_cc781905-5cde-3194-bb3b3b-136bad  _cc781905-5cde-3194- ccde-3194cf13631365c5cf3b31994cbdc13653155cf -bb3b-136bad5cf58d_      Low back pain is often a life-threatening problem, especially in advanced society, especially in the absence of industry and loss of power. Besides, it is an important health problem in terms of the cost of diagnostic approaches and treatment procedures. About 50-80% of the adult population in industrialized countries complain of low back pain at some point in their lives. Mechanical causes predominate in 95% of the patients. Nearly 90% of patients recover spontaneously. The cause was determined as spondylosis (aging and wear) in 90% of low back pain, and rheumatic diseases were observed in 2.4% of the patients. In 7.7% of the patients, low back pain was attributed to damage to the muscle and connective tissue. Only 1-3% of low back pain is due to lumbar disc herniation, and only 15% of patients with lumbar disc herniation require surgical treatment. Low back pain complaints generally start at young ages, and the frequency reaches the highest values in middle age. There is no difference in frequency between men and women.

 

      _cc781905-5cde-3194-bb3b3b-136bad  _cc781905-5cde-3194- ccde-3194cf13631365c5cf3b31994cbdc13653155cf -bb3b-136bad5cf58d_      Our waist transfers the weight of our body from our hips to our legs during daily activities. is the structure. There are 5 vertebrae (vertebrae) (L1, L2, L3, L4, L5) in our waist and cartilage pads (disc) connecting these vertebrae, joint structures and ligaments and muscles that support them   . The lumbar vertebrae act as a protector for the spinal cord and nerves, as well as contributing to movement and carrying loads. Nerves pass through the lumbar vertebrae that work the muscles of the legs, provide the sense of the legs, and control the urine, stool and sex functions.  The 5th lumbar vertebra continues with the bone we call the sacrum. The sacrum forms a whole with the pelvis and the coccyx (coccyx). This transition level has biomechanical significance. Low back movements are different at each spine level. For example, while forward bending is at the level of 75% between the 5th lumbar vertebra (L5) and the 1st sacrum vertebra (S1), it is 25% between L4-L5 and 5% in all segments between L1 and L4. . Since the movement is especially high in L4-L5 and L5-S1 distances and these two levels carry most of the load, 98% of herniated discs occur at L4-L5, L5-S1 levels.

 

      _cc781905-5cde-3194-bb3b3b-136bad  _cc781905-5cde-3194- ccde-3194cf13631365c5cf3b31994cbdc13653155cf -bb3b-136bad5cf58d_      pressure on the lumbar vertebrae (two compressions from above) force acts. In a situation where the lumbar inclination is ideal, 80% of the pressure force is carried by the disc, and the remaining 20% is carried by the joints formed at the back by the last two lumbar vertebrae. The compressive strength of the lumbar vertebrae decreases by 20% every 10 years over the age of 30 due to the decrease in the fluid content in the disc and the deterioration of its elastic structure. 75% of the applied compressions are carried by the nucleus, which is in the inner part of the disc and contains 70% water, and the nucleus is in gelous consistency, and 25% is carried by the annulus, which is located on the outside and consists of strong spiral connective tissues. Twisting or rotating motion is considered the most harmful motion as it creates both compression and shearing motion on the disc. There is a strong ligament that we call the posterior ligament (posterior longitudinal ligament) that attaches to the back of the spine and disc (where the spinal cord and nerves are located). In cases where this bond is weakened and the structure of the disc is deteriorated, these forces of the disc decrease or its suspension feature is lost. As a result, tears occur in the outer layer, which we call the annulus, especially in the posterior and posterior-lateral parts, due to the forces that the disc is exposed to, and the nucleus in the inner layer overflows through these tears. Due to the loosening of the ligament and sometimes its rupture in strong injuries, the nucleus, together with the annulus, herniates towards the canal through which the nerves pass, and the nerves may compress.

 

                Gripe:

      _cc781905-5cde-3194-bb3b3b-136bad  _cc781905-5cde-3194- ccde-3194cf13631365c5cf3b31994cbdc13653155cf -bb3b-136bad5cf58d_      Clinically, the most important complaint of patients is low back pain. It is a widespread, stabbing pain that develops gradually, increases with movement, decreases with rest, and spreads to the lower back and the leg in accordance with the distribution of the affected nerve root. It can start suddenly after a reverse movement such as leaning forward or turning backwards, intensifying with the smallest movement, leading to locking or back stiffness. The pain increases with sitting, standing, coughing, straining, driving, forward movement of the spine. It is relieved by lying down, supporting the waist, and bending backwards. The pain continues along the sciatic nerve and is referred to as "sciatic pain". When the disc herniation is extruded, lower back pain decreases or disappears, but leg complaints become more pronounced. Disc hernias developing in the mid-back line may cause low back pain without significant leg complaints. Muscle spasm and calf cramps are common.

All disc hernias  which occur with urinary incontinence or inability to make a large bowel movement, loss of strength in standing, loss of sex functions, severe sensory defects as a result of compression of all nerves below the level of hernia in it_cc781905-5cde-3194-bb3b -136bad5cf58d_ The incidence rate of the condition called cauda equina syndrome is 1%.

                 

                 Examination:

      _cc781905-5cde-3194-bb3b3b-136bad  _cc781905-5cde-3194- ccde-3194cf13631365c5cf3b31994cbdc13653155cf -bb3b-136bad5cf58d_      Decreased lumbar curvature during examination, loss of lumbar curvature during examination, loss of lumbar curvature during examination, lumbar curvature frequently the waist is tilted to one side. The patient usually leans in the opposite direction of the aching side. He wants to bend the affected leg and walks trying to put as little load on that leg as possible. Neurological examination is very important in lumbar hernia. Nerve sensitivity is determined by various stretching tests. Again, reflex disorders, loss of strength, and sensory defects are evaluated.

Age, gender, structural factors, posture of the spine, muscle strength, smoking, various occupational, psychological and social factors, recreational and sports habits and genetic factors play a role in the formation of herniated disc. Physical and work-related factors include occupations that require heavy physical labor, lifting, turning, twisting, sitting for long periods, and driving. It is known that low back complaints are less common in those with good physical activity. The risk of low back pain increases as long-term rest and conscious restriction of waist movements cause shortness and weakness in the back muscles and loss of condition.

 

                Diagnosis:

      _cc781905-5cde-3194-bb3b3b-136bad  _cc781905-5cde-3194- ccde-3194cf13631365c5cf3b31994cbdc13653155cf -bb3b-136bad5cf58d_      Imaging most important criteria in the diagnosis of the patient's magnetic resonance and radiology, including radiological examinations is the gold standard. However, direct radiographs, meylography, computed tomography, discography, electromyography (EMG) can also be used for differential diagnosis.

 

      _cc781905-5cde-3194-bb3b3b-136bad  _cc781905-5cde-3194- ccde-3194cf13631365c5cf3b31994cbdc13653155cf -bb3b-136bad5cf58d_      Disc pressure depends not only on the severity of the symptoms, but also on the amount of nerve pressure affected.

 

                 Treatment

      _cc781905-5cde-3194-bb3b3b-136bad  _cc781905-5cde-3194- ccde-3194cf13631365c5cf3b31994cbdc13653155cf -bb3b-136bad5cf58d_      Treatment of two conservative surgical veins under lumbar disc herniation.

 

                 Conservative Treatment Methods:

      _cc781905-5cde-3194-bb3b3b-136bad  _cc781905-5cde-3194- ccde-3194cf13631365c5cf3b31994cbdc13653155cf -bb3b-136bad5cf58d_      1) Bed rest is the most effective method of treatment. However, long-term absolute bed rest has not been proven to be effective in treatment, and it is also known that immobility causes weakening in bones and muscles.

      _cc781905-5cde-3194-bb3b3b-136bad  _cc781905-5cde-3194- ccde-3194cf13631365c5cf3b31994cbdc13653155cf -bb3b-136bad5cf58d_      2) Medication is an important part in the treatment of lumbar disc herniation. Analgesics and anti-inflammatories, muscle relaxants, steroids, antidepressants, antiepileptics can be used.

      _cc781905-5cde-3194-bb3b3b-136bad  _cc781905-5cde-3194- ccde-3194cf13631365c5cf3b31994cbdc13653155cf -bb3b-136bad5cf58d_      3) Physical therapy: Various physical therapy methods are used in the treatment of low back pain. These are hot or cold application, electrotherapy, traction, corset, splint, back school and manipulation therapy.

      _cc781905-5cde-3194-bb3b3b-136bad  _cc781905-5cde-3194- ccde-3194cf13631365c5cf3b31994cbdc13653155cf -bb3b-136bad5cf58d_      4) Algological treatment in patients, epidural and facial pain (pain, epidural and facial pain) countable.

 

                 Surgical treatment: 

      _cc781905-5cde-3194-bb3b3b-136bad  _cc781905-5cde-3194- ccde-3194cf13631365c5cf3b31994cbdc13653155cf -bb3b-136bad5cf58d_      Surgical treatment aims to eliminate the herniated disc herniation and nerve compression. Very few disc herniations are treated surgically.

             

                 Surgical treatment:

      _cc781905-5cde-3194-bb3b3b-136bad  _cc781905-5cde-3194- ccde-3194cf13631365c5cf3b31994cbdc13653155cf -bb3b-136bad5cf58d_      1) in attacks, 

      _cc781905-5cde-3194-bb3b3b-136bad  _cc781905-5cde-3194- ccde-3194cf13631365c5cf3b31994cbdc13653155cf -bb3b-136bad5cf58d_      2) In the presence of standing urination and defecation problems, loss of sensation,

      _cc781905-5cde-3194-bb3b3b-136bad  _cc781905-5cde-3194- ccde-3194cf13631365c5cf3b31994cbdc13653155cf -bb3b-136bad5cf58d_      3) If the patient has pain, hesitantly walking

      _cc781905-5cde-3194-bb3b3b-136bad  _cc781905-5cde-3194- ccde-3194cf13631365c5cf3b31994cbdc13653155cf -bb3b-136bad5cf58d_      4) if we've mentioned earlier findings kauna_cc31905 equina_bb31904 136bad5cf58d_ is applied.

 

      _cc781905-5cde-3194-bb3b3b-136bad  _cc781905-5cde-3194- ccde-3194cf13631365c5cf3b31994cbdc13653155cf -bb3b-136bad5cf58d_      The gold standard for the treatment of lumbar hernia is microscopic surgery today, though many surgical methods include microscopic surgery. Laser treatment in lumbar hernia is not a surgical method, it is aimed to heat the disc by entering it and to shrink the disc by losing its water and drying it. However, this method actually provides benefits in patients with an overflow hernia that does not require surgical treatment. It is of no use on advanced discs. This procedure can also be performed with a camera by entering the coccyx, which we call epiduroscopy. However, it carries serious risks in incompetent hands. Apart from this, open surgery has been abandoned today due to its disadvantages such as high risks and long post-operative recovery time. Here, two methods that are valid and effective today will be mentioned.

 

                 Microdiscectomy:

      _cc781905-5cde-3194-bb3b3b-136bad  _cc781905-5cde-3194- ccde-3194cf13631365c5cf3b31994cbdc13653155cf -bb3b-136bad5cf58d_      Approximately 1-2 cm skin cut using microscope By making use of the good illumination and magnified view of the microscope, smaller incisions, protection of muscles, connective tissues, structures around the nerve, and careful control of bleeding were ensured. In addition, less bone tissue is removed in this method, and the joints of the spine are not damaged. In this way, the operation time is shortened, the risk is reduced, less blood loss, hospital stay and return to work are shortened. All transactions are more than 99% successful in correct and experienced hands. Extremely good results are obtained if the recommendations are followed in the postoperative period. 4 hours after the operation, the patient starts walking and if he has received general anesthesia, he is discharged the next day of the operation. After a period of approximately 2 weeks, which is necessary for wound healing, the person can return to work, depending on his work, and start the exercises given. In the long term, success increases in proportion to the person's genetic structure, weight, occupation, smoking habit and compliance with the exercise program. Despite this, the fact that the surgery of lumbar hernia is considered cold among the people is due to the fact that surgery is applied to patients who do not need surgical treatment for one reason or another (misdiagnosis) or inadequate treatment in the correct diagnosis.

 

                 Endoscopic Discectomy:

      _cc781905-5cde-3194-bb3b3b-136bad  _cc781905-5cde-3194- ccde-3194cf13631365c5cf3b31994cbdc13653155cf -bb3b-136bad5cf58d_      This can be done in two ways. 1) It can be used in midline interventions and unlike microdiscectomy, the muscles do not strip from the bone. It is entered through the muscles with the help of a guide sent  after a skin incision of approximately 1 cm under X-ray guidance. The procedure is the same as for microdiscectomy. Post-operative low back pain is less. However, bleeding control is more difficult in the endoscopic method, and the risk of complications (spinal membrane rupture, nerve damage, etc.) is higher since it provides a 2-dimensional image. 2) It is advantageous in far lateral and lateral disc hernias that make up a very small portion of lumbar disc herniations  and require larger skin incision and more muscle scraping when microsurgical methods are applied. As in the first method, after a 1 cm skin incision on the side of the waist, it is entered between the muscles with the help of a guide sent  and the disc  is emptied. The patient's suitability for these methods must be evaluated clinically and radiologically. In most cases, endoscopic surgery is started and turned to microsurgery.

 

      _cc781905-5cde-3194-bb3b3b-136bad  _cc781905-5cde-3194- ccde-3194cf13631365c5cf3b31994cbdc13653155cf -bb3b-136bad5cf58d_      In some cases, complaints may continue after lumbar discectomy. This is partly due to the significant decrease in trunk muscle strength and balance after surgery. Prolonged immobility due to pain before surgery and the inability of the affected nerve to sufficiently stimulate the muscles cause thinning of the muscles. The thinned muscles become extremely weak and tire easily. Tired and weak back muscles cause increased bending stresses on the discs and ligaments. It also creates stress on the spinal joints. As a result of all these changes, pain may persist. In addition, the time between the onset of the complaints and the surgery affects the duration of the post-operative numbness and strength losses. Sometimes these findings may be permanent. Because in surgery, no operation is performed on the affected nerve. In the surgery, the pressure on the nerve is removed and conditions are provided for the pain to pass and the nerve to heal. Recurrence may occur in lumbar disc hernias. This can be from the same place and side, or it can be from a different level and from a different side. Depending on the surgical technique and the experience of the surgeon, the probability of recurrence varies between 5-15%.

 

      _cc781905-5cde-3194-bb3b3b-136bad  _cc781905-5cde-3194- ccde-3194cf13631365c5cf3b31994cbdc13653155cf -bb3b-136bad5cf58d_      As a result, we have successfully diagnosed lumbar disc herniation in patients with lumbar disc herniation. It is the most appropriate surgical treatment option.