Disc Extrusion: A Neurosurgeon’s Advice

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My doctors had told me that orthopedists and neurosurgeons have different approaches and I’d have to decide which one I preferred for managing my disc extrusion. I saw one of each and they were definitely very different. The orthopedist told me that it’s only worth operating for pain and surgery will not improve the chance of nerve recovery. He had me fill out a pain drawing but did not do a neurological exam.

The neurosurgeon, Dr. C., did a full neuro exam but no pain drawing. He said, “While it might sound cruel, I don’t care about pain. I’ve never once in my career operated solely for that indication. There are medications for pain, it’s a subjective sensation, and it will eventually go away. I only operate for motor weakness.” He told me that motor neurons are hardier than sensory neurons so weakness shows a more significant injury. 

Even the way they showed me the MRI was different. The orthopedist started with the bones of the spine. The neurologist went over the details of spinal cord and the nerves within it before moving on to talking about the extrusion.

I told Dr. C. what the orthopedist had said about only operating for pain. He said that he knew the other doctor and he did good work, but orthopedists are focused on bones, while as a neurologist he’s focused on the nerves.

The orthopedist had ordered a second MRI and the neurosurgeon went over it with me. To make for another confusing detail, the radiology report had said that the extrusion was unchanged and my other doctors had taken that report at face value. But comparing the images side by side it’s definitely a bit smaller. Often when a doctor shows me an image it’s not something I could easily pick out for myself, but this was readily apparent. (Update: I’ve read Dr. C.’s notes and he thought the herniations were a bit worse, not better. Just shows how hard communication can be. Always good to see the notes, especially for a surgical consult.)

Dr. C. told me that there are only a few red flags that would make him tell a patient that they definitely need surgery for a herniated disc, otherwise the choice is always up to the patient. For patients without red flags he encouraged three months of conservative care. That gives the herniation time to possibly heal on its own and allows time to discover the slope of improvement. If recovery is rapid it would be likely that natural healing of the nerve would happen on its own.

He starts offering surgery at three months and feels it that if surgery is going to be chosen, it should be done by six months for the best result. He’s very reluctant to operate after a year when any nerve damage would already be irreversible. No guarantees, though, that the surgery would help, the nerve could already be permanently damaged by the injury.

Nerves only continue to try to regrow for a certain period of time, possibly a year, and if they haven’t reached the muscle they control by the end of that time the nerve dies back. He said they grow at 3 mm a day and for getting from the spine to the foot I could “do the math.”

He told me that the spinal nerve can’t start healing until the compression is off of it. Given that extrusions usually resorb the compression would likely subside eventually, but not necessarily in time for the nerve to heal. Hearing that of course makes me want to choose surgery, and soon.

Being a reader and a research geek I’ve continued to read up on the treatment of disc herniations with motor weakness. It’s a contested topic that’s being duked out in the journals: I ponied up to read a recent point/counterpoint article with an example case very much like mine. But as I told my husband last night, when the experts disagree there’s no way that research alone can guide me.

It’s easier to believe someone who says they might be able to help me than someone who says they can’t. But it does make intuitive sense that getting the pressure off the nerve would help. So I’m leaning toward surgery. The other modalities I’ve tried, even PT, don’t have much evidence behind them that they help this situation either, and yet I’m quite willing to try them. Looking back I’ll want to be able to feel that I’ve done everything I could to try to heal.

As before, I’ll keep you posted on my decision.