The Causes of Disk Herniations

Answer 1

Definition

A herniated (slipped) disk occurs when all or part of a spinal disk is forced through a weakened part of the disk. This places pressure on nearby nerves.

See also:

• Acute low back pain
• Chronic low Back pain
• Sciatica

Alternative Names

Lumbar radiculopathy; Cervical radiculopathy; Herniated intervertebral disk; Prolapsed intervertebral disk; Slipped disk; Ruptured disk; Herniated nucleus pulposus

Causes, incidence, and risk factors

The bones (vertebrae) of the spinal column run down the back, connecting the skull to the pelvis. These bones protect nerves that come out of the brain and travel down your back, forming the spinal cord. Nerve roots are large nerves that branch out from the spinal cord and leave your spinal column between each vertebrae.

• The spinal vertebrae are separated by disks filled with a soft, gelatinous substance. These disks cushion the spinal column and space between your vertebrae.
• These disks may herniate (move out of place) or rupture from trauma or strain. When this happens, the spinal nerves may become compressed, resulting in pain, numbness, or weakness.
• The lower back (lumbar area) of the spine is the most common area for a slipped disk. The cervical (neck) disks are affected 8% of the time. The upper-to-mid-back (thoracic) disks are rarely involved.

Radiculopathy refers to any disease that affects the spinal nerve roots. A herniated disk is one cause of radiculopathy (sciatica).

Disk herniation occurs more frequently in middle-aged and older men, especially those involved in strenuous physical activity. Other risk factors include any conditions present at birth (congenital) that affect the size of the lumbar spinal canal.

Symptoms

Low back or neck pain can vary widely. It may feel like a mild tingling, dull ache, or a burning or pulsating sensation. In some cases, the pain is severe enough that you are unable to move. You may also have numbness.

The pain most often occurs on one side of the body.

• With a lumbar (lower back) herniated disk, you may have sharp pain in one part of the leg, hip, or buttocks and numbness in other parts. You may also feel the sensations on the back of the calf or sole of the foot. The affected leg may feel weak.
• With a cervical (neck) disk herniation, you may have pain when moving your neck, deep pain near or over the shoulder blade, or pain that radiates to the upper arm, forearm, or (rarely) fingers.

The pain often starts slowly. It may get worse:

• After standing or sitting
• At night
• When sneezing, coughing, or laughing
• When bending backwards or walking more than a few yards, especially if it is caused by spinal stenosis

You may also have weakness in certain muscles. Sometimes, you may not notice it until your doctor examines you. In other cases, you will notice that you have a hard time lifting your leg or arm, standing on your toes on one side, squeezing tightly with one of your hands, or other problems.

The pain, numbness, or weakness often will go away or improve a lot over a period of weeks to months.

Signs and tests

A physical examination and history of pain may be all that your health care provider needs to diagnose a herniated disk. A neurological examination will evaluate muscle reflexes, sensation, and muscle strength. Often, examination of the spine will reveal a decrease in the spinal curvature in the affected area.

Leg pain that occurs when you sit down on an exam table and lift your leg straight up usually suggests a herniated lumbar disk.

A foraminal compression test of Spurling is done to diagnose cervical radiculopathy. For this test, you will bend your head forward and to the sides while the health care provider puts slight downward pressure on the top of your head. Increased pain or numbness during this test is usually a sign of cervical radiculopathy.

DIAGNOSTIC TESTS

• Spine x-ray may be done to rule out other causes of back or neck pain. However, it is not possible to diagnose a herniated disk by spinal x-ray alone.
• Spine MRI or spine CT will show spinal canal compression by the herniated disk.
• EMG may be done to determine the exact nerve root that is involved.
• Nerve conduction velocity test may also be done.
• Myelogram may be done to determine the size and location of disk herniation.

Treatment

The first treatment for a herniated disk is a short period of rest with pain and anti-inflammatory medications, followed by physical therapy. Most people who follow these treatments will recover and return to their normal activities. A small number of people need to have further treatment, which may include steroid injections or surgery.

MEDICATIONS

Nonsteroidal anti-inflammatory medications (NSAIDs) and narcotic painkillers will be given to people with a sudden herniated disk caused by some sort of injury (such as a car accident or lifting a very heavy object) that is immediately followed by severe pain in the back and leg.

If you have back spasms, you will usually receive muscle relaxants. On rare occasions, steroids may be given either by pill or directly into the blood through an IV.

NSAIDs are used for long-term pain control, but narcotics may be given if the pain does not respond to anti-inflammatory drugs.

LIFESTYLE CHANGES

Diet and exercise are crucial to improving back pain in overweight patients.

Physical therapy is important for nearly everyone with disk disease. Therapists will tell you how to properly lift, dress, walk, and perform other activities. They will work on strengthening the muscles that help support the spine. You will also learn flexibility of the spine and legs.

See: Taking Care of Your Back at Home

INJECTIONS

Steroid injections into the back in the area of the herniated disk may help control pain for several months. Such injections reduce swelling around the disk and relieve many symptoms. Spinal injections are usually done on an outpatient basis, using x-ray or fluoroscopy to identify the area where the injection is needed.

SURGERY

Surgery may be an option for the few patients whose symptoms do not go away despite other treatments and time.

See also: Diskectomy

Ask your doctor which treatment options are best for you.

Expectations (prognosis)

Most people will improve with conservative treatment. A small percentage may continue to have chronic back pain even after treatment.

It may take several months to a year or more to resume all activities without pain or strain to the back. People with certain occupations that involve heavy lifting or back strain may need to change job activities to avoid recurrent back injury.

Complications

• Long-term back pain
• Loss of movement or sensation in the legs or feet
• Loss of bowel and bladder function
• Permanent spinal cord injury (very rare)

Calling your health care provider

Call your health care provider if:

• You develop persistent, severe back pain develops
• You have any numbness, loss of movement, weakness, or bowel or bladder changes

Prevention

Safe work and play practices, proper lifting techniques, and weight control may help prevent back injury in some people.

Some health care providers recommend the use of back braces to help support the spine. Such braces can help prevent injuries in people whose work requires them to lift heavy objects. However, overuse of these devices can weaken the abdominal and back muscles, making the problem worse.

References

Chou R, Huffman LH. Medications for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Intern Med. 2007;147:505-514.

Chou R, Huffman LH. Nonpharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Intern Med. 2007;147:492-504.

Chou R, Huffman LH. Diagnosis and treatment of low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Intern Med. 2007;147:478-491.

Chou R, Atlas SJ, Stanos SP, Rosenquist RW. Nonsurgical interventional therapies for low back pain: a review of the evidence for an American Pain Society clinical practice guideline. Spine. 2009;34(10):1078-93. Review.

Answer 2

A bulging disc, also known as a herniated disc, is a very common medical condition. Discs act as cushions between spinal vertebrae. They allow the spine to be flexible but they can be damaged. When discs are damaged, the fabric that makes up their outer lining can bulge or even break. This is called "herniation" and can also be referred to as a slipped or ruptured disc as well.

Typical Areas of Herniation

Bulging discs can occur anywhere in the spine, but they are most common in the lower back, known as the lumbar area. The next most common occurrence of a herniated disc is in the cervical spine, the neck. The rarest type of herniation is in the upper spine, known as the thoracic area.

What Causes a Bulging Disc?

Some people experience a herniated disc with no apparent cause at all. This is usually due to the common wear and tear of aging. More likely, an injury will cause the bulging disc. This is especially true in the lower back, where any type of improper twist or careless lifting can cause injury.

What are the Symptoms of a Bulging Disc?

Herniated discs press on the nerves of the spine, causing inflammation leading to pain or numbness anywhere along the path of whatever nerves they touch. The most common type of nerve pain is Sciatica, which is the inflammation of the sciatic nerve which runs from the lumbar spine down the leg.

How is a Bulging Disc Diagnosed?

Patients suffering from bulging discs often find themselves mistakenly treated for something else. This is due to the multitude of symptoms and variety of areas nerve inflammation affects. For example, the sharp pain in the upper leg that Sciatica might cause could be attributed to a pulled or torn hamstring at first. In order to properly diagnose a bulging disc, an MRI or CT scan is a must.

How is a Bulging Disc Treated?

The first step in treatment of a herniated disc is pain management. Once the patient is able to function painlessly, doctors need to decide on the level of damage incurred to the disc. Some herniations can heal themselves with rest. Other, more extreme cases may require surgery.

Answer 3

A spinal disk herniation can result in an extremely painful condition. It is usually the result of a lifting injury or trauma during a strenuous activity. Commonly called a slipped disc, the condition can lead to a wide range of conditions, from neurological symptoms to severe pain.

The Underlying Problem in a Disk Herniation

The spine is made up of vertebrae that are separated by small disks. When injury causes a tear in the outer ring of a spinal disk, the center portion of a spinal disk, known as the nucleus pulpous, can protrude into the spinal canal. While this injury can heal in weeks, it is a good idea to seek a physicians advice on the condition. Some herniations can be dangerous if left untreated. Others may require surgery to heal.

Common Causes of a Herniation

Extreme obesity may contribute to a herniated disk, especially in the lumbar area. This problem can be simply prevented with proper nutrition and weight management. Many patience see marked improvement in pain after substantial weight loss.

The most cited cause of a slipped disk is improper lifting. Patients often suffer the injury while lifting a load that is too heavy or bulky to carry safely. For this reason, many doctors stress the importance of proper lifting techniques, and the same principles are exercised during manual labor and exercise activities.

Nicotine in cigarettes can prevent nutrients from being absorbed into spinal discs. This is also the case of several other toxins present in cigarettes. The loss of nutrition may result in a herniated disc. This activity can also increase the overall pain levels.

Sudden or repeated strain on the back can also result in a herniation, even when proper lifting techniques are used. Individuals should always consult their doctor before beginning an exercise program. They should then begin at a baseline and slowly add weight and intensity. A sudden increase in activity can very easily result in a herniated disc.

Answer 4

Definition

A herniated (slipped) disk occurs when all or part of a disk in the spine is forced through a weakened part of the disk. This places pressure on nearby nerves.

See also:

• Acute low back pain
• Chronic low back pain
• Sciatica

Alternative Names

Lumbar radiculopathy; Cervical radiculopathy; Herniated intervertebral disk; Prolapsed intervertebral disk; Slipped disk; Ruptured disk; Herniated nucleus pulposus

Causes, incidence, and risk factors

The bones (vertebrae) of the spinal column protect nerves that come out of the brain and travel down your back to form the spinal cord. Nerve roots are large nerves that branch out from the spinal cord and leave your spinal column between each vertebrae.

The spinal bones are separated by disks. These disks cushion the spinal column and put space between your vertebrae. The disks allow movement between the vertebrae, which lets you bend and reach.

• These disks may move out of place (herniate) or break open (rupture) from injury or strain. When this happens, there may be pressure on the spinal nerves. This can lead to pain, numbness, or weakness.
• The lower back (lumbar area) of the spine is the most common area for a slipped disk. The neck (cervical) disks are affected a small percentage of the time. The upper-to-mid-back (thoracic) disks are rarely involved.

Radiculopathy is any disease that affects the spinal nerve roots. A herniated disk is one cause of radiculopathy.

Slipped disks occur more often in middle-aged and older men, usually after strenuous activity. Other risk factors include conditions present at birth (congenital) that affect the size of the lumbar spinal canal.

Symptoms

Low back or neck pain can feel very different. It may feel like a mild tingling, dull ache, or a burning or pulsating pain. In some cases, the pain is severe enough that you are unable to move. You may also have numbness.

The pain most often occurs on one side of the body.

• With a slipped disk in your lower back, you may have sharp pain in one part of the leg, hip, or buttocks and numbness in other parts. You may also feel pain or numbness on the back of the calf or sole of the foot. The same leg may also feel weak.
• With a slipped disk in your neck, you may have pain when moving your neck, deep pain near or over the shoulder blade, or pain that moves to the upper arm, forearm, or (rarely) fingers. You can also have numbness along your shoulder, elbow, forearm, and fingers.

The pain often starts slowly. It may get worse:

• After standing or sitting
• At night
• When sneezing, coughing, or laughing
• When bending backwards or walking more than a few yards

You may also have weakness in certain muscles. Sometimes, you may not notice it until your doctor examines you. In other cases, you will notice that you have a hard time lifting your leg or arm, standing on your toes on one side, squeezing tightly with one of your hands, or other problems.

The pain, numbness, or weakness will often go away or improve a lot over a period of weeks to months.

Signs and tests

A careful physical exam and history is almost always the first step. Depending on where you have symptoms, your doctor will examine your neck, shoulder, arms, and hands, or your lower back, hips, legs, and feet.

Your doctor will check:

• For numbness or loss of feeling
• Your muscle reflexes, which may be slower or missing
• Your muscle strength, which may be weaker
• Your posture, or the way your spine curves

Your doctor may also ask you to:

• Sit, stand, and walk. While you walk, your doctor may ask you to try walking on your toes and then your heels.
• Bend forward, backward, and sideways
• Move your neck forward, backward, and sideways
• Raise your shoulders, elbow, wrist, and hand and check your strength during these three tasks

Leg pain that occurs when you sit down on an exam table and lift your leg straight up usually suggests a slipped disk in your lower back.

In another test, you will bend your head forward and to the sides while the health care provider puts slight downward pressure on the top of your head. Increased pain or numbness during this test is usually a sign of pressure on a nerve in your neck.

DIAGNOSTIC TESTS

• EMG may be done to determine the exact nerve root that is involved.
• Myelogram may be done to determine the size and location of disk herniation.
• Nerve conduction velocity test may also be done.
• Spine MRI or spine CT will show that the herniated disk is pressing on the spinal canal.
• Spine x-ray may be done to rule out other causes of back or neck pain. However, it is not possible to diagnose a herniated disk by a spine x-ray alone.

Treatment

The first treatment for a slipped disk is a short period of rest with medications for the pain, followed by physical therapy. Most people who follow these treatments will recover and return to their normal activities. A small number of people will need to have more treatment, which may include steroid injections or surgery.

MEDICATIONS

People who have a sudden herniated disk caused by injury (such as a car accident or lifting a very heavy object) will get nonsteroidal anti-inflammatory medications (NSAIDs) and narcotic painkillers if they have severe pain in the back and leg.

If you have back spasms, you will usually receive muscle relaxants. Rarely, steroids may be given either by pill or directly into the blood through an IV.

NSAIDs are used for long-term pain control, but narcotics may be given if the pain does not respond to anti-inflammatory drugs.

LIFESTYLE CHANGES

Diet and exercise are crucial to improving back pain in overweight patients.

Physical therapy is important for nearly everyone with disk disease. Therapists will tell you how to properly lift, dress, walk, and perform other activities. They will work on strengthening the muscles that help support the spine. You will also learn how to increase flexibility in your spine and legs.

You may want to reduce your activity for the first couple of days. Then, slowly restart your usual activities. Avoid heavy lifting or twisting your back for the first 6 weeks after the pain starts. After 2 to 3 weeks, gradually start exercising again.

See Taking care of your back at home for more about exercise and how to prevent your back pain from returning.

INJECTIONS

Steroid injections into the back in the area of the herniated disk may help control pain for several months. These injections reduce swelling around the disk and relieve many symptoms. Spinal injections are usually done in your doctor's office, using x-ray or fluoroscopy to find the area where the injection is needed.

SURGERY

Surgery may be an option for the few patients whose symptoms do not go away with other treatments and time.

See Diskectomyfor more about how the surgery is done and who is most likely to benefit from it.

Ask your doctor which treatment options are best for you.

Expectations (prognosis)

Most people will improve with treatment. A small percentage may continue to have back pain even after treatment.

It may take several months to a year or more to go back to all of your activities without having pain or straining your back. People who work in jobs that involve heavy lifting or back strain may need to change their job activities to avoid injuring their back again.

Complications

• Long-term back pain
• Loss of movement or feeling in the legs or feet
• Loss of bowel and bladder function
• Permanent spinal cord injury (very rare)

Calling your health care provider

Call your health care provider if:

• You have severe back pain that does not go away
• You have any numbness, loss of movement, weakness, or bowel or bladder changes

Prevention

Being safe at work and play, using proper lifting techniques, and controlling weight may help prevent back injury in some people.

Some health care providers recommend the use of back braces to help support the spine. Such braces can help prevent injuries in people who have to lift heavy objects at work. However, using these devices too much can weaken the abdominal and back muscles, making the problem worse.

References

Chou R, Huffman LH. Medications for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Intern Med. 2007;147:505-514.

Chou R, Huffman LH. Nonpharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Intern Med. 2007;147:492-504.

Jegede KA, Ndu A, Grauer JN. Contemporary management of symptomatic lumbar disc herniations. Orthop Clin North Am. 2010;41:217-224.

Chou R, Atlas SJ, Stanos SP, Rosenquist RW. Nonsurgical interventional therapies for low back pain: a review of the evidence for an American Pain Society clinical practice guideline. Spine. 2009;34(10):1078-93. Review.

Reviewed By

Review Date: 06/04/2011

C. Benjamin Ma, MD, Assistant Professor, Chief, Sports Medicine and Shoulder Service, UCSF Dept of Orthopaedic Surgery. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.