Lumbar disc herniation (LDH) causes a painful compression of a nerve or its root, due to the protrusion of part of the disc between two vertebrae.  It is a relatively frequent pathology. The anatomical location of an LDH – and its consequences – vary according to the disc that is causing the problem, its location between the lumbar vertebrae and the nerves that can be damaged by the compression. “In a great majority of cases, the hernia occurs between the L4 and L5 vertebrae (L for lumbar) or between L5 and S1 (S for sacrum). In fact, these are the areas that are most solicited during movement”, points out Dr. Annie Dubuisson.

Billards is not a game

When an LDH does not cause a specific motor deficit, a large number of practitioners hesitate to systematically send their patients to the operating room as quickly as possible. In fact, in their article, the neurosurgeons from Liege a study conducted in 2007 which showed that among a group of 142 patients who were rapidly operated on (on average 2.2 weeks after the consultation for their LDH condition) and another, identical in number, and in which 55 had been operated on after 18.5 weeks, while all other individuals had benefitted from a non-invasive treatment, the results were similar at one year. So why rush into an operation?

The neurosurgeons from Liege therefore often “resist” the pressure put on them by certain patients and curb their requests for rapid intervention. "Indeed medical imaging by scanner or magnetic resonance, carried out following the patients’ complaints, probably shows degeneration or even a discal protrusion or hernia. But this is not sufficient in order to decide on the necessity of an operation. In fact lumbar degeneration affects everyone! “Being dictated to by medical imaging would be a mistake”, insists Prof. Martin. “Moreover, in numerous cases, the imagery shows that several discs are damaged: which then should the surgeon decide to operate on? Should they all be corrected while the situation could have been resolved spontaneously”?

“Let us be clear”, explains the neurosurgeon. “For simple LDHs, which cause pain in the lumbar area and in the lower members, there is never an urgent need to begin an aggressive treatment. Just like general practitioners, we tend rather to decide in terms of a range of treatments: rest, medication or infiltrations are suggested progressively in the hope of a progressive reduction of the hernia”.

Nevertheless, for around 20 % of patients, this conservative treatment does not suffice for producing the required results. In the case of these patients it might be considered judicious to remove the piece of the disc that protrudes and compresses a nerve root. “However, care should be taken”! The specialist warns. “The surgical indication must genuinely be subject to very strict selection: the examinations practiced must show a real radiological and anatomical correlation between the pain and the compressed nerve root. If this is the case, the results of the operation are then very good, just like when we remove a pebble from a shoe! On the other hand, if the decision was taken without due circumspection and rigorous selection showing the link between the hernia and the pain, the intervention is useless”.

In addition, warn the neurosurgeons, the fact of having removed the cause of the pain thanks to an intervention is not necessarily sufficient: a hernia means that great care must now be taken of the back which has experienced a problem. An LDH whether operated on or not is an alarm signal. If the patient is not warned that he or she should perhaps lose weight and in any case learn to treat their back better, new episodes of the problem may be experienced.  “For a surgeon, operating on a disc herniation takes about one hour, explaining to a patient the behavior that is necessary pre and post-operation to protect their backs takes a lot longer”, points out Prof. Didier Martin.