Lumbar Disc Prolapse/Slipped Disc
The discs in the spine are the soft tissue structures that lie between the bones (vertebral bodies). They function as both a spacer and a shock absorber. A disc is made up of a ring of outer fibres (the annulus), and central jelly-like substance (the nucleus). As a disc ages, the outer ring of fibres weakens and the nucleus dries out. This results in a weaker disc that is more prone to injury. A number of factors are thought to influence the rate of disc degeneration including inherited factors, previous injury, heavy occupations, and smoking. The annulus may eventually rupture allowing the nucleus to prolapse through it. This is a disc prolapse. A disc prolapse is also known as a disc herniation, a slipped disc, a disc bulge, or a ruptured disc.
Disc prolapses can irritate the nerve root that passes in behind the disc in the spinal canal. This nerve root irritation occurs either by direct pressure of the prolapsed material on the nerve root, or by noxious inflammation due to chemicals released from the injured disc. This nerve irritation stops the nerve from functioning normally and can cause leg pain, numbness, pins and needles, and weakness. It may be associated with back pain.
The leg pain radiates in the distribution of the nerve that is being irritated. This is typically referred to as ‘sciatica’. Sciatica is pain within the distribution of the sciatic nerve. The sciatic nerve is formed from the nerves that emerge from the spine in the lower back. The distribution of the symptoms depends on which nerve root is being irritated in the lower back. A fairly accurate assessment of the likely site of the disc protrusion can be obtained from the clinical signs and symptoms.
The Natural History of a Disc Prolapse
Disc prolapses and sciatica are very common. A disc prolapse may occur without experiencing symptoms of sciatica. When sciatica does occur, it tends to be a sudden onset, severe pain. Over the first few weeks this pain may resolve completely or settle down and plateau at a more manageable level. In many cases the sciatica completely resolves without treatment. However, treatment may hasten recovery or at least help to ease the symptoms.
Symptoms that have been present for only a short period of time are most likely to spontaneously resolve. If they have been present for more than six weeks then the likelihood of rapid resolution becomes much less. If the symptoms recur, then it is likely that there will be further recurrences.
Cauda Equina Syndrome
The cauda equina (which is Latin for “horse’s tail”) are the nerve fibres in the lower part of the spine that supply the pelvis and legs. It is a continuation of the spinal cord. These nerves can become severely compressed if there is a very large disc prolapse. This causes a distinctive pattern of symptoms. This is called cauda equina syndrome.
Cauda equina syndrome typically presents as acute onset low back pain, pain in one / both legs, and numbness or tingling between the legs. There can also be an acute disturbance of your bladder or bowel function. You need to seek urgent medical attention if you develop numbness or tingling between your legs, feel the need to urinate, but cannot go, or if you loose control of your bladder or bowels. Cauda equina syndrome is an emergency. If the pressure on the nerves is not relieved then there can be permanent nerve damage affecting leg, bladder and bowel function. If cauda equina syndrome is diagnosed then it is a surgical emergency.
Assessment of Sciatica
Sciatica is assessed by taking a detailed history of your symptoms, followed by a physical examination. The history will include questions about the onset of symptoms, as well as the current level of symptoms. It is normal to be asked about your bladder and bowel function. This enquiry relates to loss of control rather than change in regularity. It is not uncommon for patients taking painkillers to become constipated, and for patients with back pain to need to go to the loo more frequently. There should also be questions aimed at excluding other causes of your symptoms. You will also be asked about other medical problems, medications that you are taking, whether or not you have any allergies, and if you smoke.
The examination will include checking your legs for strength and sensation, as well as assessing your reflexes. If there are any concerns about loss of control of bladder or bowel function, then it may be necessary to perform a rectal examination.
Whilst the history and examination findings are frequently suggestive of a diagnosis, in any patient in whom treatment is being considered this diagnosis needs to be confirmed by an MRI scan.
Most patients with sciatica crave effective pain relief. Simple painkillers (paracetamol/codydramol) and anti-inflammatory tablets (ibuprofen/naproxen) are the most commonly prescribed, though stronger, opioid-based painkillers may be required (codeine phosphate/dihydrocodeine/tramadol). Patients with intense nerve type pain may also respond to medications that specifically act to reduce the sensitivity of the nerves (gabapentin/pregabalin).
During the very severe phase of sciatica rest may be necessary, though generally activity should be encouraged.
Physiotherapy / osteopathy / chiropractic treatment may be beneficial, but may also aggravate symptoms. Other simple interventions such as massage and heat may also help. A large proportion of patients who have suffered an acute attack of sciatica will start to improve after a couple of weeks.
An injection of steroid and local anaesthetic around the nerves aims to reduce the inflammation in the nerves, allowing the symptoms to settle down. The injection would be either a caudal epidural or a nerve root block, or both depending on the site of the disc prolapse. These injections are not effective in all patients. Your response to the injection determines what further treatment you will be offered: if you have complete relief then you will need no further treatment; if you have relief for several months before a gradual return of your symptoms then the injection can be repeated; if you have no relief or short lasting relief then we need to consider other options.
The final option is surgery. This is usually an operation called a ‘microdiscectomy’. This is indicated in patients who have persisting pain not relieved by rest or injections, or who develop progressive neurological signs and symptoms, such as weakness and numbness.
What to do once you are Better
Once your sciatica has resolved you must continue to look after your back. The fact that you have had a disc prolapse does not preclude a normal lifestyle. However, we would recommend that you:
Exercise: Undertaking an exercise program that aims to improve and maintain aerobic fitness is important. This may include regular brisk walking, swimming or cycling. Specific exercises to maintain flexibility and strengthen the abdominal and spinal muscles are important.
Avoid smoking: Smoking is associated with increased back pain and poorer outcomes from spinal surgery.
Avoid obesity: Being overweight forces the spine to carry unnecessary loads, and is associated with back pain.
Avoid heavy lifting: Patients who have had spinal problems should be cautious with heavy lifting and prolonged manual work, as this may cause a recurrent disc prolapse or further back injury.
What Patients Say
I would like to express my sincere thanks and gratitude for curing my pain. For months I have suffered in agony day and night. I was in despair and you were my last hope. Now I am not in pain! I am continually smiling and enjoying life again! March 2020
Mr Langdon was great from start to finish. I know that he saw me at the end of an already full clinic and on top of that arranged an immediate MRI…making him much later than he needed to be in getting home! I was in a great deal of pain and I very much appreciated his help in getting me sorted as fast as possible. He made sure I was early on in the running order of procedures on the day of my treatment and everything was explained well to me both before and afterwards. Cannot fault in any way. Thank you very much.
Very patient took his time explaining the surgery and aftercare. Very knowledge about my condition. Made me feel relaxed and in safe hands as I was very scared of the surgery itself and the possible risks.
Very caring, explained fully what was wrong and what he was going to do. December 2019
He was very professional and helpful before, during and after my minor treatment. December 2019
Mr Langdon was extremely helpful and reassuring. December 2019
Mr Langdon was clear and confident with his communication. This is reassuring for a patient. December 2019
Professional and treated to a high standard. Mr Langdon was excellent, he knew everything on my condition explaining all the options available. December 2019
Mr Langdon’s manner was very polite, professional and efficient, he answered all her questions and came to see her quickly after her epidural. June 2017
I have just completed a 102 mile walk over 7 days. Thank you so much for patching me up and making this experience possible. June 2017
Thank you for your specialist surgical and operational skills as well as your patient friendly approach. The two don’t always go together. We need people like you to maintain such high standards of surgery and care. October 2017
I wanted to take the opportunity to thank you and your team following my surgery. It has been so long since I felt so well and without pain. The surgery and my recuperation has far surpassed my expectations and has made a huge difference to my lifestyle. December 2017
Three months on from my back operation and I am feeling so much better. Thank you for all the kindness and support you showed when I was in such desperate pain. February 2018
Thank you so much for the work that you have done. What an incredible job you have and do. Life changing. March 2018
Thank you for all you have done for me during the last few weeks. I am most grateful not only for the main work but also the extras like telephoning to keep me informed. April 2018
I cannot thank you enough for the success of my back operation. Everyone was so pessimistic and you were so positive. May 2018
I was at all times given all necessary information, listened to, and I had confidence that Mr Langdon would complete the operation successfully. August 2018
Highly skilled and intuitive. October 2018
He was brilliant, I felt so comfortable that he would look after me even though I felt so anxious, and he made sure to give me all the information I needed. Also, every nurse and employee of Spire had nothing but brilliant things to say about Mr Langdon – I didn’t even need to ask. They would look on my notes and see I had Mr Langdon and say I was in excellent hands, and so I felt extremely happy. My partner also has disc problems so I will very much be pointing him to Mr Langdon October 2018
Very understanding and caring chap from start to finish, and a great bedside manner, unusual for some consultants. He is trying hard to understand my problems and working with me on a treatment plan for the present, and the future. November 2018
My consultant is obviously a very competent person and comes across as such. My procedure was fully explained both before and after my surgery. He also has a professional sense of humour, which helped as I was very nervous November 2018
Mr Langdon was always prepared to fully explain what was wrong and what he could do about it, he gave me a lot of confidence to make the decision to operate, and so far so good. Albeit early days. November 2018
Mr Langdon was very professional and helpful, he came in on his day off because my treatment had to be moved. November 2018
Excellent, extremely knowledgeable on his speciality. I managed to get an appointment to see him at very short notice for which I was very grateful. December 2018
Excellent surgeon, great manner, explained procedure well. December 2018
A good sense of humour, understanding and non-judgmental. They explained everything very clearly. January 2019
Mr Langdon, very professional and calm, did not push the treatment on me which I really liked, but advised and let me make up my own mind. January 2019
James Langdon is a really good person to have on your side. He’s smart, attentive and very dedicated. January 2019
I felt very safe with Mr Langdon, he fully explained the procedure, the risks and the recovery. January 2019
A very professional consultant. Showed great care and understood me as a person and patient. Saw me pre procedure and after in recovery room and own room. Visited again before going home in late evening and yet again first thing the next morning. It felt like I was Mr Langdon’s only patient which I know is far from the truth. Unfortunately, I am a nervous patient but could not have been in better hands. Many thanks January 2019
Explained everything in detail, understood my concerns, excellent bedside manner, very professional. January 2019
James Langdon is very patient – he answers questions and really listens to you and explains again if you haven’t quite got something. March 2019
Mr James Langdon was in every way, courteous, clearly good at his particular area of expertise, took time out every day to see me and check that all was ok. Was happy to answer any questions I had. April 2019
Mr Langdon was very understanding about my condition and talked me through every procedure that could help me get more mobile again. I was always at ease with him with his caring attitude. A true professional thanks. April 2019
Mr Langdon gave a full explanation of the procedure and what would happen and what to do afterwards. Perfect. May 2019
Fully informed by Consultant Surgeon and Consultant Anaethetist who put me at ease with procedure. May 2019
I saw Mr Langdon before I had the operation and he explained everything that would happen on the day of the operation. June 2019
Very attentive, understood exactly what I was saying and made me feel confident that what I was doing was the right thing. June 2019
Mr. Langdon gave you complete confidence that all would be well and that he was available if needed at any time. He showed kindness and consideration. June 2019
Calm, professional, helpful. July 2019
Everything went off so smoothly. So pleased that the operation was so successful & the next day I was able to walk around without pain. July 2019
In overall terms he was absolutely brilliant. Clearly he is a brilliant surgeon but also a wonderful and understanding human being who, whilst pointing out the risks involved in the operation, filled me with absolute confidence that if success was possible, it would definitely be achieved – and I am delighted to say that it was. He is certainly a hero to me! It was also abundantly clear that all the staff at the hospital have absolute confidence in him and hold him in the highest regard. August 2019
Excellent, he fitted me in with an early appointment and treated me extremely well. September 2019
Extremely helpful explained everything very clearly. September 2019
Mr Langdon has been very clear and concise about the treatment he would be providing and the possible outcome. He has a very professional manner and I felt very at ease with him. He provided me with lots of information and visited me numerous times after my operation to see how I was and to explain what was done and what I should expect. I would be very happy to see Mr Langdon again in the future should I have a need to. September 2019
Caring conscientious and totally professional in all respects. September 2019
Mr Langdon gave me the confidence to go ahead with surgery that I was very worried about. He is very professional and thoroughly explained all the pros, cons and side effects that could possibly happen. All of the above helped me to make a more informed decision. October 2019
James Langdon was the consummate professional. He explained his diagnosis in plain language that was easy to understand and interpret from a layman’s point of view. He was careful to manage expectations and clear about potential risks keeping them in perspective and proportionate to the circumstances. His manner was direct whilst always retaining a caring attitude listening to the patient and answering questions clearly; even taking time out to follow up with my wife whilst I was still in post Op recovery. Very thorough and I would highly recommend James. October 2019
Fully explained the treatment I required and the reasons why. I felt very confident I was in good hands. October 2019
Professional, inspires confidence. October 2019
He was very understanding explaining everything very carefully and advising me on altering medication for the procedure and when to restart normal regime. November 2019
He was courteous, listened, understood the issue very quickly. Explained everything well and was sure to confirm I understood and asked if I had questions. I didn’t feel hurried. He provided an effective and efficient service. I’d definitely recommend him. November 2019
Professional and approachable. November 2019
Extremely happy. Care was first class throughout the stay and looked after all my needs November 2019
Very approachable, caring, friendly, put me at ease. December 2019
Very approachable and knowledgeable. Felt I was in very safe hands. December 2019
Very professional throughout. December 2019
Mr Langdon diagnosed my problem, explained fully the options I had regarding treatment also all the risks involved if I chose to have an operation. Mr Langdon organised a scan to confirm his diagnosis, and explained to me prior to my operation all that was involved in the procedure. Post operation Mr Langdon visited me in my room to check on my recovery and gave me the opportunity to ask any questions on the operation. I am very satisfied with Mr Langdon and his team on my treatment. December 2019
My marks of 10 across all questions reflect my opinion of James Langdon. Brilliant in all respects, in particular his explanation to a non medical man of my problem and his solution. December 2019
Spire Harpenden Hospital
(01582) 714 304