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Disc herniation

Disc herniation is a common, distressing orthopedic disorder that often leads to an array of neurological deficits in the absence of prompt treatment. Find out more about the types, symptoms, causes, diagnosis, and treatment options of the condition.

Disc herniation Definition

It is a serious condition of the spine in which the softer central portion of an intervertebral disc is ruptured or herniated. These discs generally lie between adjacent vertebrae in the vertebral column in the form of cartilaginous joints. This sort of arrangement of the discs facilitates minimal impact of movement on the backbone. Each disc closely resembles a jelly donut with an inner gelatin-like nucleus pulposus surrounded by an outer annulus fibrosus. The condition occurs when the inner element of the disc protrudes through a crack in the outer fibrous ring, causing severe complications.

Disc herniation Incidence

Herniated discs are more prevalent in individuals between the ages 30 and 40 years. Modification in the gelatin-like nucleus pulposus may either cause spondylosis or spinal stenosis after the age of 50 or 60. Males are found to be more prone to this condition than females.

Disc herniation Synonyms

The disorder is known by many other names like:

Picture of Disc herniation

Picture 1 - Disc herniation

  • Spinal disc herniation
  • Herniated disc
  • Prolapsed disc
  • Ruptured disc
  • Slipped disc

The term “slipped disc” is an inappropriate name given to the condition. This is because the discs neither get displaced nor slip out of place. In actuality, they get degenerated or herniated.

Disc herniation Types

The condition can occur in any region of the spinal column, based on which they are classified into the following forms:

Cervical Disc herniation

There are seven vertebrae in the cervical spine numbered from C1 to C7 which are located inferior to the skull. It facilitates movement of the head and protects the spinal cord. This form commonly occurs in C4- C5, C5-C6 or C6-C7 region. It is also called “Neck disc herniation”.

Thoracic Disc herniation

The thoracic segment comprises of 12 thoracic vertebrae that increase in size from T1 through T12. It is more rigid than the cervical and lumbar sections, owing to its articulation with rib cage. It is not a very common form of herniated disc and accounts for only 0.15% to 4.0% of all cases. Rupture of the upper thoracic discs is similar to the cervical form. On the other hand, herniation of the lower section of the thoracic region resembles the lumbar type.

Lumbar Disc herniation

The lumbar region is the lower spine and is constituted by five vertebrae that are numbered L1 to L5. This is the largest and strongest movable part of the vertebral column. Majority of cases of herniated disc occur in the lumbar region where 95% of it is seen in L4-L5 or L5-S1 (sacrum). In rare cases, L3-L4 disk herniation may occur.

Depending on the direction towards which the disc undergoes swelling or bulging, the condition can also be classified into the following types:

Posterior disc herniation

In this type, the disc becomes deteriorated and bulges from between the vertebrae towards the posterior or back of the spinal column.

Anterior Disc Herniation

Tremendous stress on the posterior side of the disc may allow buildup of pressure on the anterior side, causing the nucleus pulposus to leak through a tear in the outer annulus fibrosus.

Posterolateral disc herniation

The intervertebral disc is swollen laterally to the posterior region of the spine, causing nerve irritation.

Central disc herniation

The form is manifested by acute swelling of the disc towards the center of the spinal canal that houses the spinal cord and nerve roots. This results in intolerable back and neck pain.

Paracentral disc herniation

The soft, spongy disc undergoes bulging near the center of the spinal canal.

Lateral disc herniation

In this form, the disc specifically bulges on the left or right side of the spinal column.

Far lateral disc herniation

In people affected with this type, the bulging of the disc may occur above the L4-L5 level and compress the L4 nerve root, causing radicular pain.

Disc herniation Symptoms

The location and the type of spinal nerve affected determine the symptoms of the condition. Bulging out of the discs between the vertebrae may not generate any pain and the patients could remain asymptomatic. If a disc is severely injured then the condition can be extremely painful. The most frequent symptoms of a herniated disc include:

Shooting pain

Intolerable low back pain often radiates to the back of the thighs and down to the knees, or feet on side of the body. It usually happens in the case of lumbar type. The acute neck pain that is observed during a cervical disc herniation may also shoot up to the back of the skull, scapula, shoulder, arm and hand. The symptom gets more aggravated when an affected patient stands, but lessens upon lying down. In adverse cases, both sides of the body may get equally affected.

Tingling and numbness

These are generally abnormal pricking or stinging sensations that are felt in the upper and lower back. Affected patients often complain of electric shock sensations in the upper and lower extremities of the body. The tingling sensation is sometimes known as the feeling of “pins and needles”. Sudden loss of sensation may lead to numbness in the hands, feet, fingers, and toes.

Muscular weakness

There is a decrease in the strength of the lower and upper muscles of the body. The gradual loss of muscular function is marked by feelings of fatigue and uneasiness. Risks of a paralytic attack are quite high during this condition.

Bowel and urinary incontinence

Compression of the nerves at the end of the spinal cord may cause a loss of bowel control that may lead to involuntary passage of stool. Individuals with this condition also suffer from loss of bladder or urine control that is more obvious during coughing or running. Repeated involuntary movements can lead to numbness around the genitals.

Disc herniation Causes

Ruptured disc is a sign of gradual wear and tear of the discs. These discs slowly lose their water or jelly content and undergo complete desiccation or drying. The discs become highly flexible and can easily rupture while carrying out any strenuous activity. Jobs that demand continuous sitting and crouching may push the inner nucleus pulposus outside its normal boundary. Traumatic injury to the spine can cause tiny cracks in the outer layer of the disc, forcing the inner jelly-like material to leak through it. The disc may break, once it bulges out, leading to a number of severe consequences.

Herniation of the lumbar discs could be a repercussion of lifting heavy objects by bending the back instead of keeping it straight. The nucleus pulposus of the disc gets compressed against the annulus fibrosis while sitting or bending forward. This increases the pressure and subsequently tears the exterior membrane, causing protrusion of the soft central portion. The contents of the disc migrates to the spinal cavity – the space in vertebrae through which the spinal cord travels. The sharp pain and numbness in the back arises when this inner component of the disc begins to exert tremendous force on the spinal nerves and spinal cord.

Health experts have linked this disorder to a genetic component in the body. The genes coding for proteins that are responsible for regulation of the extracellular matrix like MMP2 and THBS2 may undergo mutation, causing lumbar disc herniation.

Disc herniation Diagnosis

Physicians may suspect a herniated disc solely by observing its symptoms in affected patients. A detailed medical history of a patient is essential to determine the possible causes of the disorder. Physical examination is the initial step of diagnosis that can reveal abnormal reflexes. Straight leg raise (SLR) is one such test that can determine whether a patient with back pain is having a herniated disc. Painful sensations in the leg or foot could indicate a ruptured intervertebral disc. The condition is further evaluated by performing the following exams and tests:

 X-ray

Plain X-rays have restricted uses and can only reveal degeneration of the spine. Any form of injury or fracture in the vertebral column can also be detected by using this test.

Computed tomography scan

This medical imaging test provides cross-sectional images of the entire vertebral column. The shape and size of the spinal canal as well as the location and structure of the discs can be visualized through this procedure.

Magnetic resonance imaging

This particular imaging technique provides clearer images of the spinal cord, nerve roots, and the adjacent tissues than a CT scan. Physicians can view any inflammation, tumor, or degeneration of the spine that could be a consequence of a herniated disc.

Myelogram

It is a type of radiographic test that involves infusion of contrast medium into the subarachnoid space- the compartment within the spinal column, containing the cerebrospinal fluid (CSF). This is followed by several X-ray projections that show distinct images of the spinal cord, nerve roots and vertebral column. Displacement of the contrast material may reveal structures, causing intense pressure on the spinal nerves such a tumor or herniated disc.

Electromyogram and Nerve conduction studies

The two tests evaluate and record the electrical activity along the nerve roots, peripheral nerves, and skeletal muscles by intravenous insertion of needle electrodes. Nerve conduction studies measure how well the nerves transmit electrical signals to the muscles. Its interpretation helps physicians detect any damage or injury to these nerves.

Disc herniation Differential Diagnosis

Various symptoms of the condition have been found to be similar to a host of disorders that are often ruled out during diagnosis. These conditions include:

  • Abscess
  • Hematoma
  • Discitis/osteomyelitis
  • Mass lesion/malignancy
  • Myocardial infarction
  • Aortic dissection
  • Myofacial pain
  • Spondylosis/spondylolisthesis
  • Spinal stenosis
  • Mechanical pain
  • Discogenic pain

Disc herniation Treatment

The treatment of a ruptured disc normally varies according to the severity of the symptoms as well as the age and activity level of an affected patient. Physicians normally suggest the patients to take prolonged rest and avoid vigorous physical activities. Application of heat and ice packs relieve muscle spasm and ease back pain. The treatment options for more serious occurrences of a herniated disc include:

Image of Disc herniation

Picture 2 - Disc herniation Image

Medications

Non-steroidal anti-inflammatory medications (NSAIDs) are generally prescribed to alleviate the pain. Oral steroid medications like prednisone and methylprednisolone are also used for suppressing the regular episodes of shooting pain. Cortisone is frequently injected into a specific location in the lumbar region of the spinal canal under an X-ray guidance to reduce inflammation.

Medications that soothen the nerve, such as abapentin (Neurontin), pregabalin (Lyrica), duloxetine (Cymbalta), and tramadol (Ultram, Ryzolt), might play an essential role in treating nerve pain. Muscle relaxants such as diazepam (Valium) and cyclobenzaprine (Flexeril, Amrix) are mainly used to relax the muscles of the back and limb that spasm due to a prolapsed disc.

Surgery

Surgical interventions are usually opted when conservative treatment fails to improve the symptoms. Surgery is majorly performed to remove the herniated disc and provide sufficient space around the compressed nerve that causes the pain. However, there are high chances of a recurrent disc herniation after a surgical procedure. A varied range of treatment approaches are available, which include:

  • Artificial disc replacement
  • Anterior cervical discectomy and fusion
  • Disc arthroplasty
  • Dynamic stabilization
  • Nucleoplasty
  • Laminectomy
  • Hemilaminectomy
  • Lumbar fusion
  • Tessys method
  • Chemonucleolysis
  • Intervertebral disc annuloplasty
  • Discectomy/Microdiscectomy

Disc herniation Exercises

Physical therapy may provide temporary relief from the pain using modalities like massage, electrical stimulation and traction. It is generally combined with a proper exercise regime to decrease the continuous stress on the spine. Some of them include:

Elbow rise

In this exercise, a patient must lie on the stomach with the legs extended behind. The upper back is then slightly lifted to put the elbows and forearms on the floor. The head must be leaned back to stretch down the spinal column. This particular position should be held for 10-15 seconds before releasing the stretch.

Leg raise

The exercise strengthens the lower back and abdominals to reduce discomfort in the back. An affected patient must lie on the back with a pillow to support the head and upper back. The left leg is then extended and the right foot is placed on the floor. The left foot is straightened and raised few inches from the ground. The leg is held at this position for 3-5 seconds and then lowered. The same procedure should be followed for the opposite leg.

Back lift

In this exercise, a patient must lie on the stomach with a pillow placed under the pelvis and abdomen for additional support. The hands should be intertwined behind the back. The upper body is then slowly lifted above the ground and is held for 3-5 seconds. The body is then lowered to return to the original position.

Disc herniation Complications

The condition can give rise to a number of neurological complications like:

  • Paralysis
  • Cauda equina syndrome
  • Chronic pain
  • Permanent nerve injury

A herniated disc is curable and most patients show good improvement post-treatment. It is however, normal for the symptoms to take several weeks to dissipate. Mild activities, such as sitting upright and walking, are recommended. Incorrect movements or heavy exercises can cause a long-term impact on the spine and trigger back pain. Hence, care should be taken to avoid these.

References:

http://en.wikipedia.org/wiki/Spinal_disc_herniation

http://orthopedics.about.com/cs/herniateddisk/a/ruptureddisk.htm

http://www.mayoclinic.com/health/herniated-disk/DS00893

http://www.nlm.nih.gov/medlineplus/ency/article/000442.htm

By   Last updated September 10th, 2012

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