Assoc. Dr. Yordan Panov is the head of the "Neurosurgery" department at the Neurosurgery Clinic in Pleven. He completed his higher medical education in Pleven in 1984. He obtained a speci alty in neurosurgery at MA-Sofia in 1990, an in-depth specialization in neurosurgery at the Medical University of Tours, France, in 2002. He completed an internship at the Institute of Neurotransplantation in city of Angers - France. He also completed neurosurgery courses in Paris, Brest, Nantes, Angers, Rennes, Poitiers and Tours - France.
Disc herniation is a disease that afflicts many Bulgarians and a large number of them suffer for years before they decide to seek help. Why are we subject to so many misconceptions and fears about herniated discs? Why do we agree to endure the pain instead of seeking treatment? These are the questions we are talking about today with Assoc. Dr. Yordan Panov.
Prof. Panov, disc herniation is a disease known to medicine for a long time. Why then are there so many misconceptions about it?
- Herniated disc is the most common cause of low back pain. Here, the momentum created from previous decades is very powerful. In other places (I'm talking not only about Western Europe, but also about the whole world) things have long been clarified categorically at the medical level. It is known that the most common pain in the lower back is precisely due to displacement, pushing the disc and squeezing the nerves that exit at this level. In our country, the momentum from the 1950s does not slow down even today - people still write and talk about sciatica, about inflammation of the nerve, which happens extremely rarely with this disease. And the real cause of the pain, perhaps in 98% of cases, is due to the purely mechanical pressing. This inertia is characteristic not only of the population, but also, I must admit, of some of the colleagues. They continue to explain herniated disc pain with inflammation that resolves. And this understanding spreads as an opinion. And it should be the exact opposite - doctors should speak crystal clear and correctly explain to their patients both the cause and the ways to treat disc herniation. With us, unfortunately, things remain only on paper. In a purely scientific discussion, it seems that there are no disagreements between colleagues, but in practice it turns out to be completely different. It is correct to say that in some cases the delusions about disc herniation are maintained and stimulated due to pure bad faith, due to an impure desire to keep the patient as much as possible in some sphere of eternal treatment. That is, the patient is stuck in a certain place, where he will continue to be an eternal patient anyway. And this must change, and when there are indications for a certain type of treatment, it must be strictly followed. And for those who do not follow the rules - there should be sanctions. Yesterday we operated on a patient who had a paralyzed leg for 10 days. A had to be operated on urgently, right after he got the paralysis. The scary thing is that this patient can't get to a doctor.
Isn't the reason financial?
- No! It is an operation that lasts no more than an hour and does not require any expensive consumables. The patient simply does not have a diagnosis!
Does the problem start with diagnostics first?
- Yes, the problem starts from the lack of a clear opinion about the disease and its treatment. And on the other hand, the sick in such a condition continue to try to go to "doers", after they heard that they might possibly help them - after all, they helped the neighbor. Of course, there are also some doctors and folk healers who deal with
unconventional methods of treatment
and they can judge very accurately whether they are able to help and when they should not touch. But they are not so many. And the rest act on the principle: "As your grandmother knows, so you are." The person should do what he knows - one, two, six months, and then the patient should recover as best he can. I say this with regret and pain. And the truth is quite simple - with a disc herniation, the semi-cartilage comes out of its place, roughly speaking, in a small channel, in a limited space and is pressed. And when pressed, it must be operated.
You say there is a misinterpretation of what is a herniated disc and what is not. What do you mean?
- Yes, this is a very common problem. Patients say: I have two, three disc herniations, and they were all cured only in sanatoriums. And they most likely just had "pushes" or protrusions, which are four degrees, but not disc herniations. This is a complete misunderstanding. It is mostly characteristic of a part of unscrupulous patients who want to receive at any cost a certain group of disability in order to receive a pension. We all know such people exist. That is why patients very often say to themselves: here he had a herniated disc, but he was cured without surgery - either by going to sanatoriums, or by visiting various "fixers" or chakramists, or with a cosmodisc… And a real herniated disc is something completely different, and there are strict indications prescribed for her treatment, which have not been invented now. And if it is proven that the patient has this disease, he should undergo treatment with a smile and strive to receive adequate treatment, so that he can then lead a fulfilling life.
You say that the entire drive should be removed. And what will be left in the empty place?
- This aspect is medically cleared from all sides. Observations on the effect of treatment have been conducted for decades on patients who have undergone surgery. When this operation is done atraumatically, when the disc is carefully removed, which is anyway torn, torn, out of place, excellent results are achieved. Therefore, it is important that it is completely and very well cleaned so that no new fragments come out. Similarly, we may ask what happens if the patient does not undergo surgery and the disc remains there? In practice, it does not stay in place, even if we do not remove it surgically, because, as I said before, it unravels, tears, dehydrates. A part of it gets wet, even becomes ossified and thus causes additional pressure. And when it is surgically removed, especially in the lumbar region, then
vertebrae lie on top of each other
and relative stability is created, while mobility is not disturbed to any severe degree. So, what is being proposed recently, to replace the disc with an artificial implant, I do not consider justified, since the results without this implant are excellent. And with age, this disk changes anyway, and at a later age, it practically disappears in some patients. As we age, the body changes things on its own.
I.e. by removing the entire disc, you prevent recurrences. You've operated on 200 herniated disc patients and only one of them had a recurrence, correct?
- That's right, and I think that's logical. If we remove the damaged disk, there is nowhere for another fragment to come out. Of course, it is possible to get some disease at another level in the spine, to move the joints… Precisely for this reason, the assessment for each patient is individual. And the incorrect assessment or incomplete removal of the disc gives food to the widespread opinion that these operations are not successful in more than 50% of people, that a person goes for a second, third time to be operated on, but the problems continue…
Why does this happen?
- In some patients really
the problem is relapses,
but they by no means reach 50%, but vary from 2-3 to 10%. That is, over 90% success rate is achieved.
You say that good endoscopic results are only 60-70% of the time, due to the different position and migration of the herniated disc, as well as the accompanying narrowing of the canal through which the nerve passes. What do you mean?
- The statistics that I have indicated give an idea in what percentage of cases success is achieved in the treatment through the so-called. bloodless or endoscopic methods of treatment. It can easily be seen from the statistics that their results are much weaker and unsatisfactory compared to those of open surgery. And in fact, the difference in the cut between them is of the order of half a centimeter.
This fact is not known to us as patients. Even on the contrary, we are left with the impression that the incision in open operations is much larger compared to endoscopic ones
- The difference is really minimal, considering that the trauma of both methods is the same. But with endoscopic access, because it is through a hard, rigid tube through which the instruments are inserted, the ability to work is very limited. You can't penetrate, for example, under the root, you can't go down and up, and calmly look around for the presence of fragments. The possibility of revision of the space is much greater with open surgery. There is also no difference in bleeding between the two operative techniques.
Let's also talk about the other misconception you point out regarding herniated discs - to what extent can spas and physical therapy with mineral waters affect a herniated disc and help?
- Do you have a herniated disc that is for surgery, they do not help. They have nothing to do with a herniated disc as they can't push it back into place or evaporate it. If you have aches, joint pains, baths can help. Even the very fact that the patient rests and does not go to work can significantly improve his condition. This is already a treatment. But when we talk about a real herniated disc, things are quite different. In the presence of persistent pain, with compression of the nerve, with "drying" of the muscles, roughly speaking, which corresponds to the nerve, then you should not wait at all.