This document summarizes the surgical management of lumbar disc herniation. It outlines the absolute and relative indications for surgery, as well as the optimal timing. The available surgical interventions are listed, along with their common complications and results. Cauda equina syndrome is the absolute indication for surgery and requires immediate treatment. Relative indications include failure of conservative treatments and severe, intractable radicular pain. Open discectomy is considered the gold standard, while microdiscectomy has shorter recovery times. Patient selection influences surgical outcomes.

1. Surgical Management of Lumbar Disc Herniation

2. Objectives Absolute and Relative Indications for Surgery Timing of Surgery List of Available Surgical Interventions Complications of Surgery Results of Surgery

3. Indications for Surgery Absolute Cauda Equina Syndrome Recent Onset, Severe and Progressive Motor Deficit Relative Failure of adequate trial of non operative treatment for radicular pain Severe intractable radicular pain Herniation into an already stenotic spinal or nerve root canal Significant motor deficits with positive nerve root tension signs Large extruded fragments Recurrent radicular pain after successful trial of non operative treatment The presence of a mild or moderate motor deficit does not necessarily affect the indication for operative or non operative treatment

4. Timing of Surgery Cauda Equina Syndrome ASAP Relative Indications Lack of scientific evidence on optimal timing Rarely <6 weeks Period in which improvement in symptoms generally known to occur Should not be delayed beyond 3-4 months Chances of improvement in radicular pain are slight and decrease further after 6 months

5. Available Surgical Interventions Open Discectomy-open,fenstration,flavectomy,tailor -- Microdiscectomy -- Chemonucleolysis with Ozon, Chymopapain ---- Automated Percutaneous Nucleotomy Manual Percutaneous Discectomy Percutaneous Endoscopic Discectomy Endoscopic or Percutaneous Laser Discectomy Dskectomy plus fusion Vertebral arthroplasty

6. Complications of Surgery Wrong Level 1.2 – 3.3 % Durotomy 0.8 – 7.2 % Nerve Root Lesions 0.2 % Infection 2 – 3 % Recurrent Herniations 5 – 15 % Epidural Fibrosis Difficult to distinguish from recurrent herniation Contrast MRI investigation of choice No correlation between extent and symptoms No intervention or material shown to alter incidence Epidural Haematoma Cauda Equina Syndrome Iatrogenic Instability

7. Results of Surgery 85 – 95 % good to excellent short term results Long Term good to excellent results diminish to 55 – 70 % 10 – 18 % having required additional surgery Lower back pain usually the cause of dissatisfaction No difference between surgery or conservative Microdiscectomy Shorter hospital stay Faster return to sedentary work No difference c/w open discectomy after 8 –12 weeks No statistically significant difference in recovery of established motor deficits with or without surgery

8. Patient Factors Predicting Favourable Outcomes Absence of Lower Back Pain Radicular pain distribution with positive tension sign Higher socioeconomic status Minimal psychosocial stress

9. Summary Open (and probably micro) Discectomy Gold Standard Adhere to indications for surgery Patient selection influences outcome Chymopapain has a role to play Other interventions remain experimental Bear in mind Natural History of LDH

10. Questions