Innovations in Disc Herniation SurgeryConditions
By David Bomback, MD ONS Orthopedic Spine Surgeon
Disc herniations can occur in people of all ages however it is most common in those under 50 years old. A herniated disc can develop either from a traumatic event or gradual wear and tear – it is truly unpredictable and can even be affected by genetic predispositions or degenerative changes.
Typically, back pain is the first symptom. Depending on the severity of the herniation, after a few days or weeks, your back pain may subside, yet you may start to experience new and worsening leg pain. This might be in the form of significant radiating nerve pain that shoots down your entire leg. If you are experiencing weakness in any part of your body – especially feet, hips, quadriceps, etc. – it is important to be evaluated by a spine surgeon immediately to preserve your motor function.
If you are not feeling weakness, a spine specialist can help you manage your pain conservatively with rest, ice, activity modification, physical therapy and/or injections such as an epidural steroid injection. If these methods fail, or if you are experiencing significant pain and weakness, surgery is recommended.
About thirty years ago, surgeons would remove a large portion of the disc in the hopes of lowering the chance of re-herniation. Unfortunately, by destroying healthy tissue, the discs degenerated quicker and some even collapsed. While re-herniation rates were low, patients were left with worsening back pain, more arthritis and a higher risk of needing a spinal fusion in the future.
We realized this wasn’t the best way. So we shifted from a discectomy to a microdiscectomy which uses smaller, microscopic incisions (making it less invasive) to remove solely the portion of the disc that is compressing the nerves. This more thoughtful way of removing loose fragments instead of aggressively cleaning out the entire disc is the current standard of care. We aim to leave as much of the healthy part of the disc intact as possible. Typically, patients wake up from surgery with immediate relief from their leg pain. Numbness or tingling may take more time to disappear.
While microdiscectomy is a vast improvement from discectomy, there are still imperfections. The surgery can leave a hole where the herniation occurred. Ideally, it will get filled in with scar tissue over time, but that is not always the case. Typically, around 10 percent of patients will re-herniate their disc, with that number jumping closer to 25 percent for those who had larger defects in the disc membrane.
Medical professionals have sought to solve this clinical problem over the years. We have tried stitching over the defect, yet we found that wouldn’t hold. We’ve tried putting synthetic materials over the hole, but that simply created more scarring often irritating the nerve root even more. Neither option was effective. While stem cells don’t appear to have a role in treating active disc herniations, cell therapy could potentially help rehydrate discs and seal tears in order to help prevent herniations from occurring in the first place. Further research is needed in the future to determine biologic treatment options.
The latest advancement is a synthetic polymer inserted via metallic bone anchor to plug the hole. The implant stays where we put it and doesn’t create scarring. This has been useful for medium-to-large size defects, as small ones don’t need any extra coverage. I was the first surgeon in Connecticut to try this technique in CT and currently train physicians across the country.
Studies have shown that this implant from Barricaid was 95 percent effective at preventing a second operation for re-herniation1.
There’s no absolute way to know if a patient is a candidate for something like this until we are operating but surgeons can take their best estimate based on pre-operative MRIs. Patients should feel empowered to ask about all available options prior to surgery so that the surgeon can provide the best care possible while in the operating room.
Personally, my patients have seen great success when implants such as these were utilized. They have all returned to pre-operative activities, some being in labor-intensive jobs, possibly even a little bit faster than usual.
The field of spine surgery continues to advance with medical innovations leading to better patient outcomes. As surgeons, it is important to stay educated and continue learning so we can provide the best treatments to our patients.
- Thomé C et al. Annular closure in lumbar discectomy for prevention of reherniation: a randomized clinical trial. The Spine Journal 2018
About Dr. David Bomback
Dr. Bomback is an orthopedic spine surgeon at Orthopaedic & Neurosurgery Specialists (ONS), treating all spinal conditions including minimally invasive spine surgery, complex spinal deformities as well as revision spinal fusions. To schedule an appointment, please call (203) 869-1145 or click Schedule Appointment today.