only true for colleagues in our country, because even the well-known US surgeons published articles – in famous journals and books – which are against the use of microscope. Fortunately, today, “microdischectomy” has been the gold standard for surgeries of lumbar and cervical disc herniation. The late results of the technique we have been applying for the last 24 years have proven superior, based on the findings in relation to patient satisfaction, imaging systems and less tissue damage. When one assesses it objectively and impartially, they will definitely give credit to it. By the way, there are difficulties for the radiologists, who write reports for the MR images of the patients who underwent a surgery, in detecting the location of surgery, and they may sometimes write reports as if the patients did not have any operation. This problem is certainly an innocent one which is in favor of the patients, but against the doctor in academic terms.

How can we avoid lumbar disc herniation?

  • Maintaining a healthy weight
  • Keeping the abdominal and back muscles strong (exercises, swimming, Pilates, cycling)
  • Not lifting heavy objects, observing the relevant rules when lifting things
  • Avoid sports which are not friendly with the back (football, tennis, skiing , squash, basketball etc.)

Does endoscopic surgery work in lumbar disc herniation?

Although it seems advantageous by providing the opportunity to work through a hole of 1 cm, the possibility of reoccurrence of herniation in the future is high, because it is only the bulging piece that is removed. The supporters of this technique compare the disc surgery to tooth treatment and support the idea that another surgery can be performed, when required.

It does not have any superiority over the surgical method we use. Microsurgery method is superior, as it also allows for working with 3D images.

What if lumbar disc herniation is not treated?

Dysfunction of the nerve under the compression of herniation causes weakness in ankle or knee, and limping. Very rarely, if herniation develops suddenly and in a large size, all nerves in the canal are damaged, and urinary incontinence starts, and heavy weaknesses develop bilaterally under knees. It is a situation that requires surgery as soon as possible.

When the order between the facet joints is disturbed, the adjacent nerves get damaged unlike other joints in the body, and quality of life is affected negatively. If for instance the knee joint is affected, we feel the pain but the pain is restricted our knee and there is no vital organ that might be affected for being adjacent to the knee joint. The illness of the joints that affects our quality of life most severely – particularly when we are aged- is the illness of the joints of the spine.

3 hours after surgery, patient can normally have food and walk, and 5 hours after surgery, patient can leave for home, and can have a bath 2 days after surgery. When need be, the patient can sit but no longer than 20 minutes in each session. The patient can return to normal life 15 days after the surgery.

How does post-op healing develop in lumbar disc herniation?

Surgery aims to reduce the press by being performed on a very limited area of a disc between the vertebrae. It is advantageous in that it can be performed with local anesthesia, and the incision is small. And it is disadvantageous in that it has less healing rates. It may be applied for the medium level hernias that might improve with a bed rest. This method is not enough for the advanced cases that definitely requires a surgery.

In which cases is the partial disc surgery with laser or radiofrequency recommended?

It would serve as an option for those who have no neurological loss or can not stand or do not have time for a bed rest. I do not strongly recommend it. There is a drawback of it if performed on those with nerve damage. We feel pain as a result of the reflexive mechanism that actually protects the nerve. It is our protective reflex that makes us find solution to the problem the nerve is going through, and it does not exist to torture us. Treating the pain with medication without removing the actual reason causing the pain does not make a treatment. If those with neurological losses have undergone epidural anesthesia and cortisone, the muscle group for which the affected nerve functions should frequently be examined, and a surgery should be performed regardless of the severity of pain if the weakness is deteriorating.

What is the epidural injection method in treating lumbar disc herniation?

The most economical and effective treatment for those with lumbar disc herniation which is less severe than the medium level is bed rest with no stand up except for toilet and eating. In cases of lumbar disc herniation, the weight of the body of the patient over the level of the herniation increases herniation further when standing and sitting and causes even more damage by compressing on the nerve. For instance, a patient of 80 kg will produce around 45-50 kg of load over the suffering disc. Bed rest will rescue the disc from this weight, so the nerve will get comfortable and be under less compression. Sometime later, the relevant piece will get away from the nerve and the patient will stop complaints.

Does bed rest work in lumbar disc herniation?

Symptoms vary depending on the severity of the lumbar disc herniation. The ring getting weaker and thinner may lead to backache when pain-sensing nerves inside are stimulated upon compression. At this stage, no symptom appears in relation to nerve, because the gap between the ring and the nerve passing behind has not been filled yet. When this gap is filled and the nerve is pressed on, the alarm for protecting the nerves – the most important organ of our body- goes off, and the alarm sounds louder, and we feel a severe pain along the line either in an arm or in a leg for which the particular nerve functions. This pain is a severe one which our grandmothers refer to when they say “my sciatic has got out of control”.

First of all, the protective reflexes in the body start fighting against the pain; the body tries to find the position where the nerve would be under least press and contracts the relevant muscles to keep us in the appropriate position accordingly. If this contraction keeps on, we feel pain arising from the muscles left without blood, the local pain corresponding to the muscle contracted. Finally, there comes out a situation which first starts as a backache, and then moving down to legs if herniation is in lumbar area, or down to the arms if herniation is in the neck, while causing also pain and spoiling –reflexively- the shape of our body.

If there is herniation and the distance around the nerve is wide enough, the issue will finish with no interruption in the nervous function as blood supply to the nerve is not affected. If the press on the nerve exceeds the capacity of the protective mechanism of the body and does not allow sufficient blood flow for feeding the nerve, then nerves will sleep and cause troubles: numbness and loss of strength are the most frequent problems in such cases. If the problem is solved at this stage, the damages up to that time become temporary and nerves get back to previously functioning state. If on the contrary the issue continues, lack of blood irrevocably ruins the internal structure of the nerve and the damage becomes permanent. For instance, if there is a “foot drop”, the damage will be a permanent one even if the press is removed with surgery later.

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