Herniated Disc

Definition

A herniated lumbar disc can apply pressure to spinal nerves causing pain, numbness, tingling, sciatica, or weakness of the leg. 

This condition occurs when the intervertebral disc's outer fibers, known as the annulus, are torn so that the soft inner material, called the nucleus pulposus, ruptures out of place. If the tears occur near the spinal canal, the nucleus pulposus can push into it.

Causes

Discs rupture suddenly due to sudden, intense pressure such as might occur from falling and landing in a seated position. Sufficiently great force can break one or more vertebrae and rupture a disc. Bending applies high force to vertebral discs, and bending while lifting can add a great deal to that force, causing a rupture. 

In the thoracic spine, such pressures can also affect the spinal cord because the spinal canal of the thoracic spine affords very little extra space. Applying overmuch pressure to the spinal cord at this location can cause paralysis from the waist down.

Symptoms

Pain is the first symptom, most often in the back, and directly over the affected disc, and then radiating around to the front of the chest. Depending on which nerves are affected, disc herniation can cause pain that feels like it originates in the heart, abdomen, or kidneys.

When a herniated disc presses against the spinal cord, symptoms may include:

  • muscle weakness, numbness, or tingling in one or both legs
  • increased reflexes in one or both legs, causing spasticity
  • changes in bowel or bladder function
  • paralysis from the waist down

Diagnosis

X-rays 

X-rays can't show a herniated disc, but can help your doctor assess wear and tear in the spine.

MRI 

The most common means for diagnosing a herniated disc, MRI is painless and accurate, and appears to cause no side-effects.

CT Scan 

When X-ray and MRI don't tell the whole story, a myelogram, usually combined with a CT scan, may be recommended.

Discogram 

If lumbar disc herniation surgery is being considered, your doctor may order a discogram to locate which discs are causing pain.

EMG and SSEP 

These electrical tests can confirm that leg pain originates in a damaged nerve, and they may be required before a decision is made to proceed with surgery.

Nonsurgical Treatment

Treatment depends on symptoms. If the symptoms are improving, your doctor may suggest watching and waiting. If they are deteriorating, your doctor is more likely to suggest surgery. Many with herniated disc symptoms find that they completely resolve over several weeks or months.

Observation 

Watching to make sure that the problem does not progress. If pain is bearable and symptoms aren't deteriorating, your doctor may opt to watch and wait.

Pain medications 

These can help control pain. Over-the-counter pain relievers such as ibuprofen, Tylenol®, and newer anti-inflammatory medications, may help.

If these fail to control the pain, your doctor may prescribe narcotic or non-narcotic medications. Narcotic pain medications are very strong, but very addictive. Non-narcotic pain meds are less addictive, but somewhat less effective. Most physicians don't like to prescribe narcotics for longer than a few days, or at most a few weeks.

Rest 

For more severe pain a decrease in activity or outright rest may be in order, as well as a back brace to limit movement around the injured disc. After two days you should begin to get moving. Begin with a gentle walking program, increasing distance each day.

Physical Therapy 

Herniated disc patients are often prescribed physical therapy. A well-rounded rehabilitation program helps calm pain and inflammation, and improves your mobility and strength.

Therapy visits can help you control symptoms and resume normal activities. Exercises will focus on improving strength and coordination in the lower back and abdomen. Physical therapy will emphasize helping you develop self-care of your back using safe exercise and other techniques in response to symptoms. Sessions may be scheduled two to three times each week for up to six weeks.

Physical therapy goals are to help you:

  • learn to manage your condition and symptoms
  • return to appropriate activity levels
  • learn body posture and movements that can reduce back strain
  • maximize strength and flexibility

Epidural Steroid Injection (ESI) 

ESI is most commonly reserved for when a herniated disc causes severe pain through irritating spinal nerves, and is not often suggested except when surgery is under consideration. The success rate of ESI in reducing pain from herniated disc is only about 50%.

Surgical Treatment

Laminectomy and Discectomy 

Discectomy is the removal of the part of a herniated disc that irritates a nerve, causing pain.  The surgeon first removes part of the lamina of the vertebra, which is the roof over the spinal nerves, in order to reach the spinal canal. The nerves are gently moved aside, allowing herniated disc material to be removed and freeing the nerves from irritation.

Following surgery, patient activities may be restricted for several weeks during healing, to prevent another disk herniation. Your surgeon will discuss all such restrictions with you. 

Transthoracic Corpectomy 

Transthoracic corpectomy is a new technique for decompressing the spinal cord or spinal nerves. The doctor makes a small opening through the ribs and reaches the spine through the chest. Only minimal amounts of vertebral body and problem disc are removed, relieving pressure from the spinal cord. If a larger section of vertebra is removed, fusion surgery may immediately follow.

Fusion 

Two or more bones are fused into one solid bone -- also known as arthrodesis. When a large section of bone and disc is removed, that part of the spine can become unstable, requiring the fusion of bones above and below that section. To make the unstable bones grow together, bone graft material is inserted, with plates, rods, and screws holding the bones in place.

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