16 questions about a hernia

1. The advice for a spinal hernia was always: six weeks flat. Nowadays, doctors recommend that you keep moving. What is that good for? And is it better to operate quickly or not?

1. In the past you had to lie flat with a hernia, now you have to move. What's up with that?

1. Doctors have long believed that rest accelerated the healing process. After all, you do not burden the vertebrae. They now know that the opposite is true; movement keeps you flexible and ensures that the body clears up the hernia itself faster. As far as you can move as a hernia patient, of course, because sometimes the pain simply makes that impossible. People with a hernia often fear that movement will make the damage worse, but that concern is unfounded. Another misunderstanding is that you necessarily have to walk upright with a hernia. It is best to use the position that is the least painful.

2. Doctors have long believed that rest accelerated the healing process. After all, you do not burden the vertebrae. They now know that the opposite is true; movement keeps you flexible and ensures that the body clears up the hernia itself more quickly. As far as you can move as a hernia patient, of course, because sometimes the pain simply makes that impossible. People with a hernia are often afraid that exercise will make the damage worse, but that concern is unfounded. Another misunderstanding is that you have to walk upright with a hernia. It is best to use the position that is the least painful.

2. What is a spinal hernia?

1. A bulge in an intervertebral disc pressing on a nerve. The spine consists of seven cervical vertebrae, twelve thoracic vertebrae and five lumbar vertebrae from top to bottom. They are connected with intervertebral discs: sturdy hinges with a soft core. With age, the intervertebral discs dry out further and further, causing cracks and possible tearing of the shell. This can also happen in the event of an accident or overload. The soft core of the intervertebral disc bulges out and can press on one of the two nerves located here, often causing severe pain.

2. A bulge of an intervertebral disc pressing on a nerve. The spinal column consists of seven cervical vertebrae, twelve thoracic vertebrae and five lumbar vertebrae from top to bottom. They are connected with intervertebral discs: sturdy hinges with a soft core. With age, the intervertebral discs dry out further and further, causing cracks and possible tearing of the shell. This can also happen in the event of an accident or overload. The soft core of the intervertebral disc bulges out and can press on one of the two nerves located here, often causing severe pain.

3. Where exactly is the pain?

1. Not all patients with a back hernia have pain complaints; it just depends on where the bulge is. When it presses on a nerve, the pain is usually severe. Many hernia patients have lower back pain that radiates to one leg (on the side where the nerve is pinched).

4. Do older people in particular get a hernia?

1. The average age for a hernia is 40 years. With aging, the intervertebral discs dry out and collapse. That means that nothing can protrude. That is why a hernia almost never occurs without other problems above the age of 70. People over 50 often suffer from stenosis, whether or not in combination with a (small) hernia. Stenosis is a narrowing of the spinal canal. During life the entire spine wears (osteoarthritis). In response, the vertebral bone begins to proliferate and thicken. Spinal cord and nerves can then be compressed. Stenosis produces complaints that are comparable to those of a hernia.

5. What can be done about it?

1. There are two options: wait or operate. In 80 percent of the cases, the body clears up the bulge of the intervertebral disc itself. That means that the pressure - and the pain - will naturally ease over time. In the meantime, painkillers and certain physical therapy exercises help. Waiting does not help for eight out of a hundred patients. They are unlikely to get rid of the pain without surgery. Hence, the latest guideline states that hernia patients should be offered surgery after eighteen weeks. Sometimes, however, even with painkillers before those eighteen weeks, the pain is so excruciating that patients cannot or will not wait any longer. In that case, surgery is performed after six to eight weeks. Incidentally, it depends on the type of pain whether an operation is worthwhile. Leg pain can almost always be remedied with surgery. Back pain caused by a hernia only to a limited extent. The complaints as a result of stenosis are less often resolved by themselves. This requires more frequent surgery.

2. There are two options: wait or operate. In 80 percent of the cases, the body clears the bulge of the intervertebral disc itself. That means that the pressure - and the pain - will naturally ease over time. In the meantime, painkillers and certain physical therapy exercises help. Waiting does not help for eight out of a hundred patients. They are unlikely to get rid of the pain without surgery. That is why the latest guideline states that hernia patients should be offered surgery after eighteen weeks. Sometimes, however, even with painkillers before those eighteen weeks, the pain is so excruciating that patients cannot or will not wait any longer. In that case, surgery is performed after six to eight weeks. Incidentally, it depends on the type of pain whether an operation is worthwhile. Leg pain can almost always be remedied with surgery. Back pain caused by a hernia only to a limited extent. The complaints as a result of stenosis are less often resolved by themselves. This requires more frequent surgery.

6. Do many people suffer from hernias?

1. It is estimated that 75,000 Dutch people are affected every year.

7. Is a hernia hereditary?

1. No.

8. Can you prevent it?

1. In most cases a hernia (or stenosis) is the result of natural wear of the intervertebral discs. So you can't do anything about it. Heavy physical work does increase the risk of a hernia.

2. In most cases, a hernia (or stenosis) is the result of natural wear of the intervertebral discs. So you can't do anything about it. Heavy physical work does increase the risk of a hernia.

9. How is such a hernia diagnosed?

1. Usually an X-ray of the lumbar spine is taken first. The diagnosis of hernia cannot be made on that photo, but it is possible to detect abnormalities of the bone. In addition, it can be assessed whether there are, for example, position or shape deviations of the spine. In order to demonstrate that the pain in the leg (and any loss symptoms) is indeed caused by the bulging of an intervertebral disc, further investigation must be carried out. The main imaging examination is the MRI scan of the spine. An MRI scan reveals the hernia, as well as the pinching of the nerve root.

10. Why don't painkillers always provide relief for a hernia?

1. Because doctors are still not sure how nerve pain works, and therefore not how to block it. In most cases, a strong painkiller like morphine helps at least a little, but there are also people for whom nothing works.

11. When is an operation chosen?

1. Not every hernia requires surgery. Most complaints of a hernia will disappear on their own after a while. The decision to operate depends to a large extent on the severity of the pain and any failure. In general, surgery is not carried out earlier than 8 weeks after the complaints have arisen, unless urgent action is required. If the pain is not too bad, people often wait longer than 8 weeks. If the complaints persist, it will be decided to operate within 6 months, because it has been found that recovery is slower after a long wait. There are two types of surgical indications: Absolute operation indication In this case there are serious or rapidly occurring failure symptoms of the nerve or a group of nerves. For example, with severe paralysis symptoms of muscle groups in the legs or loss of control over the urinary bladder. Relative operation indication In this case there is so much pain that you can no longer function properly. The patient is then the one who must indicate that it is no longer possible; the complaint pattern is decisive in the decision whether or not to operate.

12. How does such an operation work?

1. A hernia operation can be performed under general anesthesia or under local anesthesia by means of an epidural. There are different surgical techniques: â € ¢ The classic 'open' operation: in which the entire operating area is exposed. â € ¢ The Micro Tube Discectomy Method (MTD): In which a cut is made of approximately 2 cm using a small tube. With the microtube technique (MTD), the operation is performed using a microscope (or magnifying glasses with a headlamp). A thin needle is inserted through an incision of about 2 cm in the back. Thicker tubes are slid over this needle, so that the correct opening is created through which the surgical instruments can be inserted. The operation is performed while the neurosurgeon looks through an operating microscope, which also allows depth to be seen. The image can be enlarged, so that the neurosurgeon can work very accurately. The advantages of the MTD technique are therefore clear: less tissue damage, a shorter hospital stay (often one day and one night) and a faster recovery . However, MTD is not suitable for everyone. The classic technique In the classic technique, the surgeon makes a two to three centimeter incision in the back, exactly above the hernia. After space has been made by moving the back muscles to the side, the bulge and the worn inner part of the intervertebral disc are removed. This is to minimize the chance of a new hernia. Hospitalization takes an average of three days.

13. Is there a risk of complications?

1. About 1 percent. Bleeding or inflammation may develop. Cystitis and thrombosis (vein blockage) occur. In case of damage to the spinal cord membrane, temporary headaches can occur when sitting upright. And if the nerves to bladder and bowels are damaged, there is a risk of incontinence.

14. How do you know who is best to go to for surgery?

1. In general, the more often a surgeon performs an operation, the better he gets at it. There is no official guideline, but 50 spine operations per year is the minimum. Do not hesitate to ask a doctor about his experience.

15. Is it true that doctors in Belgium and Germany operate faster?

1. In Belgium, surgery is performed on a hernia four times as often as here, probably because surgeons are more likely to respond to a patient's request for surgery. That is why many Dutch hernia patients go to Belgium. But if your own doctor advises against surgery, there is usually good reason for it. For example, because the hernia mainly causes back pain. This can rarely be remedied with an operation. It can even make the symptoms worse. In Germany and Belgium you may be helped quickly, but in the Netherlands there are hardly any waiting lists anymore and you can almost always come within two to three weeks.

16. Are hernia patients completely get rid of their pain?

1. The result of a hernia operation depends a bit on how you look at it. From a doctor's point of view it is often a success, because the leg pain is gone. At the same time, the patient may be less satisfied because the back pain is still present. After two years, 20 percent still have complaints, both in the group that underwent surgery and in the group that did not. Sometimes it is not possible to remove the cause of the pain. Or the brain zone that processes pain is stimulated in such a way that it no longer disappears, even if the cause disappears. Doctors have recently started paying attention to this group, for example with psychological support. These patients may also need more drastic surgery to remove an intervertebral disc. Further research is being done on this. With the cooperation of Prof. Wilco Peul, professor, neurosurgeon and department head at the Leiden University Medical Center (LUMC) and the Haaglanden Medical Center. Peul specializes in spinal surgery and is principal investigator of the Leiden-The Hague Spine-Intervention-Prognostic-Study (SIPS) Group.