By some estimates, anywhere from five to 20 adults out of every 1,000 experience a herniated disc annually. Of those who are treated for a disc herniation, 10 percent to 15 percent will have a recurrent herniation anywhere from a few weeks to many years later. For people age 30 to 50, it’s one of the most common causes of back and leg pain.
This article offers a thorough examination of herniated discs, including a description of the condition, a discussion of recurrent herniated discs, and herniated disc treatment options.
What is a herniated disc?
Between each of the pairs of vertebrae in your spine you have what are called spinal discs. They absorb the pressure on the spine by distributing the mechanical load. They also hold the vertebrae of the spine together, allow for mobility in the spine, and also create space between the vertebrae for nerves.
A disc has two parts: The outer part is called the annulus. It is a tough exterior made of annular fibers that interlink or interweave to help control rotation and bending of the spine. The middle part of the disc, called the nucleus, is made up of a soft, jelly-like filling, mainly composed of water, that helps withstand the axial forces of the spine.
In a herniated disc, the outer layer of the disc gets weak (the annular fibers), and the inner layer (the disc nucleus) pushes out, often putting pressure on a nerve. Sometimes this displacement occurs as part of the natural degeneration caused by aging; it could also happen as the result of mechanical pressures, like bending or lifting improperly.
However it happens, there are varying degrees of displacement. Sometimes, the inner material just makes a bubble in the outer layers—this is called a bulging disc. In other cases the material completely extrudes and is called a herniated disc. When this happens, the hernation also chemically irritates the nearby nerve.
How To Treat A Herniated Disc
Studies show that about 80 percent of herniated disc cases resolve themselves within approximately six weeks. That being the case, many doctors recommend trying one or more herniated disc treatments that are non-surgical to start, primarily to help manage the pain. These could include:
- Rest. As long as you can tolerate this, try giving your body time to heal.
- Take medication. Anti-inflammatory drugs like ibuprofen can help reduce the inflammation associated with a herniated disc, which may ease the nerve pressure.
- Try therapy. Strengthening the muscles around your core and back increases the spine’s stability, and helps improve its overall function.
- Get an epidural steroid injection. Injecting a steroid right on the disc herniation sometimes reduces inflammation around the spinal nerves and may provide relief for anywhere from a week to a month, or longer.
If one type of conservative treatment isn’t having any impact after a few weeks, give another one a try. By six weeks, most people will be on their way to getting better.
If You Need Surgery
Four to six months is usually enough time to know whether or not the body will heal itself. If not, surgery may be the only herniated disc treatment option left.
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The most common treatment for a first-time, isolated herniated disc is a microdiscectomy—where a small portion of the problematic disc is removed so it is no longer painfully pressing on and inflaming the nerve. It’s a minor procedure and you’ll go home the same day. For a relatively healthy person with an isolated herniated disc, a microdiscectomy rarely poses a problem. Most patients can return to light-duty, office-type work anywhere from 10 days to weeks after surgery, or return to heavy manual work at four to six weeks.
The Long-term Impact Of A Herniated Disc
Whether you have surgery or not, once you have herniated a piece of your disc, the remaining disc that has not herniated will experience an accelerated degenerative breakdown. Why? Because the disc that remains in place is now trying to handle the same mechanical “load” as it was before the displacement occurred. You’re still bending, twisting, moving, pushing, and pulling the same as you were before—but because your disc is less equipped to manage all this movement, it continues to wear down.
Degeneration happens naturally in everyone as we get older, but someone with a herniated disc experiences the process sooner and faster: As your disc degenerates, the bones start collapsing together, which could lead to spinal stenosis. At the same time your bones are collapsing, your facet joints are also undergoing a change. Normally the joints on either side of the disc are aligned, but as the bones collapse the joints no longer line up properly. That causes the cartilage in your facet joints to wear out as well. Some patients may eventually require surgical treatment to address the degeneration.
If You Experience A Recurrent Disc Herniation After A Microdiscectomy
Ten to 15 percent of herniated disc surgery patients will have a recurrent herniation in the future. Even if a herniated disc heals on its own, without surgery, the chances of a herniation happening again are fairly high.
Reherniation is somewhat more common in the first six weeks after surgery (though I have seen a recurrence happen as much as 21 years later!). After a microdiscectomy, the opening in the outer rim of the disc where the disc material came through fills in with dense but weak scar tissue—essentially not a very good barricade to keep the disc in place should it try to push through in those early days and weeks. (Medical researchers have invested huge amounts of resources into finding a way to “block” the opening where the disc comes out of place, but so far nothing stands up to the mechanical pressure that naturally occurs in the low-back area of your spine.) After six weeks, scar tissue forms and acts as a more effective barrier to keep the disc in place, though that won’t necessarily prevent it from happening again.
Recurrent Herniated Disc Treatment Options
Microdiscectomy & Fusion
Patients experiencing a recurrent herniated disc after a discectomy do not respond well to non-surgical, conservative treatments, so doctors usually recommend a second microdiscectomy. For some patients, a third recurrence means surgery a third time.
But the result of too many multiple recurrent herniated disc treatments is that, eventually, you will lose too much of the disc. In a typical microdiscectomy, you could lose approximately 15 percent of your disc. Once you have lost more than 25 or 30% of your disc, you’re at risk of spinal instability. (Discs and facet joints make up the various levels of your spine; if either of those elements are compromised to a certain degree, the spine becomes unstable.) For some patients this may happen during their first microdiscectomy, if a good portion of the disc needs to be removed; for others it might not happen until their second or third surgery.
Herniated Disc Treatments: Neck Vs. Lower Back
The surgical procedures used to treat neck (cervical) vs. lower back herniations are different.
Ninety percent of the time, treatment for a herniated disc in the neck is performed using an anterior approach (the front of the neck). Discs are located in the front of the spinal cord; a surgeon approaching from the back of the neck would have a difficult time getting around the spinal cord, and avoiding some major blood vessels as well. Herniated disc treatment for the low back is the opposite: Surgeons must use a posterior (back) approach because it’s possible to decompress pinched nerves then gently move individual nerves aside to reach the disc in that location.
In addition, a cervical microdiscectomy almost always requires an implant, either fusion or disc replacement. There’s simply not enough space to get to the back of the disc—in front of the spinal cord—to safely remove just a portion of it; as a result, the entire disc must be taken out. For a herniated disc in the low back, the portion of the disc that remains after a first-time microdiscectomy (usually 85 percent) is enough to maintain stability of the spine, thus no implant is required. (As noted previously in this article, however, recurrent disc herniation treatment may require stabilization with an implant.)
About Spinal Fusion
Instability of the spine must be addressed. Traditionally, that’s done with a spinal fusion. Here’s how fusion works:
During a typical fusion, a surgeon removes the disc material and all or part of the facet joints, inserts one or two spacers to keep the disc space open, packs the space with bone graft, and then inserts screws and rods to temporarily hold the bones in place while the bone graft heals or “fuses” the bones together. What were once two separate vertebrae are now joined as one solid mass of bone growing right through the disc space.
The problem with fusion is that it removes a joint from your spine, which limits your mobility. On top of that, taking away even a single joint means the remaining joints have to handle a greater mechanical load associated with your daily movements. The stress this creates on the levels above and below the fusion usually results in a more rapid degeneration of those levels—which usually means another fusion somewhere down the line.
Spinal fusion is also problematic in that it essentially “locks” the spine into one position, usually optimized for standing erect. Your surgeon will attempt to restore lordosis and position your head over your feet in a standing posture, to minimize the stress on your postural muscles when standing or walking. But standing is not the same as the spine’s natural position for sitting, and slumping (as we all do occasionally) can be even worse. Most of us sit at work, in the car, and in front of the TV, which can be difficult and/or painful after fusion surgery. We are learning that there is no such thing as the “correct” fusion posture, and it is becoming increasingly clear that this unnatural positioning is very damaging to the adjacent levels of your spine.
BalancedBack® Total Joint Replacement
Another option for a recurrent disc herniation after a microdiscectomy is a total disc replacement—avoiding a repeat microdiscectomy and/or fusion.
Rather than locking you into one position, the BalancedBack® Total Joint Replacement gives you a new disc and facet joint. So not only does this procedure address your problematic herniated disc, it also preserves movement in your spine after the surgery. The new, productive joint allows the levels above and below it to move naturally, and adapts to any posture, whether standing, sitting, riding in a car, or slumping on the couch watching TV. That means there’s a better chance you’ll be comfortable and pain-free in these positions, without forcing adjacent levels into potentially damaging postures. BalancedBack® moves with you—allowing the levels above and below the joint to move naturally too.
Would you like to know more about how BalancedBack® can help with recurrent disc herniation after spine surgery?
If you’re still investigating your options, visit our website to read more about BalancedBack® Total Joint Replacement. Or, schedule a complimentary call with our clinical coordinator, who can help determine whether BalancedBack® is an appropriate recurrent herniated disc treatment for you.