Herniated Disc

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Discs 

The discs are shock absorbers between the vertebrae, designed to help the back/ neck stay flexible while resisting forces in many different planes of motion. Each disc has two parts, annulus fibrosis (firm, tough outer layer) and nucleus pulposis (a softer core). Disc herniation is a condition in which a tear in the annulus fibrosis ring of an intervertebral disc allows the softer nucleus pulposus to bulge out beyond the natural outer rings.

Most common cause of disc herniation includes degenerative tears, car accident, trauma such as fall and work-injury, sports injuries, lifting or twisting injuries.  Inflammatory changes of herniated disc can cause back pain, neck pain, and if the disc impinges on the nerve, patient may experience neck pain that radiates to the arm or back pain that radiates to the leg.  In rare cases, herniated thoracic disc can create mid back pain that radiates to the chest wall or the upper abdomen.  Different terminology is used to describe the size of the herniation including bulge, protrusion, extrusion and sequestration.  In rare cases, herniation can result in leg weakness, bowel or bladder incontinence and loss of function. Pain related to disc herniation that radiates to her arm or leg is called radiculopathy  (cervical or Lumbar Radiculopathy)

SYMPTOMS

Disc disease can present in multiple ways. Acute or chronic low back pain, neck pain, Lumbar Radiculopathy  (sciatica) or cervical radiculopathy are the main complaints of individual with symptomatic herniated disc. Spinal pain associated with lifting, bending, coughing, running and spine movement could be related to HNP. Also, spine pain that travels down one leg or one arm may be due to HNP. The symptoms of disk herniation are among the leading causes of functional incapacity in both sexes and are a common source of chronic disability in the working years. 

DIAGNOSIS

Your spine specialist will evaluate you and order the appropriate diagnostic exams.   Combining physical examination with x-ray and MRI findings can confirm diagnosis of herniated disc.  In rare cases, CT scan or EMG or myelogram is necessary.

TREATMENTS

Prevention is the best medicine. A healthy lifestyle not only improves symptoms, it can actually slow the degenerative process.

Physical therapy:
Best initial treatment for herniated disc would be physical therapy for about 6 weeks.  This includes soft tissue treatment, exercise based treatment, strengthening of musculature around the spine and improving range of motion and conditioning.  Physical therapy will be transitioned to an home exercise program that you would continue.  Patient education on body mechanics and ergonomics are essential part of engagement with PT.

 

Medications:
Your spine specialist may treat your symptoms with medications.  This includes short course of steroid taper, a course of anti-inflammatory medication, muscle relaxants for tight muscles, and certain medications that may help nerve related pain.   
 

Spinal injections
In resistant cases to physical therapy and medications, spinal injections of corticosteroid can proved to be effective way of reducing pain and improving function.  For lumbar herniated disc, Lumbar Epidural injection and Transforaminal Epidural Injection  (selective nerve root block) and for cervical herniated disc, Cervical Epidural injection can effectively reduce pain.  Spine injection may last several weeks to several months. This pain management treatment can be repeated from time to time for pain levels of 6 out of 10 or more.

Minimally invasive Discectomy

If  physical therapy, epidural injections and medical management fails, x-ray guided, discectomy may be an option to treat lumbar radiculopathy (sciatica).  This is a procedure which is done under local anesthesia and requires no hospitalizations.   Automated percutaneous lumbar discectomy is different from a  larger surgical microdiscectomy as it’s performed through a tiny needle without skin incision  The aim is to decompress the nerves by removing displaced disc material. Not every herniated disc can be treated with this method and may provide appropriate relief in properly selected patients with contained lumbar disc herniation.

Spine surgery
In case of progressive weakness or loss of function, or lack of adequate symptom management with nonoperative treatments, surgery may be indicated.  In our practice, we will coordinate referral to the spine surgery and options may include discectomy, ACDF, laminoplasty, fusion, disc replacement, and laminectomy.Careful risk assessment should be done by PCP, spine surgeon and the patient before considering surgery. Most common surgical solution for herniated disc with radiculopathy is microdiscectomy.In cervical spine, discectomy may be combined with cervical fusion (ACDF) in that segment. This may also be the case for large herniated disc in the lumbar spine with associated spondylolisthesis with instability. Microdiscectomy is often successful in resolving leg pain but there is a probability that back pain ruled persist beyond the discectomy. Microdiscectomy takes a few hours to complete, with a short course of inpatient hospitalization and a few weeks of outpatient rehabilitation after discharge from the hospital. If microdiscectomy is combined with fusion, the recovery is often prolonged.