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Spinal disc herniation A spinal disc herniation (prolapsus disci intervertebralis), informally and misl eadingly called a "slipped

disc", is a medical condition affecting the spine due to trauma, lifting injuries, or idiopathic, in which a tear in the outer, fibro us ring (annulus fibrosus) of anintervertebral disc (discus intervertebralis) al lows the soft, central portion (nucleus pulposus) to bulge out. Tears are almost always postero-lateral in nature owing to the presence of the posterior longitu dinal 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 pathophysiology below). Thi s is the rationale for the use of anti-inflammatory treatments for pain associat ed 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 intac t, but can bulge when the disc is under pressure.

Terminology Most English language publications use the spelling disc more often than disk. N omina Anatomica designates the structures asdisci intervertebrales [plural form] and Terminologia Anatomica as discus intervertebralis/intervertebral disc, Some of the terms commonly used to describe the condition include herniated disc , prolapsed disc, ruptured disc and the misleading expression slipped disc. Othe r 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 ti ghtly sandwiched between two vertebrae to which the disc is attached, cannot act ually "slip", "slide", or even get "out of place". The disc is actually grown to gether with the adjacent vertebrae and can be squeezed, stretched and twisted, a ll in small degrees. It can also be torn, ripped, herniated, and degenerated, bu t it cannot "slip".] "The term 'slipped disc' may be harmful as it leads to a fa lse idea of what is happening and therefore of the likely outcome." 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.

Signs and symptoms Symptoms of a herniated disc can vary depending on the location of the herniatio n 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 nec k or low back pain that will radiate into the regions served by affected nerve r oots that are irritated or impinged by the herniated material. Often, herniated discs are not diagnosed immediately, as the patients come with undefined pains i n 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 ex perience sciatica due to irritation of one of the nerve roots of the sciatic ner ve. 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 co ntinuous 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 pr ess on soft tissues or nerves, it may not cause any symptoms. A small-sample stu dy 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

internal pressure is equali zed on all parts of the discs. such as when performing jobs that require constant sitting. The combination of membrane thinning from stretching and increa sed internal pressure (200 to 300 psi) results in the rupture of the confining m embrane. symptoms are experienced only on one side of the body. thigh. The nerve damage can result in loss of bowel and bladder control as well as sexual dysfunction. However. C6-C7). He rniation of the uppermost thoracic discs can mimic cervical disc herniations. often with serious conse quences. While sitting or bending to lift. wh ile herniation of the other discs can mimic lumbar herniations. Symptoms ca n affect the back of the skull. Compression of the cauda equina can cause permanent nerve damage or par alysis. and may radiate into the foot and/or toe. such as in standing or lying down. The jelly-like contents of the disc then move into the spinal canal. rather than lifting with the legs while the back is straight. anal/genital region (via the Perineal nerve).[8] shoulder. Cause Disc herniations can result from general wear and tear. causing symptoms of sciatica. Pathophysiology There is now recognition of the importance of chemical radiculitis in the generati . herniations often result from jobs that require lifting. internal pressu re on a disc can move from 17 psi (lying down) to over 300 psi (lifting with a r ounded back). such as MMP2 and THBS2. pr essing against the spinal nerves.[10] [edit]Lumbar Lumbar disc herniations occur in the lower back. Traumatic (quick) injury to lumbar discs commonly occurs w hen lifting while bent at the waist. the neck. Thoracic region accounts for only 0.[5][6] Typically. When the s pine is straight. affection of both sides of the body may occur. scapula.[citation needed] Herniation of the contents of the disc into the spinal canal often occurs when t he anterior side (stomach side) of the disc is compressed while sitting or bendi ng forward. shoulder girdle.[7] The majority of spinal disc herniation cases occur in lumbar region (95% in L4-L 5 or L5-S1). If the prolaps e is very large and presses on the spinal cord or the cauda equina in the lumbar region.0% of cases. has been demonstrated to contribute to lumbar disc herniation.[citation needed] There is also a strong genetic component. arm. and the contents (nucleus pulposus) get pressed against the tightly stretched and thinned membrane (annulus fibrosis) on the posterior side (back si de) of the disc.15% to 4.population can have focal herniated discs in their cervical region that do not c ause noticeable symptoms. and hand. thus producing intense and usually disabling p ain and other symptoms. Minor back pain and chronic back tiredness are indicators of general wear and tear that make one susceptible to herniation on the occurrence of a traumatic event. Mutation in genes coding for proteins involved in the regulation of the extracellular matrix. buttocks. Symptoms c an affect the lower back. The femoral nerve can al so be affected[11] and cause the patient to experience a numb. The nerves of the cervical plexus and brachial plexus can be aff ected. such as bending to pick up a pencil or falling. [edit]Cervical Cervical disc herniations occur in the neck. tingling feeling throughout one or both legs and even feet or even a burning feeling in the hips and legs. The sciatic nerve is the most commonly affected nerve. most often between the fifth & sixt h (C5/6) and the sixth and seventh (C6/7) cervical vertebral bodies. most often between the fourth a nd fifth lumbar vertebral bodies or between the fifth and the sacrum. The second most common site is the cervical region (C5-C6.[9] [edit]Thoracic Thoracic discs are very stable and herniations in this region are quite rare.

Myelograms still provide excellent outlines of space-occupying lesions. is rel eased not only by the herniated disc.[22] However. T2-weighted im ages allow for clear visualization of protruded disc material in the spinal cana l. X-ray can still play a relatively inexpensive r ole in confirming the suspicion of the presence of a herniated disc.a classic picture. and tumors. by facet joints. and in spinal stenosis. In spite of these limitations. including soft tissues.[12][13][14][15] Ther e is evidence that points to a specific inflammatory mediator of this pain. symptoms. ? IMAGE 1. as well a s enlargement. and the structures around it. degeneration. A variation is to lift the leg while the patient is sitting. but also in cases of disc tear (annular te ar). metastases and space-occupying lesions. Because it involves the injection of foreign substances. MRI scans are now preferred in most patients. and physical examination. indicating probable prolaps ed intervertebral disc . as well as to evaluate the effica cy of potential treatment options. rather than being solely du e to compression. thi s reduces the sensitivity of the test.[23] [edit]Imaging ? X-ray: Although traditional plain X-rays are limited in their ability to image soft tissues such as discs. they are still used to c onfirm or exclude other possibilities such as tumors. and surrounding areas. if the nerves are i n a state of healing from a past injury. other methods may be used to provide final confirmatio n. may also be due to chemical inflammation. called tumor necrosis factor-alpha (TNF). fractures. ? Myelogram: An x-ray of the spinal canal following injection of a contras t material into the surrounding cerebrospinal fluid spaces. An MRI performed with a high magnetic field strength usually provides the most conclusive evidence for diagnosis of a disc herniation. This will indicate whether there is ongoing nerve damage. It shows soft tissues even better than CAT scans. .[12][18][19][20] In addition to cau sing pain and inflammation. Thus the finding of a negative SLR sign is an imp ortant in helping to "rule out" the possibility of a lower lumbar disc herniatio n. At some point in the evaluation. muscles. t umors. its contents. [edit]Physical examination The Straight leg raise may be positive. or bone spurs.[16][ 17] This inflammatory molecule.[21] Diagnosis Diagnosis is made by a practitioner based on the history. it has high sensitivity. etc . nerve roots. peripheral nerves. ? Computed tomography scan (CT or CAT scan): A diagnostic image created af ter a computer reads x-rays.on of back pain. such as herniated discs. It can show the spinal cord. But it is increasingly recognized that back pain. vi sual confirmation of a disc herniation can be difficult with a CT. By revealing displac ement of the contrast material. infections. tumors. as this finding has low specificity. and muscle tissu e. ? Electromyogram and Nerve conduction studies (EMG/NCS): These tests measu re the electrical impulse along nerve roots. or a nerve roo t. or whether there is another site of ner ve compression. it can show the presence of structures that can cause pressure on the spinal cord or nerves. EMG/NCS studies are typically used to pinpoint the sources of ne rve dysfunction distal to the spine. However. Narrowed space between L5 and S1 vertebrae. It can show the shape and size of the spinal canal. If a suspic ion is thus strengthened. and nerves. tests may be performed to confirm or rule out other causes of symptoms such as spondylolisthesis. degeneration. TNF may also contribute to disc degeneration. ? Magnetic resonance imaging (MRI): A diagnostic test that produces threedimensional images of body structures using powerful magnets and computer techno logy. how ever.[12] A primary focus of surgery is to remove pressure or reduce me chanical compression on a neural element: either the spinal cord. especially when combined with CT scanning (CT myelog raphy).

anti-depressants. which can be caused by spinal disc he rniation.[25] An alternative often employed is the i njection of cortisone into the spine adjacent to the suspected pain generator. but the long-term use of NSAIDs for patients with pe rsistent back pain is complicated by their possible cardiovascular and gastroint estinal toxicity. however. ? IMAGE 3. in certain settings. did not determine the num ber of individuals in the group that had sciatica caused by disc herniation.[27] In addition.[25] [edit]Lumbar Non-surgical methods of treatment are usually attempted first. If pain due to disc herniation. such as those with failed back surgery syndrome. Pain medications are often prescribed as the first attempt to a . graduated exercise programs. the efficacy of epidural steroid injections is now generally thought to be limited to short term pain re lief in selected patients only. epidural steroid injections. physical therapy. may result in serious complications. MRI Scan of lumbar disc herniation between fourth and fifth lumbar vert ebral bodies. MRI scan of cervical disc herniation between fifth and sixth cervical v ertebral bodies. found that "After 12 weeks."[24] The study. may all be useful adjuncts to anti-inflammat ory approaches. One study on sciatica. ? IMAGE 4. 73% of patients showed reasonable to major improvement without surgery. and.[28] Fortunately there ar e now emerging new methods that directly target TNF.MRI scan of large herniation (on the right) of the disc between the L4-L 5 vertebrae. then prior to surgery it may make sense to try an anti-infl ammatory approach. protrusion. a technique known as epidural steroid injection .[29] These TNF-targeted meth ods represent a highly promising new approach for patients with chronic severe s pinal pain.[26] Although this technique began more than a decade ago for pain due to disc herniation.? IMAGE 2. or disc tear is due to chemic al radiculitis pain. [edit]Differential diagnosis ? Mechanical pain ? Discogenic pain ? Myofacial pain ? Spondylosis/spondylolisthesis ? Spinal stenosis ? Abscess ? Hematoma ? Discitis/osteomyelitis ? Mass lesion/malignancy ? Myocardial infarction ? Aortic dissection Treatment The majority of herniated discs will heal themselves in about six weeks and do n ot require surgery. in parti cular. leaving surgery a s a last resort.[29] Ancillary appro aches. and NSAIDs have limited value to intervene in tumor necrosis f actor-alpha (TNF)-mediated processes. such as rehabilitation. Often this is first attempted with non-steroidal anti-inflamm atory medications (NSAIDs). Note that herniation between sixth and seventh cervical vertebr al bodies is most common. bulge.

Disc herniations are so ubiquitous that being cavalie r in diagnosis is easy. relatively contraindicated. some of the reports discussed hig hlight the importance of a thorough case history and physical examination.lleviate the acute pain and allow the patient to begin exercising and stretching . There are a variety of other non-surgical methods used in attempts to relieve the condition after it has occurred. Most spine surgeons adhere to some guidelines. a meta-analysis of randomized controlled trials . and may include modalit ies to temporarily relieve pain (i. electrical stimulation. analgesia-assisted traction therapy (IVSAAT) 7. Non-surgical spinal decompression: A 2007 review of published research o n this treatment method found shortcomings in most published studies and conclud ed that there was only "very limited evidence in the scientific literature to su pport the effectiveness of non-surgical spinal decompression therapy. Lumbosacral back support[30] [edit]Contraindicated 1. postpone surgery.[36] Regarding the role of surgery for failed medical therapy in patients without a s ignificant neurological deficit. surgery is indicated if a patient has a signifi cant neurological deficit. it is absolutely contraindicated. The y are either considered indicated.[34] [edit]Surgical Surgery should only be considered as a last resort after all conservative treatm ents (non-surgical therapy) have been tried. Oral steroids (e. Epidural (cortisone) injection[30] 6. prednisone or methylprednisolone)[30] 5.e. massage) [30] 3. including the fol lowing: A patient with unrelenting back pain: Patients who have back pain after a bout of sciatica has resolved are not good candidates for operative treatment. weakness and genital numbness) is considered a medical eme rgency requiring immediate attention and possibly surgical decompression. Occasiona lly. A patient with an incomplete workup: When diagnosis is un certain. It is likely to be safe when used by appropriately-trained practitioners. Spinal manipulation: A 2006 review of published research stated: "Contra dictions in the literature exist in terms of the use of spinal manipulation in t he management of disc herniation. contraindicated. Weight control[30] 8. Physical therapy. to address mechanical factors.[32] [edit]Inconclusive 1. that did not alleviate the pain and heal the disc herniation. in their guidelines onchiropractic practice. these patients are the most insistent and difficult to manage. Tobacco cessation 9. Patient education on proper body mechanics[30] 2. however. Non-steroidal anti-inflammatory drugs (NSAIDs)[30] 4. traction. Any claim of absolute contraindications for lumbar disc disease would invariably be challenged. often in combination with pain killers. All surgeons can recall several cases in which a diabetic plexopathy or an epidural metastasis was missed."[31] According to the WHO. Ensure the completeness of the workup prior to proceedin g with the operation."[33] Its u se and marketing have been very controversial. or inconclusive based on the safety profile of their risk-benefit ratio and on w hether they may or may not help: [edit]Indicated 1. when there is a "frank disc herniation with accompanying signs of progressive neurological de ficit". a nd others suggesting it is contraindicated. A patient not provided adequate conservative treatment: Spine surgeons rarely commit a patient with a short per iod of sciatica and without bedrest and a steroid trial to an operation that wil l permanently alter the patient's back mechanics and strength.[35] The presence of cauda equina syndrome (in which t here is incontinence. Often.g. with some authors advocating its usefulness. Also. these are patients whose back pain improved after discectomy for a large ce ntral disc herniation. Intravenous sedation.

radicular pain (belo w the knee for lower lumbar herniations... decreased sensation in a dermatomal distribution. Lumbar disc herniation occurs 15 times more often than cervical (neck) disc hern .by the Cochrane Collaboration concluded that "limited evidence is now available to support some aspects of surgical practice". or weakness in a myotomal dist ribution) ? Conclusions. Because of the large numbe rs of patients who crossed over in both directions. causing lower back pain (lumbago) and often leg pain as well. but the rates of pain relief and of perceived recovery were faster f or those assigned to early surgery. conclusions about the superi ority or equivalence of the treatments are not warranted based on the intent-totreat analysis"[37][38] ? The Hague Spine Intervention Prognostic Study Group[39] ? Patients studied "had a radiologically confirmed disk herniation. ? Nucleoplasty[41] Surgical goals include relief of nerve compression.. More recent randomized controlle d trials refine indications for surgery as follows: ? The Spine Patient Outcomes Research Trial (SPORT) ? Patients studied "intervertebral disk herniation and persistent symptoms despite some nonoperative treatment for at least 6 weeks. 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.incap acitating lumbosacral radicular syndrome that had lasted for 6 to 12 weeks.to relieve spinal stenosis or nerve compression ? Hemilaminectomy .S .to relieve spinal stenosis or nerve compression ? Lumbar fusion (lumbar fusion is only indicated for recurrent lumbar disc herniations.a transforaminal endoscopic method to remove herniated d iscs ? Laminectomy . The former is the mos t common. as well as the relief of associated back pain and restoration of normal funct ion." [edit]Surgical options ? Chemonucleolysis . but the two most common form s are lumbar disc herniation and cervical disc herniation.. [edit]Complications ? Permanent nerve injury ? Cauda equina syndrome ? Paralysis ? Chronic pain [edit]Epidemiology Stages of Spinal Disc Herniation Disc herniation can occur in any disc in the spine. a relatively new form of surgery in the U.Pat ients presenting with cauda equina syndrome. into the anterior thigh for upper lumba r 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 tens ion sign) or a corresponding neurologic deficit (asymmetrical depressed reflex. allowing the nerve to recove r.. but has been in use in Europe for decades.. primarily used to treat low back pa in from a degenerated disc. "The 1-year outcomes were similar for patients assigned to early surgery and those assigned to conservative treatment with eventual surgery if needed. or insufficient s trength to move against gravity were excluded." ? Conclusions. muscle paralysis. "Patients in both the surgery and the nonoperative treatmen t groups improved substantially over a 2-year period. in which case it is commonly referred to assciatica.to relieve nerve compression ? Tessys method .dissolves the protruding disc[40] ? IDET (a minimally invasive surgery for disc pain) ? Discectomy/Microdiscectomy .

into the spinal canal through a tear or "rupture. bulge. Leung. producing pain down the a ccompanying leg. Autogenic mesenchymal stem cells in animal models can a rrest intervertebral disc degeneration or even partially regenerate it and the e ffect is suggested to be dependent on the severity of the degeneration. and t he coccyx. Most disc herniations occur when a person is in their thirties or forties when t he nucleus pulposus is still a gelatin-like substance. C. or disc tear.[46] has been suggested in published pilot studies to be effective for treati ng selected patients with severe pain due to disc herniation.[48][49] In the future new imagin g methods may allow non-invasive identification of sites of neuronal inflammatio n.[42] The following locations have no discs and are therefore exempt from the risk of disc herniation: the upper two cervical intervertebral spaces.HERNIATED DISC Definition A herniated disc is a fragment of the disc nucleus which is pushed out of the ou ter disc margin. With age the nucleus pulp osus changes ("dries out") and the risk of herniation is greatly reduced." In the herni ated disc's new position. ? In 14%. Specific and potent inhibitors of TNF became available in the U.5% females older than 35 experience sciatica during the ir lifetime. severe pain down the entire leg and into the foot. Cheung have reported in the European Spine Journal tha t "substantial progress has been made in the field of stem cell regeneration of the intervertebral disc. ? 4. thereby enabling more accurate localization of the "pain generators" responsi ble for symptom production."[50] http://en. bulge. males have a slightly higher incidence than females. Doctors Victor Y. or disc tear. a patented treatment meth od.[43][44][45] Targeted anatomic admin istration of one of these anti-TNF agents. ? Of all individuals.2% of the time. protrusion. it presses on spinal nerves.org/wiki/Spinal_disc_herniation#Pathophysiology Herniated Nucleus Pulposus . pain lasts more than 2 weeks. and were demonstrated to be potentially effective for treating sciati ca in experimental models beginning in 2001. L. [edit]Research The identification of tumor necrosis factor-alpha (TNF) as a central cause of in flammatory spinal pain now suggests the possibility of an entirely new approach to selected patients with severe pain due to disc herniation. etanercept. The spinal canal has limited space which is inadequate for the spinal . Future treatments may include stem cell therapy. The cervical discs are affected 8% of the time and the upper-to-mid-back (thoracic) discs on ly 1 .S . This produces a sharp. and it is one of the most common causes of lower back pain.[29][47] The scientific basis for pain relief in these patients is supported by the most current review articles.8% males and 2. in 1998. the sacrum. ? Generally.iation. protrusion. Dan ny Chan and Kenneth M. osteoarthritic degeneration (spondylosis) or spinal stenosis are m ore likely causes of low back pain or leg pain.wikipedia. After age 50 or 60. 60% to 80% experience back pain during their lifetim e.

infections. A quality MRI will accurately demonstrate the size of the spinal canal and most other medically significant factors. fractures. or whether there is another site of nerve compression. This pain often is described as sharp." The direct compression of the nerve may produce weakness in the leg or foot in a specific patter. Tolectin. There also may be resulting leg muscle weakness from a compromise of the spinal nerve affected. What Diagnostic Tests are Used for Evaluations X-rays of the low back area are obtained to search for unusual causes of leg pai n.nerve and the displaced herniated disc fragment. there may also be knee or ankle reflex loss. The compression and subsequent inflammation is directly responsible for the pain one feels down the leg.e. Sciatica is sharp pain whi ch radiates from the low back area down through the leg. depending upon the spinal nerve affected. The pain is frequently relieved by lying down or utilizing a lumbar support c hair or insert. the back pain has resolved by the time sciatica d evelops. An MRI of the lumbar spine area is o btained. . A herniated disc is frequently aided by non-steroidal anti-inflammatory medicati on such as Motrin. Feldene. nonoper ative. i. Dolo bid. termed "sciatica. It may not respond to con servative therapy. One usually begins with resting the low back area. However. This in in order to allow the spinal nerve inflammation to quiet down and resolve. For a disc to become herniated. The loca tion of the leg pain is usually so specific that the doctor can indentify the di sc level which is herniated. tumors. A nerve test may be indicated to demonstrat e whether there is ongoing nerve damage. A herniated disc is a definite displaced fragment of nucleus pushed out through a tear in the outer layer of the disc (annulus). it typically is in an early stage of degeneration. etc. or there is minimal back pain compared to the severe leg pain. as this will demonstrate the degree of disc degeneration at the herniat ed level. Naprosyn. depending upon whi ch spinal nerve is compressed. a herniated disc is preceded by an episode of low back pain or a long history of intermittent episodes of low back pain. Clinoril. walking or sittin g. Lodine. Voltaren. Typical Pain and Findings Typically. when the nucleus ac tually herniates out through the annulus and compresses the spinal nerve. An epidural steroid injection may be performed utilizing a spinal needle under x-ray guidance to direct the medication to the exact level of the disc herniation. sever with standing. This situation is the one that responds best surgery. or if the nerves are in a state of heal ing a past insult. electric shock-like. Treatment The initial treatment for a herniated disc is usually conservative. maintaining a comforta ble posture and painless activity level for a few days to several weeks. in addition to the condition of other lumbar discs in the low back. including manipulation and even chemonucleolysis. i. In addition to leg muscle weakness. then t he pain typically changes from back pain to sciatica. In this situation there is a portion of the annulus that has isolated itself fro m the rest of the disc and all or part of its displaced will out into the canal. Advil or Nuprin. Most commonly.e. into the foot in a char acteristic pattern.

fortu nately. electrical muscle stimulation. Since these factors are typically the same after s urgery. T here may be small permanent patches of numbness in the involved leg which. A micro-laminotomy requires one to two days of hospitalization after the surgery for the wound to heal and posto perative physical therapy to begin. If these conservative treatments are not successful an d the pain is still severe or muscle weakness is increasing. and my be from several sources. When this occurs. Surgery may be in the form of a percutaneous discectomy if the disc hern iation is small and not a completely extruded disc fragment. over the gen eral population. http://www. combined w ith a physician's diagnosis. the prognosis is poor for returni ng to normal life activities regardless of age. and will resolve with conservative. etc.. then a m icrolaminotomy with disc excision is necessary. Flare-ups or exacerbations of less severe and less si gnificant sciatic type pain may develop in the future (usually on an infrequent basis). Prognosis A person who has sustained one disc herniation is statistically at increased ris k for experiencing another. However. lasting several days to a coup le of weeks. ultrasound. work or behavioral habits. withou t significant long-term sequelae. there will be some discomfort in th e low back area where the operation is performed. there is an increased risk of herniated disc in this group. this information. to relax the muscles which are in spasm and secondarily inflamed from the compressed spinal nerve. Factors involved may be weight related level of physical conditionin g. There is an approximate 5% rate of recurrent disc he rniation at the same level. or is a "free fragment" as described above.htm . non-operative t reatment to relieve the pain while the spinal nerve root inflammation resolves a nd the body heals itself. This unfortunate result is not always specifically the result of sur gery. The sciatic pain down the leg should be reso lved immediately after the surgery. nonoperative treatment. The therapist will perform an in-depth evaluation. However. then surgery is nec essary. degenerated discs will go on to experience symptomatic or severe a nd incapacitating low back pain which significantly affects their life activitie s and work. The causes of this unremitting pain are not always clear or agreed on. This is controlled with pain medication. the good news is that the majority of disc herniations (90%) do not req uire surgery. and a lesser incidence of new disc herniation at ano ther level. 80-85% of patients do extremely we ll and are able to return to their normal job in approximately six weeks time.Physical therapy may be beneficial. will dictate a treatment based on successful physic al therapy treatment modalities which have proven beneficial for herniated disc patients. approximately 5% of patients wi th herniated. Pain medication and muscle relaxing medications may al so be beneficial to help physical therapy or other conservative. are not disabling.com/hnp. After a successful laminotomy and discectomy. under the direction of a physical therapist. These may include traction. Unfortunately. If the herniation is large.pmrehab.

Disk herniation occurs more frequently in middle aged and older men. Other risk factors include any co ngenital conditions that affect the size of the lumbar spinal canal. especially in the back and sides Increased pain when bending the neck or turning head to the side Pain radiating to the shoulder. gelatinous substance. The condit ion occurs when all or part of the soft center of a spinal disk is forced throug h a weakened part of the disk. fingers or chest Pain made worse with coughing. Slipped disk. These disks may herniate (move out of place) or rupture from traum a or strain. such as sensory or motor changes. especially those involved in strenuous physical activity. The spinal vertebrae are separated by d isks filled with a soft. and feet Pain made worse with coughing. Pro lapsed intervertebral disk. or laughing Spasm of the neck muscles Signs and tests A physical examination and history of pain may be all that is needed to diagnose a herniated disk. The spinal column is divided into several segments -. Lumbar disk herniation occurs 15 times more often than cervical (neck) disk herniation . upper arm. sen sation. These bones protect nerves that come out of the brain and trav el down the back and to the entire body. Cervical radiculopathy. Alternative Names Lumbar radiculopathy. examination of the spine will reveal a decre ase in the spinal curvature in the affected area. the thoracic spine (the part of the back behind the chest). Ruptured disk Causes. the lumbar spin e (lower back). The cervical disks are affected 8% of the time and the upper-to-mid-back (thoracic) disks only 1 2% of the time. Nerve roots (large nerves that branch out from the spinal cord) may become compr essed resulting in neurological symptoms. or laughing Severe low back pain Tingling or numbness in legs or feet SYMPTOMS OF HERNIATED CERVICAL DISK Arm muscle weakness Deep pain near or over the shoulder blades on the affected side Neck pain. incidence. and sacral spine (the part connected to the pelvis that does not move). Herniated intervertebral disk. and risk factors The bones (vertebrae) of the spinal column run down the back. straining. legs. which provide cushioning to the s pinal column. Most herniation takes place in the lower back (lumbar area) of the spine. and it is one of the most common causes of lower back pain.A herniated nucleus pulposus is a slipped disk along the spinal cord. and rarely the hand.the cervical spine (the ne ck). . forearm. Symptoms SYMPTOMS OF HERNIATED LUMBAR DISK Muscle spasm Muscle weakness or atrophy in later stages Pain radiating to the buttocks. connecting the sku ll to the pelvis. A herniate d disk is one cause of radiculopathy (sciatica). and muscle strength. Often. straining. Radiculopathy refers to any disease affecting the spinal nerve roots. A neurological examination will evaluate muscle reflexes.

followed by physical therapy. NSAIDs are used for long-term pain control. A small number of people need to have further treatment. will make back pain worse. Spinal injections are usually done on an outpatient basi s using x-ray or fluoroscopy to identify the area where the injection is needed. Spine MRI or spine CT will show spinal canal compression by the herniated disk. Most people who fol low these treatments will recover and return to their normal activities. SURGERY Surgery may be an option for the few patients whose symptoms persist despite oth er treatments. muscle relaxants are usually given. A foraminal compression test of Spurling is done to diagnose cervical radiculopa thy. DIAGNOSTIC TESTS EMG may be done to determine the exact nerve root(s) that is (are) involved. it is not possible to diagnosis herniated disk by spinal x-ray alone. Such injections reduce swelling around the disk and relieve many symptoms. Myelogram may be done to determine the size and location of disk herniation. overuse of these devices can weaken the abdominal and back muscl es leading to a worsening of the problem. Weight belts can be helpful in prevent ing injuries in those whose work requires lifting of heavy objects. This may require a much longer recovery period. you will bend your head forward and to the sides while the h ealth care provider provides slight downward pressure to the top of the head. especially up front in the stom ach area. which may include steroid inje ctions or surgery. more ext ensive surgery may be needed. On rare occa sions. steroids may be given either by pill or directly into the blood through a n IV. Diet and exercise are crucial to improving back pain in overweight patients. Other surgical options include microdiskectomy. dress. Spine x-ray may be done to rule out other causes of back or neck pain. INJECTIONS Steroid injections into the back in the area of the herniated disk can help cont rol pain for several months. Therapists will tell you how to properly lift. and perform other activities. If the patient has back spasms. Treatment The main treatment for a herniated disk is a short period of rest with pain and anti-inflammatory medications. Flexibility of the spine and legs is taught in many the rapy programs. LIFESTYLE CHANGES Any extra weight being carried by an individual. For this test. Diskectomy removes a protruding disk. MEDICATIONS Nonsteroidal anti-inflammatory medications (NSAIDs) and narcotic pain killers wi ll 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 fol lowed by severe pain in the back and leg. a procedure removing fragments o . However. This procedure requires general anesthesia (asleep and no pain) and 2-3 day hospital stay. but narcotics may be given if the pa in does not respond to anti-inflammatory drugs. Some health care providers recommend the use of back braces to help support the spine. T hey will also work on strengthening the muscles of the abdomen and lower back to help support the spine. In creased pain or numbness during this test is usually indicative of cervical radi culopathy. You will be encouraged to walk the first day after surgery to reduce the risk ofblood clots.Leg pain that occurs when you sit down on an exam table and lift your leg straig ht up usually suggests a herniated lumbar disk. Nerve conduction velocity test may also be done. However. Complete recovery takes several weeks. Physical therapy is important for nearly everyone with disk disease. If more than one disk needs to be taken o ut or if there are other problems in the back besides a herniated disk. walk.

It may take several months to a year or more to resume all activities without pa in or strain to the back. This procedur e may be an alternative to diskectomy in certain situations. proper lifting techniques. weakness. 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 persistent. loss of movement. severe back pain develops. People with certain occupations that involve heavy lif ting or back strain may need to change job activities to avoid recurrent back in jury. especia lly if you have any numbness. or bowel or bladder ch anges. Prevention Safe work and play practices. and weight control may help to prevent back injury in some people. . A small percentage may con tinue to have chronic back pain even after treatment. Chemonucleolysis involves the injection of an enzyme (called chymopapain) into t he herniated disk to dissolve the protruding gelatinous substance. Expectations (prognosis) Most people will improve with conservative treatment.f nucleated disk through a very small opening.