NEUROSURGERY

In cases of disc degeneration, the doctor can inject small hydrogel implants directly into the disc; these look like short pieces of spaghetti. They absorb water, expand their volume, and thereby rebuild the disc to its original height. The disc's lost cushioning function is restored, and the often chronic pain disappears.

Herniated disc, disc surgery

We initially treat most herniated discs conservatively. However, there are always exceptions to this rule. A herniated disc that does not improve and leads to increasing paralysis must be treated surgically. After a comprehensive diagnosis at our Munich East Spine Center, we will decide whether disc surgery is an option in your case. We would be happy to explain the advantages of disc surgery for you.

A herniated disc can trigger a wide range of symptoms and complaints, such as severe back pain or persistent postural problems caused by the pain. Together with you, we will find the right therapy, whether conservative or surgical. We will show you what options disc surgery offers in your case, if necessary, and which method is most suitable. Especially for symptoms that persist over a longer period, disc surgery can provide the much-needed relief.

trigger

The intervertebral discs are subjected to immense stress every day. It's not for nothing that they are also called the shock absorbers of our body. However, the discs can wear down over time, leading to a herniated disc. Most herniated discs are due to wear and tear. This can be age-related or result from excessive strain. Persistent incorrect posture, such as that which can occur during physical labor or lifting heavy objects, is also considered a trigger for a herniated disc. Other causes of a herniated disc include:

– Prolonged sitting: Incorrect sitting positions can permanently damage the lumbar spine and thus also the intervertebral disc tissue. A lack of movement can put additional strain on the spine and promote a herniated disc.

– One-off, extreme strain: This occurs, for example, in accidents, heavy lifting or falls, which subsequently lead to a herniated disc.

– Overweight: Excess body weight is also harmful to the spine and intervertebral discs. Weak back muscles, usually caused by a lack of exercise, can also trigger a painful herniated disc.

Maintaining a balanced fluid level is also important. The intervertebral discs usually regenerate overnight, during rest. For this to happen, they need sufficient fluid from the surrounding disc tissue to restore the gel-like nucleus pulposus to its suppleness. If there is too little fluid in the body, regeneration can hardly occur, or not at all.

What preliminary examinations are necessary?

Several examinations must be performed before disc surgery. A complete blood count is usually performed after a blood sample is taken. A thorough medical history is also taken before a herniated disc operation to identify any pre-existing conditions or hereditary predisposition. Further diagnostic tests before disc surgery include:

X-ray of the spine
– MRI/magnetic resonance imaging

We will discuss the type of anesthesia you will receive with you before any spinal disc surgery. We will also inform you which medications you need to stop taking before the operation.

What surgical methods are available?

In the early stages of disc bulging or narrowing, we can use conservative and regenerative procedures, such as the injection of the patient's own blood platelets with growth factors. This allows the disc tissue to regenerate. We can also inject small hydrogel implants into the disc to rebuild it. These implants bind water and alter the pH value, thereby increasing the disc's volume and cushioning function.

If surgery is necessary, we employ a variety of surgical techniques tailored to each individual case. In milder cases, for example, nucleoplasty may be considered. In this minimally invasive procedure, we remove excess disc tissue using only a thin, high-frequency probe, thus relieving pressure on the compressed nerve. Treatment of a herniated disc can also be performed microsurgically. This involves the use of a special operating microscope. We insert the particularly fine instruments through a thin sheath, which protects the muscles (microscopically assisted procedure).

In contrast, if an endoscopic disc surgery is performed, the necessary endoscopic instruments are inserted through a minimal incision to reach the disc. We would be happy to explain the exact procedure of a disc surgery to you during an initial consultation at our Munich East Spine Center.

Other surgical methods for treating a herniated disc:

– Microsurgical decompression: This surgical method is also used for spinal stenosis (narrowing of the spinal canal). The structures that cause the narrowing of the spinal canal are removed. The Over TOP or Cross Over technique we use is particularly gentle. This technique is especially gentle on the muscles and preserves stability. If the affected spinal canal also exhibits instability, spinal fusion can be performed concurrently.

– Implantation of a spacer implant: This is used in the early stages of disc narrowing or spinal canal stenosis. The small spacer is implanted between the spinous processes, relieving pressure on the facet joints and widening the spinal canal.

What is the procedure for spinal disc surgery?

A herniated disc surgery is usually performed under general anesthesia, so you won't be aware of the procedure itself. The exact procedure depends on the chosen surgical method. When a prosthesis is implanted, the surgery is performed via an anterior approach to the lumbar and cervical spine. Therefore, the spinal canal does not need to be opened.

What are the risks?

Every surgical procedure carries certain risks, and this also applies to spinal disc surgery. For example, during disc surgery, injuries to the peritoneum or ureters can occur. Injuries to blood vessels are also possible. However, the surgeon can usually correct these complications immediately. Occasionally, temporary hoarseness can occur after surgery on the cervical spine.

As with any surgery, a spinal disc operation carries an increased risk of thrombosis, impaired wound healing, or infection. If a disc prosthesis has been implanted, the implant may shift unexpectedly in the initial postoperative period. Under certain circumstances, the prosthesis can also detach from the bone or, conversely, become firmly embedded. Bleeding in the surgical area is also among the risks of spinal disc surgery.

Immediately after a herniated disc surgery, symptoms usually don't improve. It takes some time for the desired effect to occur.

Tips for the period after spinal disc surgery

After spinal disc surgery, you should absolutely avoid adopting an unnatural, protective posture. It's better to move around. Just avoid extreme twisting movements. Heavy physical exertion, including carrying and lifting, is also obviously not recommended. In the initial period, you should only carry or lift light loads, not exceeding a total weight of five kilograms. Further tips after spinal disc surgery:

– You should not drive yourself for about two weeks
Light sporting activities are possible again after about three to six weeks.

Together with you, we will develop a post-operative treatment plan tailored to your individual needs, for example, for your physiotherapist. We will precisely match the therapy to you and your requirements. We will also show you exactly what is possible after spinal disc surgery and what you should avoid for a certain period of time.

When conservative therapies fail to provide relief for herniated discs, wear and tear of the facet joints, and nerve pain in the spine, doctors can now extract a concentrate of the patient's own platelets and growth factors from their blood plasma and inject it directly into the affected areas. The growth factors contained in the injected plasma rebuild degenerated disc tissue, combat inflammation, reduce pain, and promote healing.

In cases of disc degeneration, the doctor uses cooled radiofrequency energy to deactivate the affected pain-conducting nerve fibers (technical term: Cool-RF neurotomy). To do this, he inserts two thin, specialized probes with radiofrequency electrodes directly into the degenerated disc. Radiofrequency waves create a large-area energy field between the two electrodes, which deactivates the ingrown nerve fibers. Because the two specialized probes are internally water-cooled, the energy field only reaches temperatures of approximately 65 degrees Celsius. This deactivates the pain-triggering nerve fibers, while the disc itself remains intact.

If the spine is degenerated or shows significant wear and tear, abnormal mobility increases. This should be prevented.

Previously, the affected segment was fused. Today, dynamic stabilization is possible, meaning the aim is to restore the natural range of motion. Depending on the extent of the degeneration, dynamic stabilization using various systems is employed as a treatment method.

Elastoplasty, similar to kyphoplasty, is a minimally invasive procedure for treating vertebral fractures in osteoporosis. Similar to kyphoplasty, where the doctor injects bone cement, in elastoplasty the doctor injects biocompatible, elastic VK100 silicone. This means the vertebrae are not straightened with a filler that hardens later, but rather with a material that remains elastic.

Anterior disc removal with fusion or implantation of a disc prosthesis

Using an operating microscope, the damaged intervertebral disc is removed via an anterior approach (through the neck). Complete removal of the disc relieves pressure on the nerves and spinal cord.

Subsequently, a rigid implant (cage) or a flexible implant (prosthesis) is inserted into the cleared disc space. The cervical spine gains stability through fusion (stiffening), while the range of motion of the cervical spine changes only minimally. With the use of a prosthesis, the mobility of the cervical spine is fully preserved. The healthy intervertebral discs adjacent to the operated segment are protected from increased wear and tear by the use of a prosthesis. The choice of implant depends, among other things, on the primary condition, but also on age, the height of the remaining disc material, and other criteria.

Surgery from behind

The removal of the herniated disc, thereby relieving pressure on the pinched nerve, is also performed using an operating microscope from the back, i.e., from the neck. The disc itself is preserved with this surgical technique. It is particularly suitable for herniated discs located very far laterally that do not compress the spinal cord.

Prolonged and deep-seated lower back pain often arises not from problems in the lumbar spine, but from wear and tear (osteoarthritis) in the sacroiliac joint (SI joint), which is located in the large pelvic bones. Here, the doctor can deactivate the pain-conducting nerve fibers involved using radiofrequency energy (technical term: RF neurotomy). To do this, a thin radiofrequency probe is inserted through a cannula and applied to the joint surfaces, where the nerve fibers are ablated using temperatures of approximately 60 degrees Celsius. The nerves can no longer transmit pain impulses, and the deep-seated lower back pain disappears.

Almost everyone experiences wear and tear on the lumbar spine as they age. For this reason, practically everyone experiences back pain or a sudden, sharp pain in their lower back at least once in their lifetime. Fortunately, this is usually harmless and disappears within a few days without specific treatment.

Herniated discs can also be treated conservatively:

The most important treatments are physiotherapy, pain management, and regular exercise. In the majority of cases—some sources cite up to 80 percent—symptoms subside with consistent adherence to therapy. However, if pronounced symptoms persist for more than three months, further investigation should be initiated. In cases of paralysis or bladder/bowel dysfunction, immediate evaluation is necessary to prevent permanent nerve damage. Diagnostic procedures typically involve magnetic resonance imaging (MRI) or computed tomography (CT) scans, and in specific cases, myelography (X-rays of the spinal canal with contrast medium).

After surgery, if deemed advisable, the doctor may prescribe a corset (technical term: orthosis) for the patient, which is worn temporarily and allows for increased movement early on. Today, modern models with various ready-made fits are available, which also reduce the risks of relapse (recurrence) and spinal instability.

The corset immediately provides the patient with stability that the temporarily weakened back muscles cannot offer after the procedure. Gait and posture are improved. Once the spine has become more stable and resilient through physiotherapy and the formation of replacement tissue in the operated segment, the patient no longer needs to wear the corset for as long and can gradually do without it more and more often.

An artificial disc is an alternative to spinal fusion. Although fusion surgery is still considered the standard surgical treatment for chronic degenerative disc disease, the procedure reduces pain by removing the diseased disc and thus immobilizing the segment.

However, this leads to increased wear and tear on the adjacent spinal segments. To restore healthy mobility to the degenerated spinal segment and reduce the negative effects of the fusion, the artificial intervertebral disc was developed. In certain cases, the implantation of an artificial disc has now become a routine procedure.

In osteoporosis, the decrease in bone density can lead to the collapse of the vertebral bodies. Kyphoplasty and vertebroplasty are minimally invasive treatment procedures for stable vertebral fractures resulting from osteoporosis or bone metastases in the spine. During these procedures, the doctor injects cement under anesthesia.

In this procedure, the doctor inserts a cannula through the skin into the collapsed vertebral body, through which bone cement is injected for internal stabilization. This often provides immediate pain relief. In kyphoplasty, the doctor also inserts a small inflatable balloon through a cannula, which realigns the collapsed vertebral body from the inside, preventing further collapse and vertebral misalignment.

For affected patients, both methods offer significant advantages over the conventional multi-segment fusion surgery.

Microsurgical disc surgery

Today, disc surgery in the lumbar spine is usually performed microsurgically. The surgeon gently removes the herniated disc using an operating microscope. This method is also suitable for treating recurrent herniated discs.

Spinal canal narrowing (spinal stenosis)

If the spinal canal is too narrow, the doctor uses microsurgery to reduce the increased pressure (microsurgical decompression) so that the nerves and spinal cord have more space. This involves removing bone tissue or ligaments from inside the spinal canal, usually preserving the stability of the spine. If the affected segment is also unstable, it must be fused.

Intraspinous spreader

In cases of early spinal canal stenosis and disc narrowing, minor instabilities develop, which can cause discs to bulge and ligaments to fold, further narrowing the canal. A small, specialized implant, inserted between the spinous processes on the back of the spine, can relieve pressure on the facet joints and widen the spinal canal.

Minimally invasive techniques are procedures in which the doctor performs the actual intervention solely through puncture, i.e., using cannulas and needles.

So, unlike traditional surgery, there is no "cutting" with a scalpel. Using modern needle and puncture techniques, the doctor can deliver medications with high precision, down to the millimeter, to the site of their effect, ablate pain-causing nerves, remove disc tissue, and even perform stabilization procedures. No scars, or only minimal ones, remain. Many of these procedures can be performed on an outpatient basis, allowing the patient to quickly return to full activity.

Periradicular therapy (PRT)

Injection of pain-relieving, decongestant, and anti-inflammatory medications under X-ray image guidance via a thin cannula, precisely targeted to the millimeter directly at the nerve roots. The goal of PRT (periradicular therapy) is to directly immerse, soothe, and relieve the nerve root compressed and irritated as a result of a herniated disc.

Facet infiltration

Facet joint infiltration is a targeted injection of medication for the gentle treatment of inflammation and elimination of the causes of pain in the area of the small vertebral joints.

Thermocoagulation

If facet joint injections do not provide lasting improvement, the minimally invasive procedure of thermocoagulation is used. In this procedure, the doctor inserts a thin heat probe through a cannula. Using electrical current and heat, they cauterize the nerve and locally eliminate the symptoms.

Nucleoplasty

This innovative procedure treats herniated discs without open surgery. The doctor inserts a newly developed radiofrequency probe through a cannula. The high-frequency waves (coblation technique) biologically vaporize and remove excess damaged disc material, thus stimulating natural disc healing. The treatment is simple, fast, effective, and particularly gentle on the tissue.

Hydrogel implant NucleoFix™

Mild chronic back pain often occurs in conjunction with intervertebral disc degeneration. This wear and tear is frequently due to the disc losing its ability to retain water with age. This, in turn, causes the gel-like nucleus pulposus inside the disc to dry out, diminishing its cushioning function. This process can be visualized as a juicy grape drying into a raisin. The resulting loss of the disc's shock-absorbing function can narrow the spinal canal.
This is precisely where the Nucleofix treatment (insertion of hydrogel implants) comes in: It is a biological procedure for treating intervertebral disc damage. Small hydrogel cushions, which look similar to spaghetti, counteract the signs of wear and tear by improving the water absorption and retention of the intervertebral disc and having a positive effect on the pH value of the disc's gel nucleus. The disc is essentially "hydrated.".
This innovative hydrogel method (NucleoFix™) is performed on an outpatient basis. The hydrogel is injected using a cannula. Thanks to its rapid effectiveness, the patient can resume normal activities the very next day. Hospitalization is not required.

Image below: If the gel-like nucleus of the intervertebral disc is intact, it resembles a grape. In its degenerated state, however, it resembles a dried-out raisin.

In osteoporosis, the decrease in bone density can lead to vertebral fractures. Kyphoplasty and vertebroplasty are minimally invasive treatment procedures for stable vertebral fractures resulting from osteoporosis or bone metastases in the spine. During these procedures, the doctor injects cement under anesthesia.

In this procedure, the doctor inserts a cannula through the skin into the collapsed vertebral body, through which bone cement is injected for internal stabilization. This often provides immediate pain relief. In kyphoplasty, the doctor also inserts a small inflatable balloon through a cannula, which realigns the collapsed vertebral body from the inside, preventing further collapse and vertebral misalignment. Alternatively, the doctor can also inject silicone-elastic VK100 ("elastoplasty").

In cases of wear and tear and osteoarthritis of the small vertebral joints and wear and tear in the sacroiliac joint (SI joint) in the pelvis, the doctor can deactivate the affected pain-conducting nerve fibers using radiofrequency energy (technical term: RF neurotomy). To do this, a thin radiofrequency probe is inserted via a cannula and applied to the joint surfaces, where the nerve fibers are ablated using temperatures of approximately 60 degrees Celsius. The nerves can no longer transmit pain impulses, and the back pain disappears.

When conservative therapies fail to provide relief for herniated discs, wear and tear of the facet joints, and nerve pain in the spine, doctors can now extract a concentrate of the patient's own platelets and growth factors from their blood plasma and inject it directly into the affected areas. The growth factors contained in the injected plasma promote the regeneration of intervertebral disc tissue, combat inflammation, reduce pain, and accelerate healing.

In cases of disc degeneration, the doctor can inject small hydrogel implants directly into the disc; these look like short pieces of spaghetti. They absorb water, expand their volume, and thereby rebuild the disc to its original height. The disc's lost cushioning function is restored, and the often chronic pain disappears.

Spinal fusion or fixation is the last stage in the treatment of degenerative spinal diseases.

It is used when there is no other option and the pain is so severe that it significantly impairs quality of life. Spinal fusion can now also be performed using minimally invasive techniques to minimize damage to the tissue (muscles and skin).

Transcutaneous fusion (minimally invasive spinal fusion)

Transcutaneous fusion (e.g., using the PLIF technique, approach from the back) is a minimally invasive surgical method that allows spinal fusion to be performed through the skin. This method does not require a large skin incision, nor does it necessitate extensive detachment of the back muscles from the vertebrae. The surgeon makes only several small incisions, through which the muscles are stretched. The screws required for fusion are then carefully inserted into the vertebral bodies through these incisions, thus fusing the affected vertebrae together.