Results from the treatment of sciatica due to lumbar disc protrusion

I N the past ten years surgical operations for protruded Iower lumbar intervertebral discs have become commonpIace. When it is recaIIed that prior to the present surgical era in the treatment of sciatica due to disc protrusions, severe permanent disability was unknown, the argument for conservative non-operative treatment becomes more IogicaI. On the other hand, proIonged tota disability of many months and varying degrees of residual back pain was experienced. Kirstein reported a foIIow-up study on two smaI1 groups of patients for a comparative anaIysis of the resuIts of nonoperative treatment versus partia1 disc removal. CompIete and permanent recovery from symptoms was four times as frequent in the operated group (48 per cent) as compared with the non-operated group (I 2.5 per cent). CoIonna and Friedenberg reported a simiIar study on twenty-eight patients who were not operated upon and on ninety-five patients subjected to partia1 disc excision. Seventy-one per cent of patients had residua1 pain in the unoperated group, as compared with onIy 40 per cent in the operative series. Neither group was unselected, which is aIso the case in the present study. Operations for disc protrusions are not inocuous, as both vascuIar and neuroIogic complications occur compIicating the conventiona posterior approach. At Ieast six grave injuries to the great vesseIs anterior to the vertebra1 bodies have been reported.22~27 Poppen and Ver Brugghen 44 have warned against the danger of producing a massive protrusion of disc substance with parapIegia by manipuIative procedures. In the past ten years, the author has seen nine cases of permanent parapIegia which have foIlowed “disc operations” performed elsewhere. As our knowIedge of a condition accumulates, it is often possibIe to set up ruIes of procedure for the treatment of specific cases seIected from the group. This paper wiI1 dea1 with a procedure for the seIection of cases for two types of operative treatment which is practiced in the Department of Orthopedic Surgery at the Permanente Hospitals. The aim is for as exact a diagnosis as possible folIowed by as simpIe a surgical procedure as possibIe which wiI1 yieId a Iong term resuIt for the patient.