Jun 06 2017

Herniated disc

What is Herniated Disc?

The spine consists of 33 vertebrae that form the bony framework and soft tissue pads in between vertebral bodies known as intervertebral discs. These discs serve as a cushion or shock absorber between the vertebral bodies. They also allow a certain degree of rotation movement between adjacent vertebrae for which we can twist and bend our torso. The structure of the discs is like a jelly donut with an outer fibrous and tougher ring (annulus fibrosus) and an inner softer material (nucleus pulposus).


Rupture or herniation of the nucleus pulposus through a weak point of the outer ring is known as herniated disc or slipped disc. The most common herniated disc is the one between lumbar fourth and fifth vertebrae. It is because this disc needs to absorb the impact of bearing the weight of the upper body. Additionally, the contribution of the lower lumbar vertebrae to all types of movements of the torso (flexion, extension, rotation, etc.) is greatest for which the discs between them are more susceptible to injury.


What causes Herniated Disc?

Age-related degeneration of the disc is the most common cause of herniated disc. With aging, water retaining capacity of the nucleus pulposus decreases. It becomes less flexible and local pressure increases. However, it is unusual for nucleus pulposus to herniate unless there is a weak point in the outer fibrous ring. For this reason, it is difficult to predict who will have herniated disc among degenerative disc disease patients.

For young individuals, disc herniation usually occurs after some trauma. Chronic coughing is stressful for the discs. Twisting, turning, sudden standing from seated position, lifting heavy object can cause herniated disc. Occasionally, a blow to the back or fall from a height may injure intervertebral discs.

Risk factors for developing this condition include:

  • It reduces oxygen tension in the avascular disc.
  • Naturally, extra body weight means extra stress on the lower back.
  • People who are professionally involved in weight lifting, pushing, pulling, bending sideways, are at risk of herniated disc. Car driving is associated with vibration from the road to the spine that reduces the stability of the disc structure and increases the risk of herniation.
  • Some studies suggest the possibility of genetic factors that increase the risk of a herniated disc.


What are the Symptoms of Herniated Disc?

Symptoms of herniated disc are extremely variable and do not correlate with the severity of herniation. Bulged nucleus pulposus releases chemical substances that cause inflammation of nearby structures. Bulging may occur in any direction, and mechanical compression of the nerves also produces symptoms. Compression of a motor nerve results in weakness and compression of a sensory nerve leads to pain, numbness, tingling, burning, etc. Inflammation of the nerve causes radicular type pain.

Since herniation occurs most commonly in the lower back or lumbar region, symptoms are confined to the lower back, buttock and lower limbs. Neck or cervical region can also be affected causing upper limb pain and weakness.

Typically the pain is shooting in nature that travels along the distribution of the affected nerve. It affects one side of the body. When the pain occurs in the lower back and lower limbs, it is called sciatica. The pain worsens with movement and forward bending and gets better with rest. Sometimes severe bulging of the disc may cause loss of bowel and bladder control, which is then termed as cauda equina syndrome. It is a surgical emergency because a delay in treatment may result in a permanent problem.


How do You Diagnose Herniated Disc?

A thorough history and clinical examination are correlated with lab investigations to diagnose herniated disc. A clinician will ask you about the duration, onset, and severity, aggravating and relieving factors of symptoms. Some questions are to exclude other conditions like spinal tumor and infection. Physical examination often involves raising the straight leg while lying. If the pain is elicited in that position, it is called a “positive straight leg raising test." Another is range-of-motion (ROM) testing of the lumbar and cervical spine that is more reflective of aging or degeneration of the discs.

A plain x-ray is usually obtained first. It may reveal exuberant growth from edges of vertebrae, deformity, fracture, and other gross findings. Not much information about discs is found. For diagnosis, CT, MRI, or CT myelogram is used. MRI is most sensitive among these because it provides excellent information about soft structures.

Electromyograms are sometimes performed to locate the site of nerve damage.


What are the Non-surgical Treatment Options for Herniated Disc?

  • If there is no symptom, not treatment is required. In the case of acute pain, 1-2 days of bed rest is advised. However, there is no benefit from longer bed rest.
  • 90% patients enjoy near-resolution improvement within six weeks. So, mild analgesics may be sufficient for them.
  • Avoiding painful positions is important. Your physician may find a neutral position that will be comfortable and be benefitting.
  • Drinking plenty of water to rehydrate spinal discs is scientifically proven. Applying an ice pack for initial 2-3 days will help subside local swelling or edema and reduce inflammation. Hot showers and hot packs are then advised to improve blood supply to the affected area.
  • Analgesics like ibuprofen and naproxen are useful in acute attack. Muscle relaxants like tolperisone, tizanidine offer symptomatic relief of muscle spasms and can be used for a short duration. For more severe pain your physician may prescribe narcotic analgesics. Anticonvulsants like pregabalin, gabapentin are used to soothe radicular pain (pain from nerve root compression).
  • Epidural steroid injection provides quick pain relief particularly if there are root compression and inflammation. It helps the patient to mobilize early and increase physical activities.
  • Exercises and physical therapy facilitate the removal of edema and early recovery. Exercises involving building and maintaining strength in the back and abdominal muscles are necessary to stabilize the spine and keep the discs in place. Swimming, walking, and yoga are some established and time-tested exercises for back pain.


What are the Surgical Treatment Options for Herniated Disc?

A small number of patients require surgical intervention. Indications of surgery include progressive symptoms despite optimal medical therapy, failure of medical treatment after six months, neurological deficit, and loss of bowel/bladder control.

Microdiscectomy is the most common procedure for herniated disc. It involves surgical removal of the disc fragment that is impinging on the nerves. Laser Endoscopic Discectomy is also utilized to decompressed the impinged nerves. These minimally invasive spine procedures provides advantages of less bleeding, less scarring, less soft tissue trauma, less pain so that one can experience faster recovery.

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Douglas Won, M.D.

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The first in Texas to perform micro-endoscopic laser spine surgery with an incision as small as 3 mm, Dr. Won advises multiple international spine technology companies and has helped design many groundbreaking tools for the minimally invasive spine surgery industry.

Dr. Won also innovated the Pain Mapping procedures, this diagnostic study helps to pin point the pain generator so that we can provide the least invasive spine procedures, LuMINI.

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