HERNIA OF WAIST (LUMBAL DISC HERNIA)

The spine consists of bones, which we call 'vertebrae', stacked on top of each other. In the middle of each vertebral body is the spinal cord, which is the continuation of the brain. The senses returning to the brain from various parts of the body or the orders dispersed from the brain to the body travel within the spinal cord. Nerves emerging from the level of each vertebral body in the lumbar region also spread to the hip and leg, providing the sensation and movement of these regions. These bones, called vertebrae, are connected to each other by flexible structures called 'disc' which have elastic properties. Over time, these flexible structures, namely the discs, wear out and lose their elastic properties. As such, this disc overflows backwards with traumas or loads. In other words, this disease occurs as a result of the gelatinous inner part of the discs tearing the outer part consisting of a stronger connective tissue and compressing the spinal cord and nerves. Lumbar hernia is the pathological process that occurs as a result of herniation (hernia) of the intervertebral disc(s) in the lumbar region. Depending on the movement and loading of the vertebra, 95% of hernias are seen at the L4-L5 level of the spine; L3-L4 level is in the second rank, and its incidence continues to decrease towards the proximal (3). The most obvious symptom of a herniated disc is back and leg pain. The pain that occurs in the form of sciatica can be so severe that it prevents movements such as walking, standing and sitting. Lumbar hernia can also turn into paravertebral muscle spasm, a picture in which serious symptoms such as lower extremity hypoesthesia and strength defects are seen. The incidence of lumbar hernia increases between the ages of 30-50; Its incidence decreases after the age of 60, and it is rarely seen in childhood. The fact that lumbar hernia is characterized by frequent and serious symptoms, especially in the middle-aged and working population, brings along social and economic problems. 

What are the Symptoms of Lumbar Hernia?

The most obvious symptom of a herniated disc is back pain. Patients express a localized blunt pain, especially in the lumbar region. This pain; It is usually not very uncomfortable and increases with standing and movement for a long time and decreases with rest. In accordance with the anatomical distribution of the affected nerve root and the excess of pressure, pain spreading to the leg may develop and this pain is sometimes severe enough to prevent movement. Sudden worsening of the picture may be due to a trauma, sudden movement or heavy lifting, or it may start suddenly without any reason. It can cause locking and stiffness in the waist and legs.

What are the Risk Factors of Lumbar Hernia?

The main factors that cause lumbar hernia; age, gender, obesity, smoking, sedentary lifestyle, heavy physical activity, traumatic accidents, work and occupational factors. The incidence of lumbar hernia is high between the ages of 30 and 50, which is generally considered the productive age. In general, gender is not considered as a risk factor, although there is literature that states that male gender is considered as a risk factor and the frequency of surgery due to herniated disc is 2 times higher in males than in females. In the literature, it is stated that obesity is an important risk factor in the formation of lumbar hernia due to the effect of increasing the load on the spine. Smoking negatively affects the oxygen carrying capacity of hemoglobin and the oxygenation problem in the discs are among the factors that cause lumbar hernia. Sedentary life, exposure to repetitive vibrational effects, working in jobs that require standing or sitting for a long time, weekly working days, daily working hours, physically intense work are reported as factors associated with lumbar hernia.

What are the Treatment Methods Applied in Lumbar Hernia?

Physiotherapy is the first step of conservative treatment together with medical treatment. In extremely painful cases, 3-4 days of bed rest may be recommended. Strengthening and stretching exercises can be planned for walking, abdominal muscles, gluteal region and leg muscles. Patients should be educated and especially taught to avoid movements that will increase intervertebral disc pressure. Since medical treatment will increase physiotherapy tolerance and patient comfort, it is recommended to be used simultaneously. First of all, nonsteroidal anti-inflammatory (NSAID) can be used because it will reduce inflammation and edema. Opoid analgesics can provide symptomatic relief in myorelaxants. Surgical Treatment Surgical treatment with progressive motor deficit and cauda equina syndrome is considered as an indication for emergency surgery. In addition, the presence of persistent pain that does not improve despite 4-6 weeks of conservative treatment and the detection of progressive neurological deficit during follow-up are indications for surgery. If the neurological deficit includes especially motor losses, the necessity of surgery becomes inevitable. Depending on the pathological condition of the disc, different methods such as laminectomy, discectomy, foraminotomy and spinal fusion are preferred. In the operation of herniated disc, open standard surgery can be performed, as well as in parallel with the technological developments; Less invasive techniques such as microdiscectomy and endoscopic microdiscectomy are also used. In the procedures performed with invasive methods, the operation time is short, tissue trauma and blood loss are less, and recovery and discharge occur earlier. Because of such advantages, invasive methods are accepted as the gold standard in the surgical treatment of lumbar hernia.