Lumbar Herniated Disc - Nitin Bhatia, MD

Dr. Sechrest: Hello, I’m Dr. Randale Sechrest, your host for eOrthopod.TV. Today I have with me, Dr. Nitin Bhatia. Dr. Bhatia is a spine surgeon, who is the Chief of Spine Surgery, at the University of California Irvine. Dr. Bhatia did his undergraduate training at Stanford. He then went on to Baylor College of Medicine where he completed his M.D. degree. From there, he did orthopaedic surgery training at UCLA. From there, he finished a spine fellowship at the University of Miami. Today, he practices complex spine surgery at University of California Irvine. Good day, Dr. Bhatia.

Dr. Nitin Bhatia: Thank you for having me.

Dr. Sechrest: Dr. Bhatia, what I would like to discuss over the next 20 minutes or so is the concept of herniated disc in the lumbar spine, or what some people refer to as the low back. I think everybody has heard of this concept of a ruptured disc or a herniated disc. Explain that to us. What is it?

Dr. Nitin Bhatia: Sure. It’s a great question. Unfortunately, it’s a problem that happens very commonly. The discs are the shock absorbers of the spine and their structure has two components to it. They have a firm outside and a jelly-like inside, almost like a jelly doughnut. Now the key for their function is at the jelly stays inside and allows motion both forward, backward, sideways and some rotation, and it allows the disc to absorb any shock that we feel. That’s why we can run and jump and do all the things we do. Unfortunately, if abnormal pressure is put on that disc, some of the jelly, or nucleus, can herniate out, and it becomes a problem when it herniates and starts pushing on the nerves that sit adjacent to the disc immediately behind it.

Dr. Sechrest: Now what sort of symptoms does that cause? If there’s pressure on those nerves what do I as a patient experience?

Dr. Nitin Bhatia: The classic term for it is sciatica. So you get the shooting pain down the leg, usually down the side or the back of the leg. It can also be associated with significant back pain that usually subsides within a few days. But the overall sensation is that shooting pain down the back or side of the leg; sometimes down the front as well, including numbness, tingling, or even weakness in the leg.

Dr. Sechrest: My understanding that it depends on what nerve is involved as to where the pain goes, so different people with sciatica have pain in different areas. It means a different disc is involved.

Dr. Nitin Bhatia: Exactly, and what we know is that specific nerves innervate different parts of the leg. For example, the front of the thigh is innervated by a lumbar 3 or lumbar 4; and so if the disc in that area herniates, that’s where you get your pain and numbness in the front of the thigh. But, if the lumbar 5 – sacrum 1 disc herniates, which is the very bottom level, that’s more the side or the back of the leg so you get the numbness, pain, tingling down the back of the leg. So we can actually get a pretty good idea of which disc is herniated based on the patient’s symptoms.

Dr. Sechrest: You know, I think one thing that’s always hard for patients to understand is that, a lot of these patients with sciatica, especially the young patients who have a classic herniated disc don’t have any back pain.

Dr. Nitin Bhatia: Right.

Dr. Sechrest: So when you tell them the problem is in their back they look at you like, “What are you talking about? I’ve got pain in my foot. I’ve got pain in my ankle.”

Dr. Nitin Bhatia: Exactly, and patients also come to me and say, “But I didn’t do anything. I had a very relaxing weekend. I kind of sat on the couch and watched basketball all weekend. I didn’t lift a suitcase. I didn’t go weightlifting”, and frequently there’s no inciting incident. There’s no trauma, no lifting activity, and the herniation just happens from kind of an unknown cause.

Dr. Sechrest: That’s a good point. I think that all of us tend to think about things that happened to our bodies, especially bones and joints, as an injury of some sort, and not everything that happens to us is necessarily an injury.

Dr. Nitin Bhatia: Right.

Dr. Sechrest: There’s another, I think, controversy, or maybe it’s not so controversial anymore, but it’s the concept of what’s causing the sciatica. It’s the concept of whether it’s the pressure on the nerve, or whether it’s the chemical, now, from the leaking disc. What’s your position on that?

Dr. Nitin Bhatia: Well, I definitely think it’s from the pressure on the nerve, and the reason I think that is we see a lot of people with small disc herniations. They may get an MRI scan for another reason, and they’ve got these tiny little disc herniations, but the nerves aren’t hurting. Now, they might be having some pain in the back, in the low back itself, but the sciatica is not there; and those little disc herniations are probably leaking almost as much chemical as a bigger one. But the difference is the bigger ones, or the ones that happen to be in just the right spot where they catch the nerve, cause the shooting pain; and we also know that once you take the pressure off of that nerve and take the piece of disc that’s herniated out, the pain goes away.

Dr. Sechrest: Well, let’s go back to the symptoms and what I as a patient am going to feel. We’ve talked about pain, which is obviously one of the things that the patients come in with. Sometimes we see patients that just come in and say, “My foot’s not working right. The muscle’s not working right. I don’t have a lot of pain”, or they may have numbness. What is the spectrum of things that you look for as a spine surgeon to try and determine whether this patient has a herniated disc or not? What is the most reliable symptom?

Dr. Nitin Bhatia: The most reliable symptom is one of those things that you mentioned: numbness, sometime tingling, definitely pain, in a particular nerve pattern. So, I want to see it in just one of those nerves that I mentioned before. Is it in the front where the L3 or L4 is? Is it down the back? Is it down the side? If it’s the whole leg, then I’m a little concerned that it may not be a nerve, but there may be something else going on instead of a particular nerve pattern. The weakness also should fit a particular nerve pattern to really give us an idea that that nerve itself is being injured and is now inflamed and not working correctly.

Dr. Sechrest: Now, when patients are referred to you because either their primary care physician thinks they have a herniated disc or the patients themselves make an appointment and think they have a herniated disc. How do you proceed? What do you want to know from that person, and describe how you try to make a diagnosis?

Dr. Nitin Bhatia: You know, the history is extremely important. I think we’ve talked about that, how really figuring out where the pain and where the other symptoms are is very important to give us a good mental picture of what the problem it probably is. We then do a physical exam and the things we’re really looking for are: Are the nerves irritated? We can tell that by stretching the nerves and seeing if it causes more pain? We can also check the strength. So, if someone’s having weakness in their legs or having difficulty walking on their tiptoes, it can show us that the nerves aren’t working correctly and hence their getting weakness in a particular area. Then, finally, we can get x-rays, although they usually look fairly normal, and then an MRI scan is usually the test of choice to confirm our diagnosis by looking at the nerves and looking at the discs and getting an idea if the disc is herniated in the area that we thought it would be.

Dr. Sechrest: And the MRI scan is, in your hands, the gold standard in terms of making this diagnosis.

Dr. Nitin Bhatia: That’s correct.

Dr. Sechrest: But one thing comes to mind, because I think a lot of things, as you mentioned, if you’ve got whole leg pain, a lot of things can cause pain in the leg and mimic a herniated disc. What is the most common presentation, in terms of the patient? I’ve always thought that a herniated disc is a young man’s disease or a young woman’s disease. Whereas, the older we get, that leg pain is more likely caused, not by a herniated disc but by something, bone spurs or something narrowing the area where the nerve goes out. Is that still considered correct information?

Dr. Nitin Bhatia: It is, and a herniated disc is usually someone in their 30s or 40s, and it’s usually kind of an isolated sudden problem. As we get older, we all get some arthritis and bone spurs that cause some narrowing of the spinal canal. Unfortunately, in some people, that does cause some pinching of the nerves, but it’s a much more gradual process, and it’s a very different origin than the herniated disc. Now, it can be challenging, from a history and physical point of view, to tell the difference except usually the people with the herniated disc are younger and haven’t had any symptoms before. The people with the bone spurs may have had some degenerative arthritic problems. They’re usually older, usually over the age of 60, and the MRI scans will also look different.

Dr. Sechrest: So it’s the MRI scan where you really sort of decide and whether it’s a young person or old person, that’s where you make the decision if it’s a true ruptured or herniated disc.

Dr. Nitin Bhatia: Correct. It really helps confirm the idea of that, yes.

Dr. Sechrest: Any other tests that you would recommend getting after the MRI scan to clarify it.

Dr. Nitin Bhatia: Usually the MRI scan is as much as we need. Occasionally, we can get an EMG, or nerve conduction test, which shows us particularly which muscles or nerves are having trouble, or a specialized CT scan, but those are usually only necessary in very complex problems, or problems where the diagnosis is not clear.

Dr. Sechrest: Okay. So if I’m a patient with a herniated disc, and we’ve made the diagnosis; we have an MRI scan that shows a big herniated fragment or a disc that’s out there pushing on the nerve, and I’m having pain, what are my treatment options? How do you proceed at that point?

Dr. Nitin Bhatia: Well, the good news is 90% of these herniations will get better on their own within approximately 3 months, and so our goal for those three months is to just get the patient comfortable while the body tries to resorb that herniation. Now some of the caveats to that is, if somebody comes in with real weakness in that leg, they’re kind of dragging their foot, or they’re so painful that they can’t get out of bed and can’t walk around, probably we’ve got to move a little more quickly with them. But, as long as the pain is tolerable, and the weakness isn’t too bad, we start with some anti-inflammatory medications, some physical therapy, and then perhaps some injected steroids which we call epidural injections.

Dr. Sechrest: The goal, as you mentioned, none of these things is probably going to cure the problem. The body is going to cure the problem itself and that’s just a healing process.

Dr. Nitin Bhatia: Correct.

Dr. Sechrest: We’re just covering up the symptoms or trying to reduce the symptoms so that the person can go and do their activities, work, and that sort of stuff more comfortably.

Dr. Nitin Bhatia: That’s exactly right.

Dr. Sechrest: Is there any other time where you would rush to surgery for a herniated disc?

Dr. Nitin Bhatia: In the rare case where the disc herniation is so big that the patient is having problems going to the bathroom, either bowel or bladder, that’s actually an emergency which we call a cauda equina syndrome; and that truly is a surgical emergency. If that develops, say at 9 a.m., that patient needs to be in the operating room that same day. Otherwise those bowel and bladder problems can become permanent very quickly.

Dr. Sechrest: Okay. Now define for me this cauda equina syndrome? It primarily means, I mean the patients that have this, are they having trouble leaking urine? They can’t go? Are they incontinent of bowels or are they constipated? When we say bowel and bladder changes, what do we mean?

Dr. Nitin Bhatia: It can actually be kind of a spectrum of those problems. Frequently they’ll have retention because they can’t open their bladders. Some patients have problems actually closing their sphincters as well so they have leakage. But probably most frequently we see significant retention when they have significant injury like that.

Dr. Sechrest: So their bladder fills up, they can’t go, and then they begin to leak because it’s just overflowing.

Dr. Nitin Bhatia: Right.

Dr. Sechrest: I’m assuming that full bladder causes pain, too.

Dr. Nitin Bhatia: For sure.

Dr. Sechrest: The other thing, I think, that those patients sometimes have is numbness around in their crotch area, around the vagina, around the testicles, around the rectum, and that sort of stuff.

Dr. Nitin Bhatia: And, in fact, in those patients an examination of that area is very important to check if the sensation is gone, and to see if they’re able to control their bowels and their rectum, because what we’ll find is that they lose significant control of that.

Dr. Sechrest: Is the cauda equina syndrome more worrisome at specific levels? I’ve heard different things, and I’m not certain what to worry about the most.

Dr. Nitin Bhatia: Probably the levels where it’s most serious are the low thoracic and upper lumbar spines, what we call the thoracolumbar junction. From approximately T10, T11, and T12, which are the three lowest areas of the thoracic spine, which is the chest area, and the upper one or two lumbar areas, L1 and L2. Now fortunately, that’s not a common place to have disc herniations or other spine problems, so that area is usually fairly well saved. The places where we really see the cauda equina syndrome more frequently is in the mid- or low lumbar spine, so lumbar 3, 4, and 5, which are the bottom three levels. It is quite a rare problem, though, fortunately.

Dr. Sechrest: Okay. But you can still a cauda equina syndrome with a massive disc herniation even at L5-S1, L4-5.

Dr. Nitin Bhatia: For sure.

Dr. Sechrest: Okay. Let’s talk a little bit about surgical options. Let’s say that I’ve gone through, I’ve had an epidural steroid, and I’ve tried the conservative therapy. I’ve got a little weakness, but it’s not too bad, and I’m not too concerned about that, but I’m still having pain, and I may have a little numbness and tingling. I’m three months out. I’m a patient and I’m getting a little frustrated. What are my options?

Dr. Nitin Bhatia: Well, at that point you’ve done everything right. You’ve tried the physical therapy, tried the injections, and the pain is still going on. What we know is that the longer the pressure is on the nerves the more permanent the damage becomes, and probably it’s best to get the pressure off of the nerves, either by letting the body do it within two or three months, or by surgically taking the pressure off within three to six months from the onset of the symptoms. After that point, some of the problems become more permanent and probably outcomes are worsened. So, really in that case, if you’ve done everything and the pain continues, we’re looking at surgery. Now fortunately surgery for this problem is very simple. We go in, we take out that little area of disc that herniated and pushing on the nerves. We don’t take out the whole disc, just the very herniated portion of jelly in a very small procedure, and usually the pain goes away almost immediately.

Dr. Sechrest: You know, up until several years ago I think, there was some classic research studies that pretty much said the following: if you look, if you took 100 people with a herniated disc, and you followed those people; you split them in half, 50-50, and you follow those people for 5 years, at the end of 5 years you couldn’t tell the difference between the group that had surgery and didn’t have surgery. Now I think some of that has changed, and this notion about “well, that’s true for those people at that three month period”. Do you think it’s changing at this point to where we’re more likely to look at folks who have a herniated disc and aren’t getting better at that first 3 months, that they’re better off having surgery at that point rather than waiting that 5 years?

Dr. Nitin Bhatia: For sure, and the reason is we’ve recently had some great studies come out, actually government funded, multiple center, prospective, randomized studies, which are the best kind of scientific studies we can do, where they took 100s and 100s of patients and said, “okay, some of them with these disc herniations are not going to have surgery, and some of them are going to have surgery” and then saw how they did. What they found was in the patients who they allowed to choose, so some patients said, “oh, I want to have surgery” and some patients said, “no, I don’t”, and they followed those patients. The patients who chose to have surgery early and stayed with that decision got better much faster, and got to work much sooner, and got back to their life without surgery, and their outcomes were actually better 2 years down the road. Now there was another group of patients that they’ve selected where the patients said, “I’ll do whatever you tell me to”. They split them up in half. But then some of the patients said after 6 weeks “oh no, I can’t stand not having surgery” and they would go back and forth. But even in that group, the surgical patients got better faster, more reliably, and at 2 years, their results were trending to be better than the patients who didn’t have surgery. So we’re seeing probably better results with surgery a little earlier.

Dr. Sechrest: And I think that is a definite change in the last decade in terms of what we, as spine specialists and physicians, thought 10 years ago. I think is that, 20 years ago a discectomy was an incision this big. It was huge. Nowadays, we’re doing them more and more minimally invasive, so I think the impact of that surgery is less.

Dr. Nitin Bhatia: Exactly. It used to be a surgery, as you mentioned, 4 or 5-inch incision, in the hospital 5 days, takes 3 months to recover. Nowadays, my incision, my average incision is approximately half an inch, it’s about 12-13 millimeters. It’s outpatient surgery. If surgery is at 7 a.m. you’re home be 3 p.m., and essentially back to work and doing everything within a week or two. It’s really a whole different kind of surgery then it used to be when we do it using some of the modern techniques that I have available.

Dr. Sechrest: Well, let’s talk a little bit about those techniques. How does that half inch incision and the operation that you do through that differ from the one I used to do with a 5 inch incision under direct vision.

Dr. Nitin Bhatia: Well, fundamentally, the surgery is the exact same, and I’ll tell you I would never ever recommend sacrificing the surgery in regards to getting the patient better for the size of an incision. Some people, they need a bigger incision, and so they get a bigger incision. But for this problem, what we’ve found is with the new techniques even through a tiny incision we can get the same procedure done, and the procedure involves going in, and like I said, essentially scraping away that herniated jelly. Using a microscope now and some of our minimally invasive retractors, we’re able to see just as much as we need to see and almost even better because of the great vision we have with the microscope or endoscope that we use and perform very safely. But, fundamentally, once we’re in there, whether it’s an incision this big or this big, the surgeries are the same, we just are finding a different way to get it with less side effects.

Dr. Sechrest: I definitely think that every surgeon has understood that the less normal tissue you destroy or damage, the better off the patient’s going to be.

Dr. Nitin Bhatia: Exactly.

Dr. Sechrest: So anything we can do to get in and get the job done with less destruction is better.

Dr. Nitin Bhatia: Exactly. Less destruction, less scar, faster postoperative healing, less blood loss; there are a lot of reasons to do it as long as you get the job done.

Dr. Sechrest: You mentioned, sort of, the recovery period. But what is the long-term result of a disc injury and then surgery for the disc. How long is it before I can sort of forget this happened to me and, then after that, what are the ramifications of having a herniated disc? Are there any?

Dr. Nitin Bhatia: The only restriction is no lifting more than 10 or 15 pounds. That disc is a little fragile because you’ve already had a herniation and we’ve gone in and cleaned it up. I just don’t want it to be squeezed too much. You can still walk as much as you want, be on a bicycle or in the swimming pool, but just no lifting more than 10 or 15 pounds. And after 6 weeks, you can go back to anything you want to do.

Dr. Sechrest: What is your feeling about people driving, sitting for any length of time. So if I’m a patient who has just had a discectomy and I’m thinking of taking a 12-hour road trip or I’m thinking of taking an airplane trip. I know we used to really dissuade people from that. Is that still something you would tell people not to do?

Dr. Nitin Bhatia: Well, sitting is really hard on the low back. Sitting requires a lot of the muscles to be working and we, from our studies, know that it puts a lot of pressure on the discs, so it’s not something ideal. But we do know people have to drive and they have to fly and they have to get home and that sort of thing. So, what I tell people is, if you have to drive or fly, every hour or two just plan on getting up and walking around, let those muscles relax, make sure you’re comfortable. So, if it’s going to be a 4 hour drive, make it a 5 hour drive and every hour take a 15 minute break; and if you’re on a 5 hour flight across the country, every half an hour you get up and walk around to let your back relax.

Dr. Sechrest: Okay, back to the other question. I’ve had a herniated disc. What does that mean to me?

Dr. Nitin Bhatia: Long term-wise it probably doesn’t mean too much bad news for you at all. As long as your nerves have recovered, we’ve gone and we’ve done the surgery, we’ve caught it in time, no weakness, no numbness; probably you go back and you can do anything you want to for the rest of your life. We do know that if you’ve had a herniated disc you may have some genetic predisposition to disc problem and so it’s just something that we have to keep in mind. The things I tell my patients are: you’ve got to make sure you stay in good shape, you keep doing exercises that keep your back nice and strong, try to avoid smoking if possible because that can increase the rate of disc degeneration, and if problems come back we just keep a little closer eye on you.

Dr. Sechrest: But I don’t have to worry that, all of a sudden, I’ve got a bad back and I should not do certain things, or not be athletic, or not ski or anything like that?

Dr. Nitin Bhatia: Fortunately, no. You know, the whole goal of the surgery is to get you back doing all those things, and after six weeks I tell people, “Go back. Live your normal life”, and that’s the #1 thing that we want.

Dr. Sechrest: Along those same lines – complications? We all know that all surgery doesn’t go well. What’s the risk of complications for a disc excision or a discectomy, and what kind of complications am I looking at?

Dr. Nitin Bhatia: Fortunately, the complications are extremely small. Bleeding – you lose a couple drops of blood and that’s it. Really, the only true complication, risk, is that there could be injury to the nerves or the sac that covers the nerves during the surgery, and that risk is very low, probably less than 1%. I’ve never had any in any procedure I’ve done, knock on wood, but the risk is there. So you really want to go to a surgeon with lots of experience doing this. The other risk is that if, some patients get up after surgery and go, “gosh, my leg pain is all gone, I’m going to go the gym and I’m going to lift 100 pounds or weight”. Well, you don’t want to do that because you don’t want to pound on the disc too much and some patients, unfortunately, within a few weeks after surgery have a new herniation that comes out there, especially if we do activities that aren’t appropriate for the first month or six weeks after surgery. If that happens, sometimes you have to go in and take out that little herniation. But usually, just by being a little cautious in those first six weeks, we can avoid that and really the complications are extremely low.

Dr. Sechrest: Now you mentioned a complication that you mentioned the leakage of the spinal fluid out of the spinal sac. Does that require a second operation? Or is that something that will heal itself? How do you treat that?

Dr. Nitin Bhatia: Usually if there is a leakage of the spinal fluid, we fix it at the time of the first surgery. Occasionally, if for some reason, the surgeon doesn’t notice it at the time of the first surgery, a few days of bed rest will help that heal on its own. Because these incisions are so small, it’ll tend to tamponade or kind of block itself off. Usually after 2 or 3 days of bed rest it’ll stop and get better. In very, very rare cases would it require going back in and actually sewing it back up, especially for this kind of very small procedure.

Dr. Sechrest: Well, and you know, obviously, any time we’re operating around the spine; patients are always concerned about – “Could I be paralyzed?”

Dr. Nitin Bhatia: No.

Dr. Sechrest: Whereas that a more real complication, possible complication in the neck and upper back, in the lumbar spine that’s less of a worry. So, define for me the difference between a nerve injury and really being paralyzed.

Dr. Nitin Bhatia: Sure. That’s a question I get asked all the time, and the great part about the low back, or lumbar spine, is that the risk of true paralysis is essentially zero. That’s because the spinal cord, which is the firm tube-like structure that carries all of the big nerves, comes down from the brain, through the neck or cervical spine into the chest area or thoracic spine but stops usually at the very type of the lumbar spine at L1. Below that we have what’s called the cauda equina which is just the nerve roots coming down. Now the nerve roots are very different than the spinal cord. The spinal cord is very sensitive; even a little pressure like that on the spinal cord can cause permanent paralysis. But the nerve roots are very resilient, so pressure on them for prolonged periods can have no long-term sequellae. So that’s why surgery on the low back is definitely very safe, and it’s essentially a zero risk of paralysis because, even in a worse case scenario, let’s say I took one of those nerves and cut it in an experiment. All we would see would be a very small amount of weakness in one particular area, maybe the big toe would be weak, but not the whole leg or anything like that.

Dr. Sechrest: Yes, I think that’s a very clear explanation for that. Any other concepts or any other ideas you’d like to share with patients who are maybe faced with looking at surgery for a herniated disc or trying to determine what to do about the herniated disc?

Dr. Nitin Bhatia: Well, herniated discs are a very common problem. They’re the #1 reason that people have spine surgery in the U.S. But fortunately the surgery is very reliable, very safe, and results and rapid pain relief. So for the patients who don’t get better with conservative treatments, or who just can’t wait to get better, it’s a great option. Now, by no means, do I tell patients to run out and get surgery. What we want to do is try to treat them to get them better with the best modalities possible for them, whether that’s physical therapy, medicines, or surgery. But, this is a problem that very fixable and leads to really no long-term problems.

Dr. Sechrest: I’m going to put you on the spot.

Dr. Nitin Bhatia: Good.

Dr. Sechrest: If you had a herniated disc, knowing what you know, when would you opt for surgery?

Dr. Nitin Bhatia: It would depend on how much it affected my life. If my pain was bad enough where I couldn’t leave the house, or I could kind of limp around, I would probably have surgery almost immediately. If my pain, if it was a little numbness and just occasional numbness and tingling, I would deal with it, do physical therapy, do medicines, get the injections, and then go with it. So really, I think, it’s based on how much it affects someone’s life. The same amount of pain in someone who has a desk job-they can sit at the desk and have their pain be relieved is very different than someone who is, say, a carpenter or manual laborer, who has got to be moving things all day, and they can’t have that pain because they just can’t work. So we’ve got to take into account the symptoms and how much it affects that particular patient’s life.

Dr. Sechrest: Okay. Well, thanks. That’s good information. Thank you very much.

Dr. Nitin Bhatia: My pleasure. Thank you.

Dr. Sechrest: Thanks for watching today. If you have questions about the topic that we discussed today, or any orthopaedic topic, be sure to visit eOrthopod.com. If you’re an orthopaedic surgeon or healthcare provider interested in participating as a guest on eOrthopod TV, you’ll also find instructions on how to apply to become a guest on eOrthopod TV. Thanks for watching.