Extruded Herniated Disc Treatments

If your herniation is non-contained and diagnosed as a lumbar disc extrusion and/or includes a sequestered fragment, a microdiscectomy may be recommended.

Extrusions occur when part of the nucleus breaks through the tough fibrous outer layer called the annulus fibrosus but still remains within the disc. This type of herniation may also be referred to as a non-contained herniation or trans-ligamentous herniation.

A sequestered fragment occurs when the leaking gel-like material, called the nucleus pulposus, breaks through the tough outer annulus and becomes loose within the spinal canal. This may also be referred to as a free fragment.

Microdiscectomy is the surgical method used to treat extrusions and sequestrations. It is actually more effective for treating leg pain (also known as radiculopathy) than lower back pain. It can be performed on an out-patient basis and requires general anesthesia.

A microdiscectomy is performed through a small (1 inch to 1 1/2 inch) incision in the midline of the low back. First, the back muscles (erector spinae) are lifted off the bony arch (lamina) or part of the vertebrae that surrounds the spinal column and spinal nerves. Since these back muscles run vertically, they can be moved out of the way rather than cut. The surgeon is then able to enter the spine by removing a tissue membrane over the nerve roots (ligamentum flavum), and uses either operating glasses (loupes) or an operating microscope to visualize the nerve root. The nerve root is then gently moved to the side and the gel-like material (nucleus) compressing the nerve root is then removed to relieve spinal nerve impingement.

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Years ago most spinal surgeons would make a large incision to remove the nucleus compressing the nerve and not use a microscope to visualize the compressed nerve. This approach required a long hospital stay and a prolonged recovery period.

Today, some surgeons use a surgical microscope to visualize the nerve impingement and microscopic surgical techniques involving a smaller incision to remove the nucleus compressing the nerve root. The procedure can be completed in 1-2 hours and you may be discharged the same day or hospitalized at most for one day.

In an experienced surgeon's hands, the success rate of the microdiscectomy procedure is 90-95%. However, approximately 10% of patients will experience another disc herniation at the same level. The recurrence is most likely to occur within the first three months following surgery, although it can occur years later. If the disc does herniate again, a revision microdiscectomy will generally be performed. Unfortunately, after a recurrence, you are at risk for further recurrences (15-20%). Recurrence rates of lumbar herniated disc after microdiscectomy have been reported as high as 26%.10 If the herniation occurs multiple times, a spinal fusion to stop motion at the disc level and remove all the disc material may be considered.

In up to one-third of patients, a significant complication of the microdiscectomy procedure is radicular (leg) pain.11 This pain can result from recurrent disc herniation or from fibrosis of the nerve root as a result of intra-operative manipulation. If it is due to fibrosis, the leg pain is difficult to treat and may remain a long term complication.