GAYETA, MAYCHELLE H.

Herniated Nucleus Pulposus (HNP) Alternative Names Lumbar radiculopathy Cervical radiculopathy Herniated intervertebral disk Prolapsed intervertebral disk Slipped disk Ruptured disk Bulging disk Compressed disk Definition A herniated nucleus pulposus is a slipped disk along the spinal cord. The condition occurs when all or part of the soft center of a spinal disk is forced through a weakened part of the disk. Anatomy 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 fibrous tissue (annulus fibrosus). In disk herniation, an intervertebral

disk's central portion herniates through the surrounding annulus fibrosus into the spinal canal, putting pressure on a nerve root. (There is often a progression of small fissures in the annulus fibrosis before the disk herniates.) 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. Genetic factors are suspected of playing a role in disk herniation. Prolonged exposure to a bent-forward work posture is correlated with an increased incidence of disk herniation. Pain from a herniated disk is usually greatest when sitting and is lessened when standing. 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

The sequestrated disk may occur as fragments from the annulus fibrosis and nucleus pulposus are outside the disk proper.2% of the time *Nerve roots (large nerves that branch out from the spinal cord) may become compressed.• fibrosis perforates and material of the nucleus moves into the epidural space. A herniated disk is one cause of radiculopathy (sciatica). legs. resulting in neurological symptoms. fingers. 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. especially in the back and sides Increased pain when bending the neck or turning head to the side Pain radiating to the shoulder. and muscle strength 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 Foraminal compression test of Spurling -is done to diagnose cervical radiculopathy. straining. or chest Pain made worse with coughing. such as sensory or motor changes Prevalence middle-aged and older men involved in strenuous physical activity congenital conditions that affect the size of the lumbar spinal canal . straining. and rarely the hand. For this test. and feet Pain made worse with coughing. upper arm. you will bend your head forward and to the sides while the health care provider Causes These disks may herniate (move out of place) or rupture from trauma or strain Brought about by as a car accident or lifting a very heavy object *Radiculopathy refers to any disease affecting the spinal nerve roots. Symptoms SYMPTOMS OF HERNIATED LUMBAR DISK Muscle spasm Muscle weakness or atrophy in later stages Pain radiating to the buttocks. forearm. or laughing Spasm of the neck muscles Exams and Tests physical examination history neurological examination will evaluate muscle reflexes. Lumbar area Most herniation takes place Occurs 15 times more often than cervical (neck) disk herniation It is one of the most common causes of lower back pain Cervical disks 8% of the time and the upper-to-midback (thoracic) disks only 1 . sensation.

inflammatory medications Followed by physical therapy include steroid injections Surgery MEDICATIONS >(NSAIDs) and narcotic pain killers 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 >NSAIDs are used for long-term pain control >narcotics may be given if the pain does not respond to anti-inflammatory drugs >muscle relaxants are usually given ff the patient has back spasms >steroids may be given either by pill or directly into the blood through an IV INJECTIONS Steroid injections in the area of the herniated disk can help control pain for several months reduce swelling around the disk and relieve many symptoms. it is not possible to diagnosis herniated disk by spinal x-ray alone.provides slight downward pressure to the top of the head. more extensive surgery may be needed. using xray or fluoroscopy to identify the area where the injection is needed.Increased pain or numbness during this test is usually indicative of cervical radiculopathy 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. This may require a much longer recovery period. Encouraged the pt. to walk the first day after surgery to reduce the risk ofblood clots *Complete recovery takes several weeks. SURGERY *Done if symptoms persist despite other treatments Diskectomy removes a protruding disk requires general anesthesia (asleep and no pain) and 2 . Treatment Short period of rest with pain and anti. Microdiskectomy procedure removing fragments of nucleated disk through a very small opening Chemonucleolysis involves the injection of anenz yme (called chymopapain) into the herniated disk to dissolve the . done on an outpatient basis. Spine x-ray may be done to rule out other causes of back or neck pain. However. If more than one disk needs to be taken out or if there are other problems in the back besides a herniated disk.3 day hospital stay. Nerve conduction velocity test may also be done. Spine MRI or spine CT will show spinal canal compression by the herniated disk.

. walk. • Flexibility of the spine and legs is taught in many therapy programs. • Weight belts can be helpful in preventing injuries in those whose work requires lifting of heavy objects Prevention Safe work and play practices. Possible 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) When to Contact a Medical Professional persistent. proper lifting techniques. • Back braces to help support the spine *overuse of these devices can weaken the abdominal and back muscles. body mechanics and weight control may help to prevent back injury in some people. severe back pain develops numbness loss of movement weakness bowel or bladder changes LIFESTYLE CHANGES • Any extra weight being carried by an individual.protruding gelatinous substance. This procedure may be an alternative to diskectomy in certain situations. leading to a worsening of the problem. dress. and perform other activities • Work on strengthening the muscles of the abdomen and lower back to help support the spine. • Diet and exercise are crucial to improving back pain in overweight patients • Training on how to properly lift. especially up front in the stomach area will make back pain worse.

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