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attempted must be discussed. There are two options, both which have clinical and literature support. One approach is the repeat microdiscectomy, usually through a larger incision. The patient usually does not improve as fast or as far. The other option is a complete discectomy with fusion. Fusion can be beneficial if the disk space has collapsed and there is significant swelling in the adjacent vertebral bodies. Fusion involves a more extensive post-operative rehabilitation. It takes longer, involves more physical therapy and may involve wearing a brace.
TREATMENT INSTABILITY
Many times the source of pain, paresthesia and weakness is instability. Instability can be from multiple causes and demonstrated in many ways. Instability, as is most back disease, is controversial. Instability may be congenital, something with which one is born. Even though the defect has been life long, there may be no symptoms until adulthood. Instability may be traumatic and instability may be degenerative. Some surgeons think fusion should be performed for all recurrent herniated disks, some think fusion is for discogenic disease, some regard fusion as the treatment for instability with movement of the spinal segment. On the other hand, some surgeons think that fusion should not be performed. The answer could be anyone of these, or better yet, in the middle. When fusion is suggested, each type and approach should be discussed. Fusion can take place in the front of the vertebral body by an approach through the front or through the back. Fusion can take place in the back of the bone by an approach through the back. Or, fusion is done to the anterior and posterior part of the spine by one or both approaches. Fusion may use only bone or bone and metal. The bone used can be the patient's own or donated. It's obvious that the choices are complex and numerous. These should be discussed with the doctor. It would not be unusual to get a second opinion. It would not be unusual for the person giving the second opinion to recommend a slightly different approach.
POST TREATMENT CARE
It is very important to maintain chronic back care after the acute treatment process. Back care is life long. It consists of daily exercise routine, proper back posture with sitting and lifting. During the immediate post operative period leg stretching exercises are needed to try to reduce scar tissue. Sometimes at surgery anti-scar medicine is used. However, scar tissue still may form. It's occurrence and extent cannot be predicted. The back should be iced for 5 or more days after surgery. Activity should be limited to walking and lying down. If too much activity is tried too soon after surgery there may be increased back pain or even the return of leg pain. If this occurs, stop the activity; lay down, then return to half of the activity the next day. Sitting should be limited to twenty minutes at a time in a straight back chair. The back tissue is not completely healed until 3 months after surgery. One should slowly and steadily increase their activity until it is back to normal at three months. The back and leg will be as good as it is going to be at one year after surgery. At that time any remaining tingle or numbness may be permanent. Pain medication and occasionally antibiotics are given to go home. For temporary flare up of leg pain weeks to months after surgery, if there are no contra-indications, use anti-inflammatories for 4 days in a row. For pain that starts quickly try ice to the back. Otherwise, several months after surgery the use of warm moist heat to the back for twenty minutes at a time, 4 to 5 times per day, is an excellent way to help the back or leg pain. It is not unusual that the pain returns several days after surgery. It will lasts for as long as two- three weeks (Continued on page 24)
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