Unpacking Herniated Discs: A Neurosurgeon's Essential Guide

**Ever wonder if your nagging back pain is a herniated disc? Top Zurich neurosurgeon Professor Evaldas Cesnulis cuts through the confusion, revealing that most back pain isn't a herniated disc at all, but often stems from everyday facet joint issues. He clearly explains the *real* red flags, like radiating pain or weakness, and shares a surprising truth.****Peter Zombori:** Hello everybody, and welcome to our medical talk today with Professor Cesnulis from Zurich, a top neurosurgeon. We'd like to discuss herniated discs, a topic we receive many requests about. I thought this would be a great opportunity to explore what herniated discs are, what we can do about them, and the types of surgeries that can be performed. But I'd like to start with the symptoms.If someone experiences back pain, does that automatically mean they have a herniated disc, or are there more specific symptoms to look out for?**Prof. Evaldas Cesnulis:** No, back pain does not automatically mean a herniated disc. Your question is excellent because you immediately went to symptoms, which is the first crucial point: what symptoms does the patient have, and do they have any complaints at all?If you were to take 100 people off the street and perform an MRI of their lumbar or cervical spine, in two-thirds of those cases, you would see some degenerative aging issues, such as bulging discs or protrusions. This is especially true in countries where MRIs are readily available at a patient's request and payment, rather than by a doctor's order. People get these reports, read them, don't understand half of it, but are deeply impressed, thinking, "Wow, I have a herniated disc!" However, these patients often have no symptoms at all. So, the main issue is the presence of symptoms.**Watch the full video here:****Prof. Evaldas Cesnulis:** When we talk about back pain, in the absolute majority of cases, a herniated disc is not the culprit. The problem often lies with the **facet joints**. If I can use a spine model, you'll see on the back, at every level, on both the left and right sides, we have these facet joints where two segments of the spine connect. In aging conditions, these facet joints degenerate and can cause back pain. This is the most common cause of back pain.When we talk about the symptoms of a herniated disc, it's typically due to the **compression of the nerves**. You can see the yellow nerves exiting the spinal canal. This compression causes pain that radiates into the leg (if we're talking about the lumbar spine) or into the arm (for the cervical spine). So, the most common symptom is this **radiating pain** that follows the path of the affected nerve.There are also two other significant symptoms: **loss of sensitivity** in a specific area, like the inner part of the foot, or a **loss of motor functions**, such as difficulty moving, lifting, or pressing the foot, or moving the knee. These are the key symptoms of a disc herniation.**Peter Zombori:** So, if a patient has these symptoms, do they automatically need surgery? Can you explain what happens during such a surgery?**Prof. Evaldas Cesnulis:** Before we talk about surgery, Peter, let's discuss which patients actually need to undergo surgery. This is very important.If a patient only experiences **pain without any loss of sensitivity or motor deficit**, then we first need to consider how long they've had the pain. Sometimes the pain can be very acute and debilitating, immobilizing patients and making it difficult to get out of bed. However, this acute condition often lasts only a week or a few days.These patients typically **do not need to be operated on** if they only have pain. With proper non-surgical therapy—which includes non-steroidal medications, targeted X-ray or CT-guided infiltrations of the affected nerve, and physiotherapy—about 80% of patients will achieve the same quality of life they had before the onset of the disease within two to three months. So, they don't need surgery.We only operate on patients who **have not benefited from this non-surgical treatment**. This is crucial.The second important point, besides pain, is the presence of **neurological deficits**. If a patient cannot lift their foot, move their knee, or experiences any kind of paralysis, then it becomes an individual decision based on the severity of the deficit. Sometimes, non-surgical management can still be effective, and the patient may recover. However, in some cases, surgery may be necessary even with a short history of symptoms.**Prof. Evaldas Cesnulis:** Now, if we discuss surgery, there are several individual decisions to be made. Primarily, there are two main ways to perform lumbar disc surgery:- **Endoscopic disc surgery:** This involves a small incision and endoscopic tubes. This approach isn't always suitable.- **Microdiscectomy:** If endoscopic surgery isn't possible, we perform a microdiscectomy. This is a microsurgical, open operation with a slightly longer skin incision. We approach the disc from behind, between two bony arches of the spine, which is a natural opening. We may need to drill a small amount, about two or three millimeters, to enlarge this window and gain access to remove the herniated disc.The exact procedure depends on the consistency of the disc. Sometimes, the disc fragment is simply lying in the spinal canal and can be easily removed. Other times, we need to carefully scrape the disc to remove the degenerated tissues. The ultimate goal of both surgeries is to **decompress the nerve** so that, by the end of the procedure, the nerve is free of any compression and has good blood supply.**Peter Zombori:** Mhm. So, if I may summarize, 80% of herniated disc problems can be solved or managed with non-surgical treatments?**Prof. Evaldas Cesnulis:** Yes, if the patient seeks medical attention promptly and doesn't wait for the pain to become chronic. In such cases, 80% of these herniated discs do not require surgery.**Peter Zombori:** And for the remaining 20%, there are two approaches: endoscopic and microsurgical. Thank you very much, Professor.**Prof. Evaldas Cesnulis:** Microsurgical. Thank you.**Peter Zombori:** It was great talking to you. I've learned a lot, and hopefully, our viewers have as well. Thank you for your time.**Prof. Evaldas Cesnulis:** Thank you.