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Herniated Disc

Herniated Vertebral Disc

The majority of herniated discs occur in the lumbar region of the lower back, usually due to age-related degeneration.


Presentation

Most of the spinal disc herniations are painful as they impinge upon the spinal nerve which comes out through the vertebral column. Sometimes they present with no symptoms at all and may be diagnosed randomly on spinal images taken for some other condition. The symptoms produced can be anywhere along the course of the nerve which is known as a referred pain. The degree of pain can be variable from person to person.
Spinal disc herniation most commonly occurs in the lumbar area L4-L5, L5-S1.The next commonest site is the cervical area C5-C6, C6-C7.
Lumbar disc hernia typically presents with sharp shooting pain in the buttocks, thigh and calf. The pain can radiate till the foot. Pain affects mainly one side only. There is tingling numbness in the parts supplied by the impinged nerves. Occasionally, there may be muscle weakness of a limb inhibiting movements and physical activities. The sciatic nerve is the most commonly affected nerve and the pain is commonly known as Sciatica. [2]
Cervical disc hernia present with tingling, numbness weakness or pain in the shoulder, neck, arm or hand. There is limitation of neck movements.
As the condition advances there maybe change or loss of bowel and bladder control depending on the extent of nerve compression. [2]

Weakness
  • Cervical disc hernia present with tingling, numbness weakness or pain in the shoulder, neck, arm or hand.[symptoma.com]
  • ): Weakness in the biceps (muscles in the front of the upper arms that bends your elbow) Weakness in the wrist extensor muscles (the muscles that bend your wrist up like you were riding a motorcycle) Numbness, tingling, and pain can radiate to the thumb[ssrehab.com]
  • A 76-year-old woman presented with an extremely rare case of symptomatic gas-containing disc herniation manifesting as left posterolateral thigh pain and ankle dorsiflexion motor weakness.[ncbi.nlm.nih.gov]
  • Tingling Numbness or weakness in the leg Pain between shoulder blades Radiating pain down your arm to your hands Weakness or numbness in your arms or shoulders Changes in sensation Strain or injury Age-related degeneration within the disk Overview The[spinecenter.nm.org]
  • The symptoms in some patients may include only leg pain or weakness. The specific location of leg pain and weakness depends on which nerve is irritated.[getmovinwithpoa.com]
Epilepsy
  • Children diagnoses and treats all neurosurgical conditions of infants, children and adolescents, with special expertise in the management of pediatric brain tumors, hydrocephalus, spinal cord disorders, Chiari malformations, craniosynostosis, AVM's and epilepsy[massgeneral.org]
Back Pain
  • The threshold of deterioration used to classify recurrent back pain was the minimum clinically important difference in back pain (Numeric Rating Scale Back Pain [NRS-BP]) or Disability (Oswestry Disability Index [ODI]), which were 2.5 of 10 points and[ncbi.nlm.nih.gov]
  • Abstract The role of interspinous devices (ISD) after lumbar herniated disc surgery for the prevention of postoperative back pain is controversial.[ncbi.nlm.nih.gov]
  • These findings also reaffirm the importance of workers' compensation in understanding the differences in patients with chronic low back pain.[ncbi.nlm.nih.gov]
  • CONCLUSION: The patients with chronic low back pain due to disc herniation presented higher levels of TNF-alpha and IL-6, but not of IL-1 or sTNF-R.[ncbi.nlm.nih.gov]
  • CONCLUSIONS: Ozone therapy appears to yield positive results and low morbidity rates when applied percutaneously for the treatment of chronic low back pain.[ncbi.nlm.nih.gov]
Leg Pain
  • Narrow spinal canals or herniated discs can be associated with leg pain. However, it is not known whether quantitative measurements of the spinal canal or herniated disc are sensitive and specific for low back-related leg pain.[ncbi.nlm.nih.gov]
  • PURPOSE: To evaluate the efficacy of nucleoplasty technique in patients with leg pain caused by radicular encroachment.[ncbi.nlm.nih.gov]
  • Predefined factors that could possibly be a predictive factor were collected: gender, age at surgery, level of surgical pathology, profession of the patient, and at discharge: leg pain, back pain, medication used for leg pain, new neurological deficit[ncbi.nlm.nih.gov]
  • The study covered 100 patients who had low back and leg pain due to such processes. Of these, 60 patients (group A) had a monoradicular pain pattern, average duration 2 months, due to a herniated lumbar disc.[ncbi.nlm.nih.gov]
  • The symptoms in some patients may include only leg pain or weakness. The specific location of leg pain and weakness depends on which nerve is irritated.[getmovinwithpoa.com]
Neck Pain
  • Back and neck pain are among the most common conditions people suffer from. For some, back and neck pain is an annoyance or inconvenience; for others, it can be debilitating.[northwell.edu]
  • Spinal manipulation applied to the cervical spine is a relatively safe and effective treatment for neck pain and headache.[ncbi.nlm.nih.gov]
  • Patients with isolated neck pain may be erroneously diagnosed with a simple neck strain or sprain.[uscspine.com]
  • Symptoms may include low back or neck pain along with pain radiating into the leg ( sciatica ) or arm, along with weakness and/or numbness. Back in the Game Patient Stories[hss.edu]
  • A herniated disc is one of the most common causes of back and neck pain.[nyulangone.org]
Tingling
  • The patient no longer complained of numbness and tingling in the left lower extremity and the goals for the patient had been attained.[ncbi.nlm.nih.gov]
  • Once the pain does start to improve, it is unlikely to return, although it may take longer for the weakness and numbness/tingling to improve.[ssrehab.com]
  • Cervical disc hernia present with tingling, numbness weakness or pain in the shoulder, neck, arm or hand.[symptoma.com]
  • You may be asked to fill out a diagram that asks you to pinpoint your symptoms of pain, numbness, tingling, and weakness. X-rays or magnetic resonance imaging (MRI) may be ordered.[medtronic.com]
  • Once the pain improves, it is unlikely to return, although it may take longer for the weakness and numbness/tingling to improve.[emoryhealthcare.org]
Stroke
  • Currently Browsing: Imaging Neuroendovascular Imaging Working as part of the Fireman Vascular Center, the interventional specialists of the Neuroendovascular Program perform minimally invasive, image-guided treatments for conditions including stroke and[massgeneral.org]
Sexual Dysfunction
  • The nerve damage can result in loss of bowel and bladder control, as well as sexual dysfunction. If you have these symptoms, seek medical care right away.[southeasternspine.com]
  • This can cause permanent weakness, paralysis, loss of bowel and bladder control, and sexual dysfunction. If this occurs, emergency surgery is the only option. Seek medical advice if: There is any bladder or bowel dysfunction.[medicalnewstoday.com]
Urinary Incontinence
  • Doctors say you should go to the emergency room if you experience urinary incontinence or uncontrolled sphincters. If a hernia is making your normal body functions difficult, that’s a sign of something quite serious that needs medical attention.[steptohealth.com]

Workup

A thorough medical history and a physical examination is enough to diagnose the condition. Medical history includes complete onset and progress of symptoms. The medical practitioner does a complete neurological examination to determine reflexes, muscle strength, movements and sensations. The straight leg raise test maybe positive [3] and is important to rule out other spinal conditions. An abnormal neurological examination is enough to pin point to a herniated disc.

Diagnostic tests are required and usually done when the treatment is not working.

Imaging techniques include radiographs and Magnetic Resonance Imaging (MRI). Though an MRI is more expensive, it is more useful as it produces three-dimensional images of body structures. It can show the spinal cord, nerve roots as well as soft tissue tumours and other surrounding tissues. Thus, an MRI is very useful for a conclusive diagnosis. Plain radiographs are useful but might not be conclusive.

A Myelography might also be done where a contrast dye is injected to see the spinal cord. This determines the extent of herniated disc. An MRI is preferred as it is a non-invasive method.

Sometimes an electromyography (EMG) should be conducted to locate the exact nerve involved.

The above mentioned imaging techniques are rarely needed in early course of the disease.

Treatment

The treatment ranges from conservative to surgical depending upon the level of discomfort experienced by the patient and the degree of disc degeneration [4].
The first line of treatment is pain relief and rest. Pain relief in the form of non-steroidal anti-inflammatory drugs (NSAIDs) [5] are given. Along with these muscle relaxants are prescribed.

Exercises are taught to reduce pain and encourage movement. Physical therapy in the form of massage, traction, electric stimulation [4] and heat or ice packs are also recommended [5].
Total restriction of movement is not advised as it can delay healing and prevent faster recovery. It is better to remain as active as possible through simple exercises and muscle strengthening techniques.

Surgery is usually advised if the herniated disc causes loss of function of the limbs or there is loss of bowel and bladder function [6]. Surgery is also recommended if the patient does not improve within six weeks of conservative treatment. Discectomy is done when the surgeon removes the damaged and protruding disc, keeping the remaining disc intact [7].

Maintaining a healthy weight and good posture can help prevent a herniated disc. [8]

Prognosis

Almost all cases show spontaneous resolution by 6-12 weeks. A patient usually feels better by 3 months. Relapse is common. Surgery has a very high success rate enabling the patient to get back to daily activities within a week.

Etiology

Spinal disc herniation results from a normal physiological aging process resulting in loss of elasticity and degeneration of the spinal discs. They can also occur from general wear and tear during daily activities like lifting heavy objects and straining.

Sedentary lifestyle also aggravates the disorder. Obese individuals are at a higher risk due to the additional weight load on the spinal discs. Sometimes degeneration occurs without any apparent reason.

Epidemiology

Majority of disc prolapses occur in the lumbar region of the lower back, though 10% cases are seen in the upper spine [1].

The incidence is higher in men than women, between 30 and 50 years of age. It is very rarely seen in young children. In the elderly, the disc no longer has the soft gelatinous portion hence is unlikely to encounter this condition.

Sex distribution
Age distribution

Pathophysiology

It is now being understood and recognised that back pain is not caused solely due to compression on nerve fibres, but can also result due to chemical inflammation.

Degeneration can begin in early adulthood in such a way that herniation becomes inevitable. Loss of hydration of nucleus pulposus also occurs with aging.

Histological studies revealed that whatever maybe the etiology of the tear, the bulging portion, always involves material from nucleus pulposus. Degenerated discs usually have no blood supply, and show a varied distribution of collagen fibres.

Radicular pain maybe due to an inflammatory response triggered by Tumour Necrosis Factor-alpha (TNFα). TNFα is not only released in herniated discs but also in other spinal degenerative disorders. TNFα can also increase spinal disc degeneration. There is also an increased presence of macrophages and Interleukin-1. These macrophages are found in both acute and chronic inflammation. Herniations occur mainly posteriorly or posterolaterally where the annulus fibrosus is the weakest.

Prevention

As there are various causes for herniated disc, prevention is very comprehensive. Majority of cases are caused due to heavy lifting or heavy straining, so stressful physical labour should be avoided.

Exercise should be done regularly to strengthen and tone muscles [9]. Proper body posture should be maintained as it can aggravate a prior herniated disc. Weight loss is advised to reduce pressure on these discs [10].

Summary

A herniated disc is a medical condition involving the spine, wherein there is an abnormal protrusion of the soft central portion of an inverterbral disc due to a tear in the outer fibrous layer of the disc. Disc herniation is also known as prolapsed disc or ruptured disc.

These invertebral discs resemble a donut with a tough outer fibrous layer (anulus fibrosus) and gelatinous soft central portion (nucleus pulposus). When the prolapsed disc compressed on adjacent nerve fibres there is severe pain, weakness and tingling numbness. This usually happens due to degeneration related to age, but trauma, heavy lifting and other heavy physical straining have also been implicated [1].

Patient Information

A herniated disc is a condition which affects the spinal column. The human vertebral column has 26 bones which are cushioned by soft spongy pad like structures called as discs. Typically, a disc has an outer fibrous layer and an inner soft elastic core.

Herniated disc normally happens when the soft inner portion bulges from the fibrous exterior layer due to weakness or degeneration. This leads to severe pain and discomfort as this bulging compresses the nearby spinal nerve fibres.

A herniated disc is commonly called as slipped disc, which normally happens with age. Regular daily activities such as lifting, and straining can also bring about this condition.

A slipped disc can occur anywhere from the neck to the lower back, the lower back being more common. If the herniated disc is in the lower back, the patient will have severe pain along the buttocks, thigh and calf. It may also radiate till the foot. If the herniated disc affects the neck, there will be pain along the arm and shoulders which might radiate till the fingers. Along with this, there will be tingling numbness and muscle weakness.

It is best to seek medical care if there is persistent pain in upper and lower back which restricts daily activities. There may also be changes or loss in bowel and bladder control.

Physical examination along with a complete medical history is enough for the doctor to come to a diagnosis. The physician does a complete neurological examination to check reflexes, muscle strength and sensations. Imaging tests may be done- mainly X-rays, MRI and CT scans.Nowdays, physicians may advice a myelography wherein a contrast dye is injected into the spinal column to study the spinal cord and exact nerve affected.

Treatment depends on the level of discomfort experienced and is mainly conservative. Medication mainly involves non-steroidal anti-inflammatory drugs to alleviate pain and inflammation. Physical therapy and exercise should be done regularly to strengthen muscle tone and ease movements. Total rest should be avoided and patient should be encouraged to be as active as possible to promote faster healing. Surgery is done only if above treatment fails and pain still persists. Surgery involves removal of the protruded disc.

Prevention may not be possible but few steps can be taken to reduce the severity mainly by maintaining a healthy weight and using safe postures for lifting. This condition cannot be completely cured and can also relapse later. Herniated disc does well with conservative treatment and the patient is able to resume his daily activities and lead a normal life.

References

Article

  1. Hu SS, et al. (2006). Disorders, diseases, and injuries of the spine. In HB Skinner,(Ed.) Current Diagnosis and Treatment in Orthopedics. 4th ed. (pp. 221–297). New York: McGraw-Hill.
  2. Rihn JA, et al. Duration of symptoms resulting from lumbar disc herniation: Effect on treatment outcomes. J Bone Joint Surg Am. 2011 ; 93(20): 1906–14.
  3. Waddell G, McCulloch JA, Kummel E, Venner RM. Nonorganic physical signs in low-back pain. Spine. 1980 Mar-apr; 5(2): 117–25
  4. Chen R, Cros D, Curra A, et al. The clinical diagnostic utility of transcranial magnetic stimulation: report of an IFCN committee. Clin Neurophysiol. 2008 Mar; 119(3): 504–32
  5. Pinto RZ, Maher CG, Ferreira ML, Hancock M, et al. Epidural corticosteroid injections in the management of sciatica: a systematic review and meta-analysis. Ann Intern Med. 2012 Dec 18;157(12): 865–77.
  6. Leininger B, Bronfort G, Evans R, Reiter T. Spinal manipulation or mobilization for radiculopathy: a systematic review. Phys Med Rehabil Clin N Am. 2011 Feb;22(1): 105–25.
  7. Manusov, EG. Surgical treatment of low back pain. Prim Care. 2012 Sep;39 (3): 525–31.
  8. Marrone, Lisa (2008). Overcoming Back and Neck Pain. p. 31. Harvest House.
  9. Hahne AJ, Ford JJ, McMeeken JM. Conservative management of lumbar disc herniation with associated radiculopathy: a systematic review. Spine. 2010 May 15;35 (11): E488–504.
  10. Vroomen PC, de Krom MC, Knottnerus JA. Predicting the outcome of sciatica at short-term follow-up. Br J Gen Pract. 2002 Feb; 52 (475): 119–23.

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Last updated: 2019-07-11 21:57