Disc prolapse / Slipped disc / Sciatica :

Who gets a disc prolapse ?

Most commonly it is seen between 30 to 40 years of age.

Why disc prolapse happens ?

It could be caused by accident or trauma, lifting unaccustomed, heavy weight with improper technique, travelling in bumpy and rough roads, straining yours back too much.

At which level it is affected?

Disc prolapses are common in the lumbar level because of maximum loading occurs at lower spine, so at L4-L5 and L5-S1 level disc herniation are common.

What happens in disc prolapse?

This prolapse compresses the spinal nerves, exiting the spine and it causes a mechanical and inflammatory changes around the nerves and ultimately it causes pain, tingling & numbness in leg and feet area.

What are the symptoms of disc prolapse?

Mild compression causes back pain, radiating down the leg, tingling, numbness, electric shock like sensation or burning or stabbing or shooting sensation.

These symptoms may be in lower back, buttocks, back or side of thigh, back of knee, calf muscles and ankles and upto soles and toes. It may occur in one leg or both leg. Patient may have to take rest after walking for few distances.

These symptoms may vary depending on level and degree of compression.

What happens in case of severe compression?

Severe disc prolapse and compression of the spinal nerve causes inability to move ankle or feet (foot drop), inability to control bowel habits and urination or total numbness of the entire limb. Severe compression could also lead to numbness around the saddle region (around the anus) called cauda equina syndrome.

It draws attention to urgent surgical decompression. You must see your physician immediately, if you have above symptoms, back pain with high fever (infection), tumour, major trauma or vertebral fracture.

Is treatment always required for disc prolapse?

Fortunately, 70% to 80% of patients, the disc prolapse resolves on its own. So conservative management is sufficient for first six week unless it is severe disc prolapse.

How can we diagnosed disc prolapse?

Do X-ray, MRI of lumbar spine and clinically correlate with patients. Nerve conduction studies (NCS) and Electromyography (EMG) may require in some cases.

How can we treat disc prolapse conservatively?

If patients have mild form of disease, then we can put patients on conservative management for first 6 weeks along with rest.

Antineuropathic medications : It works better then regular pain killers.

In severe muscle spasm, we can give muscle relaxant and as required oral steroids.

Bed rest of 3 days or more than 3 days is not advisable.

We can encourage patients to resume mild activities and physical therapies and rehabilitations exercise as early as possible.

Precaution to take in sciatica

We advice not to lifting heavy weight, till disease is recovered.

To avoid smoking.

We don’t advice for wearing lumbar belt for long periods of time as it may cause muscle atrophy.

We advice to take physical therapies like, TENS, Ultrasound, waves in mild form of disease. Yoga and core strengthening exercises have best role for early recovery. 

How to treat disc prolapse / sciatica?

If patient may have still persistent pain and radiating leg pain in spite of giving conservative management, we offer intervention approach.

1. Transforaminal neuroplasty it is to be given under IITV guidance for suspected compressed nerve. We give local anaesthestic and anti-inflammatory medications to relieve nerve root inflammation and edema caused by nerve compression. It can be done at any age.
2. Epidural injection : Caudal and lumbar epidural injections act on the target and it is very effective in relieving sciatic pain.

Epidural procedure for spondylitis / sciatica :

In epidural procedure, pain relieving medications are administered to target nerves, to relieve pain in the neck, shoulder and arm, which is cause by pinched nerve or inflamed nerve in cervical spine. Cervical epidural procedure, we inject anti-inflammatory, pain medications like cortisone into cervical region of spine.

This injection is not given into bone, muscle or spinal cord. It is used to treat chronic pain, inflammation, radicular pain in arm , forearm and stiffness of neck and shoulder. This is totally painless procedure. Procedure is done in operation theatre and it takes 20 mins. After procedure, patient is shifted in recovery room for observation. Patients are usually discharged after 2 hours.

3. Disc decompression procedure : We use disc – FX for contained disc, we do procedures like hydrodissection decompressor neucleotome to reduce the disc material. Percutaneous discectomies are safe and day care procedures to be done under local anaesthesia. It is stich- less procedures.
4. Endoscopic discectomies : It is very minimally invasive procedures. It is done under local anesthesia and sedation. It is a key hole and advanced procedure.
5. Ozon nucleolysis : Spine needle is placed in the affected disc. Ozone gas is prepared from Germany based ozone generator and injected through needle. Ozone causes shrinkage of disc and reduces its inflammation around the nerve
6. Ozon discectomy or Ozon nucleolysis for slipped disc

Intervertebral disc is made of nucleous pulposus, which is jelly like material, which contain 90% of proteoglycans . When ozone is injected into disc with specialised needle, the proteoglycan embedded in the jelly like material are broken down and so it is not capable of retaining water. As a result, disc shrink inside and mummified which is as equivalent to surgical discectomy and for that procedure it is called ozone discectomy or ozone nucleolysis.

Success rate is about 88%, which is comparable to surgical discectomy (50% to 90%) . Complications are very nil as much less then open surgery. It has been published in “Anesthesia and pain general that 85% of disc operation can be avoided with this non surgical intervention technique.

Ozone therapy : It is to be done under local anesthesia with patient awake.

Usually 1 to 2 sitting at the interval of 2-4 weeks are required. But in some resistant cases, additional procedures may be required.

When to do surgeries and what are the surgical option ?

If patients have red flag like neurological deficiency, foot drop, complete numbness of legs, unable to control defecation and if patient may not respond with nerve blocks ,then surgery is required. In case of cauda equina, it may required urgent surgical decompression.

Surgeries we do laminectomies, discectomies, micro-discectomies, lumbar interbody fusion surgeries (TLIF), lumbar stabilisation and disc replacement and Transforaminal lumbar endoscopic fusion.

Patient requires hospital stay of 3-5 days and recovery time is 3-4 weeks. Post operative physiotherapy or spine strengthening is recommended.

Transforaminal neuroplasty or Transforaminal epidural block

What is Transforaminal injection ?

It is a injection of anti-inflammatory drugs to be given at side of compresed nerve roots in epidural space.

How it works ?

Anti-inflammatory drugs at target level reduce the inflammation of exiting nerve root and swelling and it relieves pain, tingling and numbness produced by nerve root irritation.

Is this procedure painless?

Yes, we desensitiize the skin and deeper tissue with local anaesthetics by using thinnest needle along with mild sedation, so patient can tolerate whole procedures smoothly.

How is Transforaminal block performed ?

Under all aseptic precaution, patient is kept on prone position. With use of IITV machine, we inject medications on directly nerve root.

What I feel after Transforaminal block?

After block, you may feel slightly heaviness or may be numbness in your arm or leg. This effect is due to use of local anaesthetics. Also you may feel relieve of pain, this effect  last for few hours. Actual pain relief starts from 3^rd day.

When I can go home or performed routine activities?

It is a daycare procedure. We don’t advice to drive a car or performed machinery operating for one day. You can do your routine activity, office work on 3^rd day. You may apply ice to the injection site for 3 days. Usually you will feel mild aching at the injection site only.

Will the Transforaminal injection help me?

Patients who have radiating pain in leg or arm, respond very well than the patients with low back pain or neck pain.

Patient with a recent onset of leg pain, respond very well than long standing pain like for 2 years.

How many transformainal injection do patient needed ?

If patient have mild disc prolapsed then, most of the patients no need of 2^nd injection as it relieves inflammation.

But if the patient’s  1^st transforminal block does not relieve your pain within 3 weeks, than we advice to take 2^nd injection or if patients have completed 3 injections, then we advice for surgery.

Is there any risk or side effect?

It is a very safe procedures. Temporary pain at injection site

is the consequence from block.

In which patients the injection can not be given?

If patient is on warfarin medications, blood thinner medications, poorly controlled diabetes or has active infection in anybody part and tight canal  stenosis, then we avoid this block or may give after stabilising this condition.

Caudal neuroplasty

It is a form of caudal epidural injection to be given in multiple disc prolapse like L4-L5  & L5-S1. In this procedure tuohy needle is placed in caudal epidural space, which is lowest space in our lumbosacral spine and we give anti-inflammatory medications, injections, hyaluronidase or hypertonic saline.

This reduces swelling, adhesion around the nerve. It is to be used the pain originating from disc or may be given after failed spine surgery.