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When does one require surgery for disc prolapse?

Q: I am a 20 years old girl. From the past 8 months I have been having right leg pain originating from the hips. Recently, an MRI has been done and the doctor says that I am suffering from disc prolapse in L4-L5 regions. Some experts also say that it is a slip disc. I have already consulted three doctors, out of which one doctor, who is a neurosurgeon, has advised a surgery without a second thought. Another doctor has advised complete bed rest along with the use of a corset and no surgery at present. I am very worried as to what to do now, as I don't want to go for a surgery right now. Can you please help me decide?

A:I can understand your dilemma. Most people that are normal would like to avoid a surgical intervention. When you get a conflicting opinion there can be greater confusion. Allow me to clear your mind of this confusion. First of all slip disc and disc prolapse are all terms used to loosely describe the same problem that is of intervertebral disc that has protruded or come out beyond its normal confines. This is a degenerative process hastened by several environmental, occupational and genetic factors. The discs normally take care of the shock absorbing function in the spine and to some extent allow the suppleness of your back. Once it degenerates or protrudes beyond its confines, symptoms come on because it pinches some nerves in the neighbouring area. There are several theories on the cause of pain in a disc prolapse but important thing is to realise that once a disc has come out there is nothing that can put it back. It can never regain its normal shock absorbing function. Medicines and exercises only help the body to cope with the problem, nothing more. The issue of strict bed has been laid to rest by an excellent study reported in the New England Journal of Medicine, where it is clearly proven by a randomised control study that it is not necessary to have strict bed rest. Those patients that are allowed activities governed by their tolerance to pain followed by exercises do the best. So you do not need to be confined to bed. Surgery is specifically indicated only when you have: 1. Intractable and severe pain, or2. Recurrent attacks of pain that cuts into your economic activity, or 3. Objective significant paralysis in some muscle groups, or 4. Complete paralysis coming on including urinary and bowel symptoms. These are the only indications for surgery. In the pre MRI era, we also used to have another indication of doubtful diagnosis. From your history I do not think you fall into any of these and therefore there is no harm in waiting. Having said that, your doctor will need to guide you regarding your physical signs. Do not go by the MRI report. Surgery is based on patient’s symptoms and signs and not on the MRI severity of disc prolapse. In case surgery is required, it is reasonably safe and patient is out of bed in 48 hours time with stitch removal in two weeks and back to activity in three to four weeks. Microsurgery is only one technique and I do not think it makes too much difference in outcome other than the size of the incision. But make sure it is done from a centre where these surgeries are done regularly. As far as delay in surgery is concerned the world authority on back pain, Alf Nachemson from Sweden, has found that there is no significant difference between the long-term findings between the operated and un-operated cases. I hope I have been able to clear some of your doubts.


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