16 questions about a back hernia
So I can move freely?
The advice for a back hernia was always: six weeks flat. Today, doctors advise you to keep moving. What’s that good for? And is it better whether or not to have surgery quickly?
1. In the past you had to lie flat with a back hernia, now you have to move. What’s up with that?
Doctors have long believed that rest accelerated the healing process. You tax the vertebrae then not. They now know that the opposite is true; movement keeps you flexible
and ensures that the body clears the hernia faster. As far as you can move as a hernia patient, of course, because sometimes the pain simply makes that impossible.
People with a hernia are often afraid that exercise will worsen the damage, but that concern is unwarranted. Another misconception is that you have to walk upright with a hernia. It is best to take the position that is least painful.
2. What is a hernia in the back?
A bulge of an intervertebral disc pressing on a nerve. The spinal column consists of seven cervical vertebrae, twelve thoracic vertebrae and five lumbar vertebrae from top to bottom. They are connected with intervertebral discs: sturdy hinges with a soft core. With age, the intervertebral discs continue to dry out, causing them to crack and possibly tearing the sheath. This can also happen in the event of an accident or due to overload. The soft core of the intervertebral disc then bulges out and can press on one of the two nerves located here, often resulting in severe pain.
3. Where exactly is the pain?
Not all patients with a back hernia have pain complaints; it just depends on where the bulge is. When it presses on a nerve, the pain is usually severe. Many hernia patients have pain in the lower back, which radiates to one leg (on the side where the nerve is pinched).
4. Do older people in particular get a hernia?
The average age for a hernia is 40 years. With age, the intervertebral discs dry out and collapse. That means nothing can bulge out. That is why a hernia without other problems above the age of 70 almost never occurs. However, people over 50 often suffer from stenosis, whether or not in combination with a (small) hernia. Stenosis is a narrowing of the spinal canal. Throughout life, the entire spine wears down (arthrosis). In response to this, the vertebral bone proliferates and becomes thicker. The spinal cord and nerves can then be crushed. Stenosis gives complaints that are comparable to those of a back hernia.
5. What can be done about it?
There are two options: wait or operate. In 80 percent of cases, the body clears the bulge of the intervertebral disc itself. This means that the pressure – and the pain – will subside over time. In the meantime, painkillers and certain physiotherapy exercises.
Waiting does not help in eight out of a hundred patients. Without surgery, they probably won’t get rid of the pain. That is why the latest guideline states that hernia patients should be offered surgery after eighteen weeks. Sometimes the pain is even with painkillers before those eighteen weeks, however, so unbearable that patients cannot or do not want to wait any longer. In that case, surgery is already done after six to eight weeks. Incidentally, it depends on the type of pain whether surgery is useful. Leg pain can almost always be treated well with surgery. Back pain caused by a hernia only to a limited extent.
The symptoms as a result of stenosis are less likely to go away on their own. Surgery needs to be done more often.
6. Do many people suffer from a hernia?
It is estimated that 75,000 Dutch people suffer from it every year.
7. Is a hernia hereditary?
New.
8. Can you prevent it?
In most cases, a hernia (or stenosis) is the result of natural wear and tear of the intervertebral discs. So you can’t do anything about that. Heavy physical work does increase the risk of a hernia.
9. How is a hernia diagnosed?
Usually a x-ray of the lumbar spine. The diagnosis of hernia cannot be made on that photo, but it is possible to detect abnormalities of the bone. In addition, it can be assessed whether, for example, there are deviations in the position or shape of the spine. To demonstrate that the pain in the leg (and possible failure symptoms) is indeed caused by the protrusion of an intervertebral disc, further research needs to be carried out.
The most important imaging study is the MRI scan of the spine. An MRI scan shows the hernia, as well as the compression of the nerve root.
10. Why do painkillers not always provide relief for a hernia?
Because doctors still don’t really know how nerve pain works, and therefore don’t know how to block it. In most cases, a strong painkiller like morphine at least a little, but there are also people for whom nothing works.
11. When is an operation chosen?
Not every hernia needs surgery. Most complaints of a hernia go away on their own over time. The decision to operate depends to a large extent on the severity of the pain and any existing loss. In general, surgery is not performed earlier than 8 weeks after the onset of the complaints, unless urgent is required. If the pain is not too bad, it is often waited longer than 8 weeks. If the complaints persist, it will be decided to operate within 6 months, because it has been shown that recovery is slower after a long wait. There are two types of surgery indications:
Absolute operation indication In this case there is serious or rapidly occurring failure of the nerve or a group of nerves. For example, with severe paralysis symptoms of muscle groups of the legs or loss of control over the urinary bladder.
Relative surgery indication In this case, there is so much pain that you can no longer function properly. The patient is then the one who has to indicate that this is no longer possible; the pattern of complaints determines whether or not to operate.
12. How does such an operation go?
A hernia operation can be performed under general anesthesia or under local anesthesia by means of an epidural. There are different surgical techniques:
• The classic ‘open’ operation: in which the entire surgical area is exposed.
• The Micro Tube Discectomy Method (MTD): In which a cut is made of approximately 2 cm and with the help of a tube.
With the microtube technique (MTD), the operation is performed using a microscope (or magnifying glasses with a headlamp). A thin needle is inserted through an incision of about 2 cm in the back. Increasingly thicker tubes are slid over this needle, so that the correct opening is created through which the surgical instruments can be inserted. The operation is performed while the neurosurgeon looks through an operating microscope, which also allows depth to be seen. The image can be enlarged, allowing the neurosurgeon to work very accurately. The advantages of the MTD technique are therefore clear: less tissue damage, a shorter hospital stay (often one day and one night) and a faster recovery. However, MTD is not for everyone.
The classic technique
In the classic technique, the surgeon makes an incision of two to three centimeters in the back, just above the hernia. After making space by sliding the back muscles to the side, the bulge and worn inner part of the intervertebral disc are removed. This is to minimize the risk of a new hernia. Hospitalization lasts an average of three days.
13. Is there a chance of complications?
About 1 percent. There may be bleeding or inflammation. cystitis and thrombosis (vein blockage) occur. When the spinal cord membrane is damaged, temporary headaches can occur when sitting upright. And if the nerves to the bladder and intestines are damaged, there is a risk of incontinence.
14. How do you know who is best for an operation?
In general, the more often a surgeon performs surgery, the better he gets at it. There is no official guideline, but 50 spinal operations per year is the minimum. Don’t be afraid to ask a doctor about his experience.
15. Is it true that doctors in Belgium and Germany operate faster?
In Belgium, hernias are operated on four times as often as here, presumably because surgeons are more likely to respond to a patient’s surgery request. That is why many Dutch hernia patients go to Belgium. But if your own doctor advises against surgery, there is usually a good reason for it. For example, because the hernia mainly causes back pain. It is rarely treated with surgery. It can even make the symptoms worse.
In Germany and Belgium you may be helped quickly, but there are hardly any waiting lists in the Netherlands and you can almost always get in within two to three weeks.
16. Do hernia patients completely get rid of their pain?
The result of hernia surgery depends a bit on how you look at it. From a doctor’s point of view, it is often a success, because the leg pain is gone. At the same time, the patient may be less satisfied because the back pain is still present. After two years, 20 percent still have complaints, both in the group that had surgery and in the group that did not. Sometimes it is not possible to remove the cause of the pain. Or the area of the brain that processes pain has been stimulated to such an extent that it does not go away, even if the trigger disappears. Doctors have recently started paying attention to this group, for example with psychological counseling. These patients may also need to undergo more drastic surgery, which involves the removal of an intervertebral disc. Further research is being done on this.
With the cooperation of Prof. Dr. Wilco Peul, professor, neurosurgeon and head of department at the Leiden University Medical Center (LUMC) and the Haaglanden Medical Center. Peul specializes in spine surgery and is principal investigator of the Leiden-The Hague Spine-Intervention-Prognostic-Study (SIPS) Group.
Sources):
- Plus Magazine