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spinal disc herniation

 
Medical Encyclopedia: Herniated Disk
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Definition

Disk herniation is a rupture of fibrocartilagenous material (annulus fibrosis) that surrounds the intervertebral disk. This rupture involves the release of the disk's center portion containing a gelatinous substance called the nucleus pulposus. Pressure from the vertebrae above and below may cause the nucleus pulposus to be forced outward, placing pressure on a spinal nerve and causing considerable pain and damage to the nerve. This condition most frequently occurs in the lumbar region and is also commonly called herniated nucleus pulposus, prolapsed disk, ruptured intervertebral disk, or slipped disk.

Description

The spinal column is made up of 26 vertebrae that are joined together and permit forward and backward bending, side bending, and rotation of the spine. Five distinct regions comprise the spinal column, including the cervical (neck) region, thoracic (chest) region, lumbar (low back) region, sacral and coccygeal (tailbone) region. The cervical region consists of seven vertebrae, the thoracic region includes 12 vertebrae, and the lumbar region contains five vertebrae. The sacrum is composed of five fused vertebrae, which are connected to four fused vertebrae forming the coccyx. Intervertebral disks lie between each adjacent vertebra.

Each disk is composed of a gelatinous material in the center, called the nucleus pulposus, surrounded by rings of a fiberous tissue (annulus fibrosus). In disk herniation, an intervertebral disk's central portion herniates or slips through the surrounding annulus fibrosus into the spinal canal, putting pressure on a nerve root. Disk herniation most commonly affects the lumbar region between the fifth lumbar vertebra and the first sacral vertebra. However, disk herniation can also occur in the cervical spine. The incidence of cervical disk herniation is most common between the fifth and sixth cervical vertebrae. The second most common area for cervical disk herniation occurs between the sixth and seventh cervical vertebrae. Disk herniation is less common in the thoracic region.

Predisposing factors associated with disk herniation include age, gender, and work environment. The peak age for occurrence of disk herniation is between 20–45 years of age. Studies have shown that males are more commonly affected than females in lumbar disk herniation by a 3:2 ratio. Prolonged exposure to a bent-forward work posture is correlated with an increased incidence of disk herniation.

There are four classifications of disk pathology:

  • A protrusion may occur where a disk bulges without rupturing the annulus fibrosis.
  • The disk may prolapse where the nucleus pulposus migrates to the outermost fibers of the annulus fibrosis.
  • There may be a disk extrusion, which is the case if the annulus fibrosis perforates and material of the nucleus moves into the epidural space.
  • The sequestrated disk may occur as fragments from the annulus fibrosis and nucleus pulposus are outside the disk proper.

— Jeffrey P. Larson, RPT


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Sci-Tech Dictionary: herniated disk
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Home > Library > Science > Sci-Tech Dictionary
(′hər·nē′ad·əd ′disk)

(medicine) An intervertebral disk in which the pulpy center has pushed through the fibrocartilage. Also known as slipped disk.

Alternative Medicine Encyclopedia: Herniated Disk
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Home > Library > Health > Alternative Medicine Encyclopedia

Definition

Disk herniation is a breakdown of a fibrous cartilage material (annulus fibrosus) that makes up the intervertebral disk. The annulus fibrosus surrounds a soft gel-like substance in the center of the disk called the nucleus pulposus. Pressure from the vertebrae above and below may cause the nucleus pulposus to be forced against the sides of the annulus. The constant pressure of the nucleus against the sides of the annulus will cause the fibers of the annulus to break down. As the fibers of the annulus break down, the nucleus will push toward the outside of the annulus and cause the disk to bulge in the direction of the pressure. This condition most frequently occurs in the lumbar region and is also commonly called a herniated nucleus pulposus, prolapsed disk, ruptured disk, or a slipped disk.

Description

The spinal column is made up of 24 vertebrae that are joined together and permit forward and backward bending, side bending, and rotation of the spine. There are seven cervical (neck), twelve thoracic (chest region), and five lumbar (low back) vertebra. There are intervertebral disks between each of the 24 vertebrae as well as a disk between the lowest lumbar vertebrae and the large bone at the base of the spine called the sacrum.

Disk herniation most commonly affects the lumbar region. However, disk herniation can also occur in the cervical spine. The incidence of cervical disk herniation is most common between the fifth and sixth cervical vertebrae. The second most common area for cervical disk herniation occurs between the sixth and seventh cervical vertebrae. Disk herniation is uncommon in the thoracic region.

The peak age for occurrence of disk herniation is between 20 and 45 years of age. Studies have shown that males are more commonly affected than females in lumbar disk herniation by a 3:2 ratio. Long periods of sitting or a bent-forward work posture may lead to an increased incidence of disk herniation.

There are four classifications of disk pathology:

  • A protrusion occurs when a disk bulges without rupturing the annulus fibrosus.
  • A prolapse occurs when the nucleus pulposus pushes to the outermost fibers of the annulus fibrosus but does not break through them.
  • An extrusion occurs when the outermost layer of the annulus fibrosus is torn and the material of the nucleus moves into the epidural space.
  • A sequestration occurs when fragments from the annulus fibrosus or the nucleus pulposus have broken free and lie outside the confines of the disk.

Causes & Symptoms

Any direct or, forceful in a vertical direction pressure on the disks can cause the disk to push its nucleus into the fibers of the annulus or into the intervertebral canal. A herniated disk may occur suddenly from lifting, twisting, or direct injury, but more often it will occur from constant compressive loads over time. There may be a single incident that causes symptoms to be felt, but very often the disk was already damaged and bulging prior to any one particular incident.

Depending on the location of the herniation, the herniated material can also press directly on nerve roots or on the spinal cord. Pressure on the nerve roots or spinal cord may cause a shock-like pain sensation down the arms if the herniation is in the cervical vertebrae or down the legs if the herniation is in the lumbar region.

In the lumbar region a herniation that presses on the nerve roots or the spinal cord may also cause weakness, numbness, or problems with bowels, bladder, or sexual function. It is unclear if a herniated disk causes pain by itself without pressing on neurological structures. It is likely that irritation of the disk or the adjacent nerve roots may cause muscle spasm and pain in the region of the disk pathology.

Diagnosis

Several radiographic tests are useful for confirming a diagnosis of disk herniation and locating the source of pain. X rays show structural changes of the lumbar spine. Myelography is a special x ray of the spine in which a dye or air is injected into the patient's spinal canal. The patient lies strapped to a table as the table tilts in various directions and spot x rays are taken. X rays showing a narrowed dye column in the intervertebral disk area indicate possible disk herniation.

Computed tomography scan (CT scans) exhibit the details of pathology necessary to obtain consistently good treatment results. Magnetic resonance imaging (MRI) analysis of the disks can accurately detect the early stages of disk aging and degeneration. Electromyograms (EMGs) measure the electrical activity of the muscle contractions and possibly show evidence of nerve damage.

A number of physical examination procedures may be used to determine if a herniated disk is pressing on a nerve root. While these tests may not identify the definitive presence of a herniated disk, they are very useful for indicating if there is pressure on a nerve root from some structure such as a herniated disk. The straight leg raise test may be used to identify pressure on nerve roots in the lumbar region while the Spurling's test (involving neck motion) may be used to identify compression of nerve roots in the cervical region. Compression of nerve roots in the cervical, thoracic, or lumbar regions may be apparent with the slump test.

Treatment

It is unclear if herniated disks cause pain themselves, or if they must press on a nerve root to cause pain. Pain may also occur with herniated disks as a result of mechanical or neurological irritation of surrounding structures such as muscles, tendons, ligaments, or joint capsules. Therefore, many treatment strategies will be primarily focused on managing symptoms that occur in conjunction with a herniated disk. Unless a serious neurological problem exists, most symptoms of a herniated disk will resolve on their own. Yet, the interventions listed below may greatly speed the time required to resolve symptoms associated with a herniated disk.

Chiropractic manipulations are often used to treat herniated disks. There is often significant joint restriction that accompanies a herniated disk and the manipulative therapy is effective at helping to mobilize movement restrictions in the spine. Mobilizing the spine will help the patient get back to moderate activity levels sooner. The earlier an individual can return to moderate activity levels, the quicker they can expect a resolution of their symptoms. Chiropractic manipulations are generally done with a greater frequency when a condition is in an acute stage. The frequency of treatments will be reduced as the condition improves.

Osteopathic therapy, considered by some to be an alternative treatment, may use manipulations or manual therapy techniques very similar to those of chiropractors. However, osteopathic physicians often employ more manual therapy techniques that focus on the role of the muscles and other soft tissues in producing pain sensations with herniated disks. Osteopathic physicians may also recommend use of the same medications prescribed by allopathic physicians. Some osteopaths also perform surgery for herniated disks.

Acupuncture involves the use of fine needles inserted along the pathway of the pain to move energy through the body and relieve the pain. Neurological irritation is considered to be a frequent source of pain with a herniated disk. Many believe acupuncture is particularly effective for pain management and addressing this neurological irritation. Acupuncture can also help break the cycle of pain and muscle spasm that often accompanies a herniated disk.

Massage therapists focus on muscular reactions to the herniated disk. Neurological irritation that comes with a herniated disk will often cause excessive muscle spasms in the lower back muscles. These spasms will perpetuate dysfunctional movements in the joints of the spine and may exaggerate compressive forces on the intervertebral disk. By relaxing the muscles, massage therapists will attempt to manage the symptoms of disk herniation until proper movement can be restored. Proper movement and avoidance of aggravating postures, like sitting for long periods, will often be a great help in completely resolving the symptoms.

Allopathic Treatment

Unless serious neurologic symptoms occur, herniated disks can initially be treated with pain medication. Pain medications, including anti-inflammatories, muscle relaxants, or in severe cases, narcotics, may be used if needed. Bed rest is sometimes prescribed. However, bed rest is frequently discouraged as a treatment for herniated disks unless movement is severely painful. It has become apparent that prolonged periods of bed rest may aggravate symptoms, slow down the healing time, and cause other complications.

Epidural steroid injections have been used to decrease pain by injecting an anti-inflammatory drug, usually a corticosteroid, around the nerve root to reduce inflammation and edema (swelling). This treatment partly relieves the pressure on the nerve root as well as resolves the inflammation.

Physical therapists are skilled in treating acute back pain caused by disk herniation. The physical therapist can provide noninvasive therapies, such as ultrasound or diathermy, to project heat deep into the tissues of the back or administer manual therapy, if mobility of the spine is impaired. They may help improve posture and develop an exercise program for recovery and long-term protection. Traction can be used to decrease pressure on the disk. A lumbar support can be helpful for a herniated disk at this level as a temporary measure to reduce pain and improve posture.

Surgery may be used for conditions that do not improve with conservative treatment. There are several surgical approaches to treating a herniated disk. A number of surgical procedures may be used to remove a portion of the intervertebral disk that may be pressing on a nerve root. When a portion of the disk is removed through a surgical procedure it is called a discectomy. Sometimes a spinal fusion will be performed after disk material has been removed. In this process a portion of bone is taken from the pelvis and placed between the bodies of the vertebrae. A spinal fusion will limit motion at that vertebral segment, but may be helpful in the event that significant disk material has been removed.

Chemonucleolysis is an alternative to surgical removal of the disk. Chymopapain, a purified enzyme derived from the papaya plant, is injected into the disk space to reduce the size of the herniated disks. The reduction in size of the disk relieves pressure on the nerve root. In 2002, Tokyo doctors produced evidence that a growth factor called vascular endothelial growth factor (VEGF) may speed up the process of injured disk resorption.

In September 2002, a noted orthopedic and spine authority named John Engelhardt became the first American to receive an artificial disk replacement (using the Bristol disk) in an operation in Switzerland. The artificial disk technology was still in clinical trials in the United States and was not expected to be approved until about 2005 or later.

Expected Results

Only a small percentage of patients with unrelenting neurological involvement, leading to chronic pain of the spine, need to have a surgical procedure performed. This fact strongly suggests that many patients with herniated disks respond well to conservative treatment. Alternative therapies can play a significant role in managing the pain and discomfort for the majority of patients with a herniated disk. In fact, magnetic resonance imaging (MRI) studies of the lumbar spine have indicated that many people without any back pain at all have herniated disks. This finding means it is unclear what role the herniated disk plays in many back pain cases. For many of these patients, proper symptom management of pain and improvement in joint motion and mobility through manual therapies will be enough to fully resolve their symptoms. For those patients who do require surgery, options are available for newer and less invasive procedures that will allow a quicker healing time.

Prevention

Proper exercises to strengthen the lower back and abdominal muscles are key in preventing excess stress and compressive forces on lumbar disks. Good posture will help prevent problems on cervical, thoracic, and lumbar disks. A good flexibility program is critical for prevention of muscle spasm that can cause an increase in compressive forces on disks at any level. Proper lifting of heavy objects is important for all muscles and levels of the individual disks. Good posture in sitting, standing, and lying down is helpful for the spine. Losing weight, if needed, can prevent weakness and unnecessary stress on the disks caused by obesity.

Such alternative treatments as chiropractic, massage therapy, or acupuncture may play a very important role in prevention of herniated disk problems. Regular use of these approaches may help maintain proper muscular tone and reduce the cumulative effects of postural strain that may lead to the development of disk problems.

Resources

Books

Hammer, W. Functional Soft Tissue Examination and Treatment by Manual Methods, 2nd ed. Gaithersburg, MD: Aspen, 1999.

Kessler, R.M. Management of Common Musculoskeletal Disorders: Physical Therapy Principles and Methods. Philadelphia: J.B. Lippincott Co., 1990.

Liebenson, C. Rehabilitation of the Spine. Baltimore: Williams & Wilkins., 1996.

Maciocia, G. Foundations of Chinese Medicine. London: Churchill Livingstone, 1989.

Magee, D.J. Orthopedic Physical Assessment. Philadelphia: W.B. Saunders, 1992.

Waddell, G. The Back Pain Revolution. London: Churchill Livingstone, 1998.

Periodicals

"Factor Could Speed Absorption of Herniated Disks." Pain & Central Nervous System Week (July 29, 2002): 2.

"Industry Authority Becomes First American to Receive Artificial Cervical Disk." Medical Devices & Surgical Technology Week (September 22, 2002): 3.

Jensen, M., et al. "Magnetic Resonance Imaging of the Lumbar Spine in People Without Back Pain." New England Journal of Medicine 331 (July 14, 1994): 69.

[Article by: Whitney Lowe; Teresa G. Odle]

Wikipedia: Spinal disc herniation
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Home > Library > Miscellaneous > Wikipedia
"Slipped disc" redirects here. For other uses, see Slipped disc (disambiguation).
Spinal disc herniation
Classification and external resources
ICD-10 M51.2
ICD-9 722.0-722.2
OMIM 603932
DiseasesDB 6861
MedlinePlus 000442
eMedicine orthoped/138 radio/219
MeSH D007405

A spinal disc herniation (prolapsus disci intervertebralis), informally and misleadingly called a "slipped disc", is a medical condition affecting the spine, in which a tear in the outer, fibrous ring (annulus fibrosus) of an intervertebral disc (discus intervertebralis) allows the soft, central portion (nucleus pulposus) to bulge out. Tears are almost always posterior-ipsilateral in nature due to the presence of the posterior longitudinal ligament in the spinal canal. This tear in the disc ring may result in the release of inflammatory chemical mediators which may directly cause severe pain, even in the absence of nerve root compression (see "chemical radiculitis" below). This is the rationale for the use of anti-inflammatory treatments for pain associated with disc herniation, protrusion, bulge, or disc tear.

It is normally a further development of a previously existing disc protrusion, a condition in which the outermost layers of the annulus fibrosus are still intact, but can bulge when the disc is under pressure.

Contents

Terminology

Normal situation and spinal disc herniation in cervical vertebrae.

Some of the terms commonly used to describe the condition include herniated disc, prolapsed disc, ruptured disc and the misleading expression "slipped disc". Other terms that are closely related include disc protrusion, bulging disc, pinched nerve, sciatica, disc disease, disc degeneration, degenerative disc disease, and black disc.

The popular term "slipped disc" is misleading, as an intervertebral disc, being tightly sandwiched between two vertebrae to which the disc is attached, cannot actually "slip", "slide", or even get "out of place". The disc is actually grown together with the adjacent vertebrae and can be squeezed, stretched and twisted, all in small degrees. It can also be torn, ripped, herniated, and degenerated, but it cannot "slip".[1] "The term 'slipped disc' may be harmful as it leads to a false idea of what is happening and therefore of the likely outcome."[2][3] However, one vertebral body can slip relative to an adjacent vertebral body. This is called spondylolisthesis and can damage the disc between the two vertebrae.

The spelling "disc" is based on the Latin root discus. Most English language publications use the spelling "disc" more often than "disk". Nomina Anatomica designates the structures as "disci intervertebrales" [plural form] and Terminologia Anatomica as "discus intervertebralis/intervertebral disc", [singular form].[4]

Regional distribution

Frequency

Stages of Spinal Disc Herniation

Disc herniation can occur in any disc in the spine, but the two most common forms are lumbar disc herniation and cervical disc herniation. The former is the most common, causing lower back pain (lumbago) and often leg pain as well, in which case it is commonly referred to as sciatica.

Lumbar disc herniation occurs 15 times more often than cervical (neck) disc herniation, and it is one of the most common causes of lower back pain. The cervical discs are affected 8% of the time and the upper-to-mid-back (thoracic) discs only 1 - 2% of the time.[5]

The following locations have no discs and are therefore exempt from the risk of disc herniation: the upper two cervical intervertebral spaces, the sacrum, and the coccyx.

Most disc herniations occur when a person is in their thirties or forties when the nucleus pulposus is still a gelatin-like substance. With age the nucleus pulposus changes ("dries out") and the risk of herniation is greatly reduced. After age 50 or 60, osteoarthritic degeneration (spondylosis) or spinal stenosis are more likely causes of low back pain or leg pain.

Cervical disc herniation

MRI scan of cervical disc herniation between fifth and sixth cervical vertebral bodies. Note that herniation between sixth and seventh cervical vertebral bodies is most common.

Cervical disc herniations occur in the neck, most often between the fith & sixth (C5/6) and the sixth and seventh (C6/7) cervical vertebral bodies. Symptoms can affect the back of the skull, the neck, shoulder girdle, scapula,[6] shoulder, arm, and hand. The nerves of the cervical plexus and brachial plexus can be affected.[7]

Thoracic disc herniation

Thoracic discs are very stable and herniations in this region are quite rare. Herniation of the uppermost thoracic discs can mimic cervical disc herniations, while herniation of the other discs can mimic lumbar herniations.[8]

Lumbar disc herniation

MRI scan of large herniation (on the right) of the disc between the L4-L5 vertebrae.

Lumbar disc herniations occur in the lower back, most often between the fourth and fifth lumbar vertebral bodies or between the fifth and the sacrum. Symptoms can affect the lower back, buttocks, thigh, and may radiate into the foot and/or toe. The sciatic nerve is the most commonly affected nerve, causing symptoms of sciatica. The femoral nerve can also be affected.[9] Can cause the patient to experience a numb, tingling feeling throughout one or both legs and even feet or even a burning feeling in the hips and legs.

Causes

Narrowed space between L5 and S1 vertebrae, indicating probable prolapsed intervertebral disc - a classic picture.

Disc herniations can occur from general wear and tear, such as jobs that require constant sitting, but especially jobs that require lifting. Traumatic (quick) injury to lumbar discs commonly occurs from lifting while bent at the waist, rather than lifting while using the legs with a straightened back. Minor back pain and chronic back tiredness is an indicator of general wear and tear that makes one susceptible to herniation on the occurrence of a traumatic event from bending to pick up a pencil or a traumatic injury from a fall. When the spine is straight, such as standing or lying down, internal pressure is equalized on all parts of the discs. While sitting or bending to lift, internal pressure on a disc can move from 17 psi (lying down) to over 300 psi (lifting with a rounded back).

Smoking is a major risk factor as the chemicals within smoke cause diminished nutrition and oxygenation of the discs leading to dehydration & degeneration which can then proceed to herniation.[citation needed]

Herniation of the contents of the disc into the spinal canal often occurs when the front side (stomach side) of the disc is compressed while sitting or bending forward, and the contents (nucleus pulposus) get pressed against the tightly stretched and thinned membrane (annulus fibrosis) on the rear (back side) of the disc. The combination of membrane thinning from stretching and increased internal pressure (200 to 300 psi) results in the rupture of the confining membrane. The jelly-like contents of the disc then move into the spinal canal, pressing against the spinal nerves, thus producing intense and usually disabling pain and other symptoms.

There is also a strong genetic component. Mutation in genes coding for proteins involved in the regulation of the extracellular matrix, such as MMP2 and THBS2, has been demonstrated to contribute to lumbar disc herniation.[10]

Symptoms

Symptoms of a herniated disc can vary depending on the location of the herniation and the types of soft tissue that become involved. They can range from little or no pain if the disc is the only tissue injured, to severe and unrelenting neck or low back pain that will radiate into the regions served by affected nerve roots that are irritated or impinged by the herniated material. Often, herniated discs are not diagnosed immediately, as the patients come with undefined pains in the thighs, knees or feet. Other symptoms may include sensory changes such as numbness, tingling, muscular weakness, paralysis, paresthesia, and affection of reflexes. If the herniated disc is in the lumbar region the patient may also experience sciatica due to irritation of one of the nerve roots of the sciatic nerve. Unlike a pulsating pain or pain that comes and goes, which can be caused by muscle spasm, pain from a herniated disc is usually continuous or at least is continuous in a specific position of the body.

It is possible to have a herniated disc without any pain or noticeable symptoms, depending on its location. If the extruded nucleus pulposus material doesn't press on soft tissues or nerves, it may not cause any symptoms. A small-sample study examining the cervical spine in symptom-free volunteers has found focal disc protrusions in 50% of participants, which shows that a considerable part of the population can have focal herniated discs in their cervical region that do not cause noticeable symptoms.[11][12]

Typically, symptoms are experienced only on one side of the body. If the prolapse is very large and presses on the spinal cord or the cauda equina in the lumbar region, affection of both sides of the body may occur, often with serious consequences.

There is now recognition of the importance of “chemical radiculitis” in the generation of back pain.[13] A primary focus of surgery is to remove “pressure” or reduce mechanical compression on a neural element: either the spinal cord, or a nerve root. But it is increasingly recognized that back pain, rather than being solely due to compression, may also be due to chemical inflammation.[13][14][15][16] There is evidence that points to a specific inflammatory mediator of this pain.[17][18] This inflammatory molecule, called tumor necrosis factor-alpha (TNF), is released not only by the herniated disc, but also in cases of disc tear (annular tear), by facet joints, and in spinal stenosis.[13][19][20][21] In addition to causing pain and inflammation, TNF may also contribute to disc degeneration.[22]

Diagnosis

Diagnosis is made by a practitioner based on the history, symptoms, and physical examination. At some point in the evaluation, tests may be performed to confirm or rule out other causes of symptoms such as spondylolisthesis, degeneration, tumors, metastases and space-occupying lesions as well as evaluate the efficacy of potential treatment options.

Physical examination

Straight leg raise

Main article: Straight leg raise

The Straight leg raise may be positive; this finding has low specificity, however it has high sensitivity. Thus the finding of a negative SLR sign is an important in helping to "rule out" the possibility of a lower lumbar disc herniation. A variation is to lift the leg while the patient is sitting.[23] However, this reduces the sensitivity of the test.[24]

Imaging

  • X-ray: Although traditional plain X-rays are limited in their ability to image soft tissues such as discs, muscles, and nerves, they are still used to confirm or exclude other possibilities such as tumors, infections, fractures, etc.. In spite of these limitations, X-ray can still play a relatively inexpensive role in confirming the suspicion of the presence of a herniated disc. If a suspicion is thus strengthened, other methods may be used to provide final confirmation.
  • Computed tomography scan (CT or CAT scan): A diagnostic image created after a computer reads x-rays. It can show the shape and size of the spinal canal, its contents, and the structures around it, including soft tissues.
MRI Scan of lumbar disc herniation between fourth and fifth lumbar vertebral bodies.
  • Magnetic resonance imaging (MRI): A diagnostic test that produces three-dimensional images of body structures using powerful magnets and computer technology. It can show the spinal cord, nerve roots, and surrounding areas, as well as enlargement, degeneration, and tumors. It shows soft tissues even better than CAT scans.
  • Myelogram: An x-ray of the spinal canal following injection of a contrast material into the surrounding cerebrospinal fluid spaces. By revealing displacement of the contrast material, it can show the presence of structures that can cause pressure on the spinal cord or nerves, such as herniated discs, tumors, or bone spurs. Because it involves the injection of foreign substances, MRI scans are now preferred in most patients. Myelograms still provide excellent outlines of space-occupying lesions, especially when combined with CT scanning (CT myelography).
  • Electromyogram and Nerve conduction studies (EMG/NCS): These tests measure the electrical impulse along nerve roots, peripheral nerves, and muscle tissue. This will indicate whether there is ongoing nerve damage, if the nerves are in a state of healing from a past injury, or whether there is another site of nerve compression.

Treatment

The majority of herniated discs will heal themselves in about six weeks and do not require surgery. One study found that "After 12 weeks, 73% of patients showed reasonable to major improvement without surgery." [25]

If pain due to disc herniation, protrusion, bulge, or disc tear is due to chemical radiculitis pain, then prior to surgery it may make sense to try an anti-inflammatory approach. Often this is first attempted with non-steroidal anti-inflammatory medications, but the long-term use of NSAIDS for patients with persistent back pain is complicated by their possible cardiovascular and gastrointestinal toxicity; and NSAIDs have limited value to intervene in tumor necrosis factor-alpha (TNF)-mediated processes.[26] An alternative often employed is the injection of cortisone into the spine adjacent to the suspected pain generator, a technique known as “epidural steroid injection”.[27] Although this technique began more than a decade ago for pain due to disc herniation, the efficacy of epidural steroid injections is now generally thought to be limited to short term pain relief in selected patients only. [28] In addition, epidural steroid injections, in certain settings, may result in serious complications. [29] Fortunately there are now emerging new methods that directly target TNF. [30] These TNF-targeted methods represent a highly promising new approach for patients with chronic severe spinal pain, such as those with failed back surgery syndrome. [30] Ancillary approaches, such as rehabilitation, physical therapy, anti-depressants, and, in particular, graduated exercise programs, may all be useful adjuncts to anti-inflammatory approaches. [26]

Conservative treatment

Pain medications are often prescribed to alleviate the acute pain and allow the patient to begin exercising and stretching.

There are a variety of non-surgical alternatives used in treatment of the condition, including:

  1. Bed rest and lumbo-sacral support belt.
  2. Physical therapy
  3. Massage therapy
  4. Non-steroidal anti-inflammatory drugs (NSAIDs)
  5. Oral steroids (e.g. prednisone or methylprednisolone)
  6. Epidural (cortisone) injection
  7. Intravenous sedation, analgesia-assisted traction therapy (IVSAAT)
  8. Weight control [31]
  9. Chiropractic

Surgery

Surgery should only be considered as a last resort after all conservative treatments (non-surgical therapy) have been tried, that did not alleviate the pain and heal the disc herniation.

Surgery is indicated if a patient has a significant neurological deficit.[32] The presence of cauda equina syndrome (in which there is incontinence, weakness and genital numbness) is considered a medical emergency requiring immediate attention and possibly surgical decompression.

Regarding the role of surgery for failed medical therapy in patients without a significant neurological deficit, a meta-analysis of randomized controlled trials by the Cochrane Collaboration concluded that "limited evidence is now available to support some aspects of surgical practice". More recent randomized controlled trials refine indications for surgery

  • The Spine Patient Outcomes Research Trial (SPORT)
    • Patients studied. "intervertebral disk herniation and persistent symptoms despite some nonoperative treatment for at least 6 weeks...radicular pain (below the knee for lower lumbar herniations, into the anterior thigh for upper lumbar herniations) and evidence of nerve-root irritation with a positive nerve-root tension sign (straight leg raise–positive between 30° and 70° or positive femoral tension sign) or a corresponding neurologic deficit (asymmetrical depressed reflex, decreased sensation in a dermatomal distribution, or weakness in a myotomal distribution)
    • Conclusions. "Patients in both the surgery and the nonoperative treatment groups improved substantially over a 2-year period. Because of the large numbers of patients who crossed over in both directions, conclusions about the superiority or equivalence of the treatments are not warranted based on the intent-to-treat analysis"[33][34]
  • The Hague Spine Intervention Prognostic Study Group[35]
    • Patients studied. "had a radiologically confirmed disk herniation...incapacitating lumbosacral radicular syndrome that had lasted for 6 to 12 weeks...Patients presenting with cauda equina syndrome, muscle paralysis, or insufficient strength to move against gravity were excluded."
    • Conclusions. "The 1-year outcomes were similar for patients assigned to early surgery and those assigned to conservative treatment with eventual surgery if needed, but the rates of pain relief and of perceived recovery were faster for those assigned to early surgery. "

Surgical options include:

  • Microdiscectomy[36]
  • IDET (a minimally invasive surgery for disc pain)
  • Laminectomy - to relieve spinal stenosis or nerve compression
  • Hemilaminectomy - to relieve spinal stenosis or nerve compression
  • Lumbar fusion (lumbar fusion is only indicated for recurrent lumbar disc herniations, not primary herniations)
  • Anterior cervical discectomy and fusion (for cervical disc herniation)
  • Disc arthroplasty (experimental for cases of cervical disc herniation)
  • Dynamic stabilization
  • Artificial disc replacement, a relatively new form of surgery in the U.S. but has been in use in Europe for decades, primarily used to treat low back pain from a degenerated disc.
  • Nucleoplasty[37]

Surgical goals include relief of nerve compression, allowing the nerve to recover, as well as the relief of associated back pain and restoration of normal function.

Emerging treatment options

The identification of tumor necrosis factor-alpha (TNF) as a central cause of inflammatory spinal pain now suggests the possibility of an entirely new approach to selected patients with severe pain due to disc herniation, protrusion, bulge, or disc tear. Specific and potent inhibitors of TNF became available in the U.S. in 1998, and were demonstrated to be potentially effective for treating sciatica in experimental models beginning in 2001. [38][39][40] Targeted anatomic administration of one of these anti-TNF agents, etanercept, a patented treatment method,[41] has been suggested in published pilot studies to be effective for treating selected patients with severe pain due to disc herniation, protrusion, bulge, or disc tear. [30][42] The scientific basis for pain relief in these patients is supported by the most current review articles. [43][44] In the future new imaging methods may allow non-invasive identification of sites of neuronal inflammation, thereby enabling more accurate localization of the "pain generators" responsible for symptom production.

Investigational treatments

Future treatments may include stem cell therapy. Doctors Victor Y. L. Leung, Danny Chan and Kenneth M. C. Cheung have reported in the European Spine Journal that "substantial progress has been made in the field of stem cell regeneration of the intervertebral disc. Autogenic mesenchymal stem cells in animal models can arrest intervertebral disc degeneration or even partially regenerate it and the effect is suggested to be dependent on the severity of the degeneration."[45]

See also

References

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  36. ^ [considered spam Microdiscectomy]
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  41. ^ US patent 6537549 and others
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External links

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Dorsopathies / spinal disease (M40-M54, 720-724,737)
Deforming dorsopathies
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Spondylopathy
Back pain
Intervertebral disc disorder
Schmorl's nodes · Degenerative disc disease · Spinal disc herniation
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