Index
WHAT IS A L5-S1 DISC HERNIATION?
As we have already discussed on occasion, Things you may not know about the spine 5 lumbar vertebrae, and then the spine continues with the sacrum. The L5-S1 segment is made up of the L5 vertebra, intervertebral disc, facet joints, ligaments muscles and the first sacral vertebra.
A disc herniation occurs when the contents of the L5-S1 intervertebral disc leak out of the disc and into the lumbar canal., sometimes the disc material can compress and affect the nerve structures. When we have an L5-S1 hernia, the L5 root can be affected as it exits through the hole that forms between both vertebrae., and the root S1 before it leaves the column. If the hernia is very large, it can also affect the sacral roots and produce a cauda equina syndrome..
SYMPTOM
When a hernia occurs, it can happen that one or more of the nerve structures that are at this level are compressed.. The main symptom that we are going to have is a sciatica.
Sciatica is radiating pain that runs down the back of the thigh and down the leg to the foot.. Usually associated with weakness and sensory disturbances. At the level of the L5-S1 segment, we can have the L5 root, the S1 root and the dural sac affected., being able to affect more than one nervous structure at the same time depending on the size of the hernia or the narrowness of the lumbar canal.
LEFT L5-S1 DISC HERNIA VS RIGHT L5-S1 DISC HERNIA
The symptoms of a left L5-S1 disc herniation are the same as those of the herniated disc, the only thing I would change is the leg the pain radiates through. In the case of very large central hernias, the 2 legs
L5 symptoms: The L5 root at the level of L5-S1 can be affected by lateral hernias, that do not have to be very large since many times we have associated a narrowness of the conjunction hole (remember that the L5 root exits the spine through the hole formed by the L5 and S1 vertebrae). The L5 root can also be affected by larger central hernias.. The symptoms caused by the compression of the L5 root by a herniated disc L5-S1 is a sciatica that runs through the buttock and down the posterolateral aspect of the thigh., lateral aspect of the leg and dorsum of the foot. Many times they have associated weakness to get on heels.
S1 symptoms: In this case we will have a pain radiating through the buttock, posterior aspect of the thigh running down the lateral aspect of the leg and foot. We would notice weakness to bend the toes and stand on the tiptoes and the area with altered sensitivity would be the external face of the leg and foot. The S1 root is responsible for the Achilles reflex that we would have diminished.
Symptoms due to compression of the dural sac: Very large hernias can cause compression of the dural sac and give a set of symptoms known as cauda equina syndrome consisting of saddle anesthesia, you would have less sensitivity in the inner thigh, genitals and pelvic floor and loss of sphincter control and impotence. Cauda equina syndrome is a medical emergency that requires urgent decompression.
DIAGNOSIS
Magnetic resonance. It is the best test to diagnose disc pathology and in which we see the nerve structures more clearly. Although it is necessary to put the MRI images in context with the symptoms, since on many occasions there are findings that have no clinical repercussion and we run the risk that they are attributed symptoms that do not correspond to them., hence the importance of going to a spine pathology specialist who knows how to properly interpret your symptoms and give them a correspondence in the magnetic resonance images.
Electromyography. It is a test that will indicate which root or roots are affected. Remember that a root can be affected at different levels, the L5 root could be affected at the L4-L5 or L5-S1 level. Electromyography consists of placing some electrodes on the leg through which we are going to pass some currents, We will measure the time it takes for the electrical stimulus to reach the foot and if the signal intensity is lost along the route. In the event that the time that the electrical signal takes is greater or it reaches the final electrode weaker, we can tell which root is affected.
TREATMENT OF L5-S1 DISC HERNIA
In principle, sciatica caused by an L5-S1 disc herniation is a benign process that resolves only in 8-12 weeks. However, in some cases we will need to perform a decompression and remove the herniated disc.. In cases of severe pain that we cannot control in any way, significant loss of mobility or cauda equina syndrome, urgent or preferential surgery is indicated.
PHARMACOTHERAPY
In the first phases of pain we will use analgesics we can use paracetamol or NSAIDs (anti-inflammatory), spasm can be reduced by muscle relaxants. In the case of not being able to control the pain, we can include in the treatment opioids and drugs that lower the pain threshold such as pregabalin and gabapentin.
PHYSIOTHERAPY TREATMENT
During the acute period, manual treatments should be focused on reducing inflammation and achieving muscle relaxation and increasing mobility, reducing stiffness.. Treatments such as manual therapy, electromodulation, or dry needling may be helpful at these times. Any type of spinal manipulation or traction should be avoided if you have an L5-S1 disc herniation and are in an acute phase.
TECHNIQUES PAIN UNIT
In cases where the pain is not controlled with conservative treatment, the next step is to perform a foraminal infiltration or an epidural infiltration., what we do is insert a needle into the space surrounding the dural sac or into the hole through which the nerve root exits to deposit an anti-inflammatory medication in this place (usually a corticosteroid and local anesthetic) that diffuses through the tissues and reduces pain. In case of more localized pain that affects a specific root, pulsed radiofrequency could be performed, This technique consists of introducing a catheter near the nerve root that emits radiofrequency (heat), that will alter the transmission of pain, decreasing the intensity of the pain signal that the brain will receive. It will also lower the pain threshold, that is, a more powerful painful stimulus will be needed to feel pain. It is a technique that is performed with local anesthesia and sedation and is ambulatory..
TREATMENT OF DISC HERNIA WITH LASER OR RADIO FREQUENCY.
The treatment of disc herniation with laser or radiofrequency can be considered as the previous step to surgery. These are percutaneous techniques that are performed with local anesthesia and sedation and that are ambulatory.. They basically consist of inserting a needle into the intervertebral disc that emits heat, the goal is to evaporate the water contained in the intervertebral disc and reduce its volume. Reducing the volume of the intervertebral disc reduces the pressure that the disc exerts on the nerve structures and thus reduces pain.. The biggest drawback of these techniques is that they are not indicated for all types of hernias, should be used on fairly healthy discs and can only be used on contained bulges or hernias.
SURGICAL TREATMENT, THE MICRODISCECTOMY
It is the standard technique and the most used today.. A more or less small incision is made in the back of 2-5 cm and through systems that magnify vision (a microscope, some magnifying glasses) we open the L5-S1 space and remove the herniated disc, for this we have to dissect the musculature and sometimes damage the facet joint and remove the ligamentum flavum.
SURGICAL TREATMENT, SPINE ENDOSCOPY.
Spinal endoscopy is a novel technique consisting of introducing a camera through the hole through which the nerves exit, in this way we can access the interior of the spine and treat herniated discs.. The good thing about this technique is that by using a "natural" access, it is not necessary to damage the muscles or the joints to access the interior of the spine and therefore the bleeding., postoperative pain is less and recovery is faster. Click on the link to know what a column endoscopy consists of.